Year

2021

Degree Name

Doctor of Philosophy

Department

School of Medicine

Abstract

Background Deprescribing is an intervention used to help reduce the risks associated with inappropriate polypharmacy, especially for older adults. However, rates of polypharmacy use have continued to increase worldwide, including in Australia. Limited research is available that considers deprescribing and the management of polypharmacy from the perspective of both older adults and GPs. This is despite the key role both play in decision making. This study investigated deprescribing as an aspect of medication management. The role of older adult health literacy was explored to determine if this was an important facilitator of shared decision making about deprescribing.

Aim The aim of this research was to explore the factors which influence the process of deprescribing in primary care in Australia.

Objectives 1. How does the structure of the healthcare environment in primary care in Australia facilitate or impede discussions about polypharmacy and deprescribing between older adults and their GPs?

2. What is the relationship between perceptions of ageing and the likelihood of discussions about polypharmacy and deprescribing?

3. What is the role of health literacy in managing polypharmacy and making decisions about deprescribing?

4. What, if any, is the relationship between attitudes to medication use, age cohort, socio-economic status and the likelihood of discussions about polypharmacy and deprescribing?

Methods A sequential, explanatory mixed methods approach was employed adopting a pragmatic theoretical stance. The views of GPs and autonomous, community living, older adults using five or more medications, were included. An initial quantitative phase was conducted using two observational cross-sectional surveys with GPs (n=85) and the second with older adults (n=187). A new survey tool was developed to assess GP practices and attitudes toward deprescribing, as no tool existed at the time. The older adult survey included two previously validated tools: the Patients’ Attitudes Towards Deprescribing tool (PATD) and the All Aspect of Health Literacy Scale (AAHLS). A second qualitative phase using individual interviews was also conducted with GPs (n=16) and older adults (n=25).

The data for both quantitative studies were analysed using descriptive statistics and bivariate analysis of correlations and relationships between groups employing SPSS version 24. Qualitative data was explored using thematic analysis assisted by organising and coding the data in NVivo 12. Finally, the results from each study were considered together in order to identify points at which findings complemented, converged or diverged from each other.

Results Structural and attitudinal factors were found to influence the process of deprescribing in Australia. GPs were often prevented from playing to the strengths of their generalist role when co-ordinating medication management. This was the result of structural factors such as short consultation times, poor communication between multiple healthcare providers and unclear lines of responsibility for medication management decisions. Continuity of care, provided by GPs, resulted in trust. The presence of trust was important to ameliorate the effects of uncertainty associated with medication management and deprescribing, in the context of multimorbidity. However, trust also resulted in some older adults deferring medication decisions to their GP and giving precedence to the decisions of specialists.

Participants explicitly noted the role of structural factors however the influence of attitude was implied. Both older adults and GPs held negative attitudes toward age and ageing. This disrupted shared decision making and normalised medication use in the context of old age. A pragmatic attitude toward the use of medications meant GPs and older adults were more concerned about finding a level of appropriate polypharmacy and maintaining this over time, as opposed to deprescribing. Research driven numerical goals for polypharmacy use carried little weight although there was a general desire to use as few medications as possible, especially in those using 10 or more.

High health literacy scores were associated with a willingness to consider deprescribing. Older adult participants described specific health literacy practices related to the daily management of their often complex and burdensome medications regimens. However, health literacy capabilities played a limited role in deprescribing decision making as older adult capabilities were generally not acknowledged or applied in consultations.

Conclusion Implications for practice highlight opportunities to improve shared decision making. The consistent use of comprehensive medication reviews is recommended to allow older adults to share their daily experiences, goals and preferences regarding polypharmacy use. The acknowledgement and use of older adult health literacy capabilities would enable a collaborative approach to shared decision making. Recognition of capabilities would also reduce the disempowerment experienced by many because of the influence of negative stereotypes towards older people.

The influence of frailty appears to be important although numbers of frail individuals in this study were small. Further research is needed to explore the impact of increasing health literacy demands and reduced access to primary care at a time when medication management needs are increasing.

The pragmatic approach, using a mixed methods design, allowed the production of practical knowledge. It added a greater level of insight particularly the exploration of health literacy level and practices and the barriers to health literacy use in consultations.

FoR codes (2008)

111702 Aged Health Care, 111717 Primary Health Care

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.