4 June 2018

GPs need to see clear reasoning behind deprescribing

Clinical Evidence Based General practice

Unclear hospital discharge summaries may be hampering efforts to tackle unnecessary polypharmacy, with GPs calling for better communication of the rationale behind drug changes.

Deprescribing has come under the spotlight recently, as the population ages and the burden of polypharmacy on both the individual and the healthcare system becomes apparent. 

While hospital admission offers a good opportunity to take patients off unnecessary medication, continuity of care rests on these changes being communicated to the patient’s GP, the audience at Choosing Wisely’s national meeting last week heard.   

Instead, GPs are often left wondering whether there was a reason for discontinuing the medication, or whether it was simply forgotten in the write up. 

To find out how to improve deprescribing efforts, Mai Duong, a research pharmacist and project manager at Sydney’s Royal North Shore Hospital, and her team undertook interviews with 12 GPs recruited through the PHN. 

“What GPs said was that they actually welcomed communication by telephone [with an attending hospital physician], which was efficient for them, especially for complex patients such as the elderly, who are on multiple medications, have multiple comorbidities and are frail, or who have rebound or recurrent issues,” Ms Duong said. 

For these patients, GPs felt that this was an efficient way to explain a complicated history, Ms Duong said. 

While missing information was an obvious concern, GPs also called for simple and concise information in the discharge summaries.

To understand what this would look like, the team asked GPs to write down their ideal phrasing for a patient who has had medication discontinued. 

“Our GPs were unanimous in how they wanted to have changes recorded in the discharge summary: simple, clear and short,” Ms Duong said.

A format for hospital staff emerged, which was to include: medicine name, action taken, duration, rationale and what was expected of GPs in the follow up. One example of this might be: “Oxazepam 15mg daily was reduced to 15mg/10mg on alternating days for two weeks due to adverse effects. Please review, aiming to stop.”

The GPs didn’t need long-winded discussions, simply a rationale and they could put the rest together themselves. 

Ms Duong said it was also important for hospital staff and GPs to make the reasons for deprescribing clear to the patient. 

The decision to take a patient off a drug in a hospital didn’t mean the initiation was incorrect, and it could also be safer to withdraw some medications in hospital where there is 24-hour monitoring rather than in the community. 

For patients, one of the major barriers to effective deprescribing was when patients had fragmentation of care, seeing multiple different doctors and receiving conflicting advice, Ms Duong said. 

The deprescribing template developed in this research will be one of several tools the team implement in a pilot trial in two teaching hospitals later this year to reduce unnecessary polypharmacy.