Re: Too much medicine in older people? Deprescribing through shared decision making
We thank Jansen and colleagues for this paper on shared decision making related to deprescribing. Discussions surrounding deprescribing can be difficult to have. We agree there is a clear need for patient-friendly deprescribing resources that facilitate discussions surrounding continuation of a medication versus trying deprescribing, and foster shared, informed decisions that are consistent with patient values.
Our research group believes that patient decision aids (PtDAs) can address this gap. PtDAs are structured tools that outline different treatment options (i.e. the decision to continue or have a medication deprescribed), quantify the benefits and harms of outcomes, and allow patients to rate how important outcomes are to them [1,2]. They can be delivered on their own or in consultation with a clinician (called a consult PtDA). PtDAs increase knowledge surrounding a decision, help patients have realistic expectations of different options and reduce decisional conflict [3].
In recognizing the potential of PtDAs to facilitate these discussions, our group has developed a consult PtDA surrounding the decision to continue a proton pump inhibitor (PPI) at the same dose or try deprescribing [4]. Our tool outlines the benefits and harms of options and allows patients to clarify values. Content is based on an evidence-based PPI deprescribing guideline and support tool[5] developed by our research team [Farrell B, Pottie K, Thompson W, et al. Deprescribing proton-pump inhibitors: an evidence based clinical practice guideline. Unpublished manuscript (submitted to PLOS ONE March 2016)]. The consult PtDA describes the rationale for considering the decision to continue a PPI at the same dose or have it deprescribed, and also what to do if symptoms come back – both of these areas have been described as barriers to deprescribing [6,7]. Our PtDA was developed by physicians, pharmacists and patients and is currently being piloted in Ottawa, Canada.
Our consult PtDA operationalizes the framework Jansen and colleagues outline, and provides a practical tool to facilitate discussions surrounding continuation versus deprescribing of medications. We aim to demonstrate that consult PtDAs can support clinicians in having these discussions and hope other PtDAs can be developed for different medication classes to help engage and foster shared, informed decision making.
Wade Thompson BScPhm and Barbara Farrell BScPhm PharmD
Bruyère Research Institute, Ottawa, Ontario, Canada
REFERENCES
1. Ottawa Hospital Research Institute. Patient Decision Aids [Internet]. 2015 [cited 2016 Jun 6]. Available: https://decisionaid.ohri.ca/
2. Coulter A, Stilwell D, Kryworuchko J, Mullen PD, Ng CJ, van der Weijden T. A systematic development process for patient decision aids. BMC Med Inform Decis Mak 2013;13 Suppl 2:S2.
3. Stacey D, Légaré F, Col NF, Bennet CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions ( Review ). Cochrane Database Sys Rev 2014;(1):CD001431.
4. ClinicalTrials.gov. Should I Continue Taking My Acid Reflux Medication? Development and Pilot Testing of a Patient Decision Aid. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2015 [cited 2016 Jun 6]. Available: https://clinicaltrials.gov/ct2/show/NCT02558049
5. Farrell B, Pottie K, Thompson W, Boghossain T, Pizzola L, Rashid J, et al. Proton pump inhibitor deprescribing algorithm [Internet]. 2015 [cited 2016 Jun 6]. Available: http://www.open-pharmacy-research.ca/wordpress/wp-content/uploads/ppi-de...
6. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30(10):793–807.
7. Smeets HM, De Wit NJ, Delnoij DMJ, Hoes AW. Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care. Eur J Gen Pract 2009;15: 219–225.
Competing interests:
Dr. Farrell declares that she has received research funding from the Government of Ontario for the purposes of developing deprescribing guidelines; received financial payments from Institute for Healthcare Improvement and Commonwealth Fund for deprescribing guidelines summary and from Ontario Pharmacists Association and Canadian Society of Hospital Pharmacists for speaking engagements.
