[Deprescribing statinsand other cardiovascular medications Barriers and facilitators]. / Déprescription des statines et autres médicaments cardiovasculaires. Obstacles et facilitateurs.

Considering the growing problematic of polypharmacy, this article summarizes barriers and facilitators to deprescribing cardiovascular medications, from the point of view of physicians and patients. Patients seem to be more open to discontinue cardiovascular medications when their physician suggests to do so, or if they dislike the medication. Physicians tend to consider deprescribing more if they had positive experiences with deprescribing in the past, or if their patients ask them to. The most common barrier for patients is the fear of health deterioration. Patient desire to continue with their usual medication or past negative experiences with depresecribing are frequently reported as barriers by physicians.

Vu le problème croissant de la polypharmacie, cet article résume les différents obstacles et facilitateurs à la déprescription des médicaments cardiovasculaires, du point de vue des médecins et des patients. Ces derniers sont plus enclins à stopper des médicaments cardiovasculaires lorsque cela leur est proposé par leur médecin traitant ou s'ils n'aiment pas le médicament. Les médecins arrêtent plus facilement les traitements s'ils ont déjà eu des expériences positives de déprescription et si leurs patients le leur demandent. L'obstacle le plus fréquent pour les patients est la peur d'une détérioration de leur état de santé. Pour les médecins, la volonté du patient de poursuivre le traitement, ou une expérience passée négative avec la déprescription, sont des obstacles fréquents.

Older Adult Attitudes toward Deprescribing Statins in Primary Cardiovascular Prevention Versus General Medications.

Background: There is little evidence for statins for primary cardiovascular prevention in older adults. Consequently, it is important to assess patient attitudes toward the use of statins, which might differ from attitudes toward other medications. We aimed to describe older patient attitudes toward deprescribing statins versus general medications. Methods: We conducted a survey using the revised Patients' Attitudes Toward Deprescribing questionnaire in its original version and adapted to statin use in adults ≥65 years taking a statin for primary prevention. Results: Among the 47 participants (mean age 74.6 years), 42 (89%) were satisfied with their current therapy, but still willing to stop ≥1 of their medications upon their doctor's advice. About 68% (N = 32) were satisfied with their statin therapy, while 83% (N = 39) would accept to consider deprescribing. Twenty-six (55%) participants were concerned about missing future benefits when stopping their general medications and 17 (36%) when stopping their statin. Eight (17%) participants believed they were experiencing side effects of statins and twice as many for general medication (38%, N = 18). Conclusion: Our study provides insight about differences and similarities in patient attitudes toward deprescribing general medications and statins in primary prevention. This information could support patient-centered conversations and shared-decision making about deprescribing.

Older Adult Perspectives on Statin Continuation and Discontinuation in Primary Cardiovascular Disease Prevention: A Mixed-Methods Study.

Background and Purpose: Evidence for statin use for primary cardiovascular disease prevention in older adults is limited. When evidence on risk-benefit profile of a medication is uncertain, using it or not becomes a preference-sensitive decision. We aimed to assess and explore patient perspectives on continuation and discontinuation of statins used for primary cardiovascular prevention in older adults. Patients and Methods: We used a convergent mixed-methods design, conducting in parallel a survey among 47 patients and three focus groups (FGs) with 14 patients total. We recruited patients aged ≥65 years and taking a statin for primary cardiovascular prevention. The survey and FGs aimed to assess and explore patient experiences of statin use, and views on statin continuation and discontinuation, including patient decision-making. Quantitative and qualitative data were first analyzed separately - descriptive statistics for quantitative data and thematic analysis for qualitative data - and then integrated to create metainferences, using joint displays. Results: Forty-one percent of patients (N=19) were reluctant to discontinue the statin, whereas 22% (N=10) were willing to try discontinuing it. A reason to continue the statin was its perceived necessity, while self-estimated low cardiovascular risk and wish to reduce medication burden were given as reasons to discontinue it. Lack of expertise assumed by the patients to decide about statin continuation or discontinuation, uncertainty about statin indication, and fear of having a cardiovascular event after discontinuation made many patients uncertain about deciding to continue or discontinue the statin. In this context, 70% (N=33) would rather have their physician choose for them, and 94% (N=44) would continue taking the statin for as long as their physician told them to do so. Conclusion: This study highlights factors that influence patient willingness to continue or discontinue statins, patient uncertainty about statin continuation or discontinuation, and the important role physicians play in the decision-making process.

Barriers and facilitators to deprescribing of cardiovascular medications: a systematic review.

OBJECTIVE: To synthesise the current knowledge on barriers and facilitators to deprescribing cardiovascular medications (CVMs) at the levels of patients, informal caregivers and healthcare providers (HCPs). DESIGN/SETTING: We conducted a systematic review of studies exploring/assessing patient, informal caregiver and/or HCP barriers and/or facilitators to deprescribing CVMs. DATA SOURCES: Ovid/MEDLINE and Embase from January 2003 to November 2021. DATA EXTRACTION AND SYNTHESIS: We performed a deductive thematic analysis based on the framework of specific barriers and facilitators to deprescribing CVMs created by Goyal et al. We added a quantification of the occurrence of categories and themes in the selected articles to identify the resounding themes that indicate the greater impetus to address in future research. RESULTS: Most frequent deprescribing barriers for patients, informal caregivers and HCPs included uncertainty due to lack of evidence regarding CVM deprescribing (in n=10 studies), fear of negative consequences following deprescribing (n=13) and social influences (n=14). A frequently reported facilitator to deprescribing, especially for patients and informal caregivers, was the occurrence of adverse drug events (n=7). Another frequently reported facilitator for patients were dislike of CVMs (n=9). Necessity and benefit of CVMs were seen as barriers or facilitators similarly by patients and HCPs. CONCLUSION: The differences in patient, informal caregiver and HCP regarding barriers and facilitators to deprescribing CVMs stress the need for ground discussions about beliefs and preferences of each stakeholder implicated in deprescribing decisions. Furthermore, HCP uncertainty regarding CVM deprescribing highlights the need to provide HCPs with tools that enable sharing the risks and benefits of deprescribing with patients and ensure a safe deprescribing process. PROSPERO REGISTRATION NUMBER: CRD42020221973.

Qualitative evaluation of primary care providers' experiences caring for frequent users of the emergency department.

OBJECTIVES: Many interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care. DESIGN: Qualitative study using in-depth semistructured interviews and inductive thematic analysis. SETTING: Canton of Vaud, Switzerland. PARTICIPANTS: Thirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs). RESULTS: U-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs. CONCLUSIONS: This study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.