Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults

Abstract

Background/objectives: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.

Design: National cross-sectional survey.

Setting: Ambulatory.

Participants: Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians.

Measurements: Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.

Results: In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).

Conclusions: While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

Keywords: cardiovascular medications; deprescribing; polypharmacy; variation in care.

Figure 1.

Deprescribing behavior according to specialty A. Percent of respondents that considered deprescribing cardiovascular medications in the prior month B. Reported reasons for considering deprescribing cardiovascular medications (* indicates p-value<0.05)

Figure 2.

Physician-physician communication about deprescribing cardiovascular medications according to specialty A. Percent of respondents that discussed deprescribing cardiovascular medications with another clinician in the prior month B. Reported reasons for discussing deprescribing cardiovascular medications with another clinician (* indicates p-value<0.05)

Figure 3.

Reported barriers to deprescribing cardiovascular medications according to specialty (* indicates p-value<0.05)