Rapid Response:
Re: Too much medicine in older people? Deprescribing through shared decision making
We thank Jansen and colleagues for this paper on shared decision making related to deprescribing. Discussions surrounding deprescribing can be difficult to have. We agree there is a clear need for patient-friendly deprescribing resources that facilitate discussions surrounding continuation of a medication versus trying deprescribing, and foster shared, informed decisions that are consistent with patient values.
Our research group believes that patient decision aids (PtDAs) can address this gap. PtDAs are structured tools that outline different treatment options (i.e. the decision to continue or have a medication deprescribed), quantify the benefits and harms of outcomes, and allow patients to rate how important outcomes are to them [1,2]. They can be delivered on their own or in consultation with a clinician (called a consult PtDA). PtDAs increase knowledge surrounding a decision, help patients have realistic expectations of different options and reduce decisional conflict [3].
In recognizing the potential of PtDAs to facilitate these discussions, our group has developed a consult PtDA surrounding the decision to continue a proton pump inhibitor (PPI) at the same dose or try deprescribing [4]. Our tool outlines the benefits and harms of options and allows patients to clarify values. Content is based on an evidence-based PPI deprescribing guideline and support tool[5] developed by our research team [Farrell B, Pottie K, Thompson W, et al. Deprescribing proton-pump inhibitors: an evidence based clinical practice guideline. Unpublished manuscript (submitted to PLOS ONE March 2016)]. The consult PtDA describes the rationale for considering the decision to continue a PPI at the same dose or have it deprescribed, and also what to do if symptoms come back – both of these areas have been described as barriers to deprescribing [6,7]. Our PtDA was developed by physicians, pharmacists and patients and is currently being piloted in Ottawa, Canada.
Our consult PtDA operationalizes the framework Jansen and colleagues outline, and provides a practical tool to facilitate discussions surrounding continuation versus deprescribing of medications. We aim to demonstrate that consult PtDAs can support clinicians in having these discussions and hope other PtDAs can be developed for different medication classes to help engage and foster shared, informed decision making.
For more about our deprescribing guidelines research: http://www.open-pharmacy-research.ca/research-projects/emerging-services...
Wade Thompson BScPhm and Barbara Farrell BScPhm PharmD
Bruyère Research Institute, Ottawa, Ontario, Canada
REFERENCES
1. Ottawa Hospital Research Institute. Patient Decision Aids [Internet]. 2015 [cited 2016 Jun 6]. Available: https://decisionaid.ohri.ca/
2. Coulter A, Stilwell D, Kryworuchko J, Mullen PD, Ng CJ, van der Weijden T. A systematic development process for patient decision aids. BMC Med Inform Decis Mak 2013;13 Suppl 2:S2.
3. Stacey D, Légaré F, Col NF, Bennet CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions ( Review ). Cochrane Database Sys Rev 2014;(1):CD001431.
4. ClinicalTrials.gov. Should I Continue Taking My Acid Reflux Medication? Development and Pilot Testing of a Patient Decision Aid. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2015 [cited 2016 Jun 6]. Available: https://clinicaltrials.gov/ct2/show/NCT02558049
5. Farrell B, Pottie K, Thompson W, Boghossain T, Pizzola L, Rashid J, et al. Proton pump inhibitor deprescribing algorithm [Internet]. 2015 [cited 2016 Jun 6]. Available: http://www.open-pharmacy-research.ca/wordpress/wp-content/uploads/ppi-de...
6. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30(10):793–807.
7. Smeets HM, De Wit NJ, Delnoij DMJ, Hoes AW. Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care. Eur J Gen Pract 2009;15: 219–225.
Competing interests: Dr. Farrell declares that she has received research funding from the Government of Ontario for the purposes of developing deprescribing guidelines; received financial payments from Institute for Healthcare Improvement and Commonwealth Fund for deprescribing guidelines summary and from Ontario Pharmacists Association and Canadian Society of Hospital Pharmacists for speaking engagements.