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\title{Deprescribing practice in a resource-limited setting: Healthcare
providers' insights}



\author[1]{Henok  Tegegn }%
\author[1]{Begashaw Melaku Gebresillassie}%
\author[2]{Daniel Asfaw  ERKU }%
\author[1]{Asrat  ELIAS }%
\author[3]{Abdella Birhan  YABEYU}%
\author[1]{Asnakew Achaw  AYELE }%
\affil[1]{University of Gondar}%
\affil[2]{The University of Queensland School of Pharmacy}%
\affil[3]{Addis Ababa University College of Health Sciences}%


\vspace{-1em}



  
  \date{June 13, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Aims: Inappropriate polypharmacy poses adverse drug events, mortality,
and high healthcare costs. Deprescribing could minimise inappropriate
polypharmacy and the consequence thereof. This study aims to evaluate
healthcare providers' (HCPs) attitudes toward, and experiences with the
deprescribing practice. Methods: An institution-based cross-sectional
study was conducted among HCPs at the University of Gondar Referral
Hospital, Ethiopia. Perception of HCPs on deprescribing was measured by
Linsky et al. validated tool. This tool has five dimensions that could
affect HCPs' decision to discontinue medications intentionally. One-way
ANOVA was used to test the association between socio-demographic
variables and their perception of deprescribing decisions. Results: Of
85 HCPs approached, about 82 HCPs with a 96.5\% response rate were
included in the final analysis of this study. Most HCPs (87\%) were less
likely or not at all to be affected by a strong relationship between
HCPs and their patients to make a deprescribing decision. However, HCPs
believed that formal education, significant physical health conditions,
objective response to the clinical endpoint of the medication (e.g.,
blood pressure), and on-the-job experience profoundly influenced them to
decide on deprescribing. According to the post-hoc analysis of one-way
ANOVA, clinical pharmacists seemed to have a better attitude toward
deprescribing decisions compared to physicians. (p = 0.025). Conclusion:
HCPs' decision to discontinue a medication could be multifactorial, and
HCPs could be influenced by education level and their experience to
discontinue a medication intentionally. A therapy-specific deprescribing
algorithm, multidisciplinary collaboration, and continuous education
development should be instituted to guide HCPs in the deprescribing
decision process.%
\end{abstract}%



\sloppy


\textbf{Title:} Deprescribing practice in a resource-limited setting:
Healthcare providers' insights

\textbf{Running title:} Deprescribing in resource-limited settings

\textbf{Abstract}

Aims:~Inappropriate polypharmacy poses adverse drug events, mortality,
and high healthcare costs. Deprescribing could minimise inappropriate
polypharmacy and the consequence thereof. This study aims to evaluate
healthcare providers' (HCPs) attitudes toward, and experiences with
deprescribing practice.~

{\label{aimsinappropriate-polypharmacy-poses-adverse-drug-events-mortality-and-high-healthcare-costs.-deprescribing-could-minimise-inappropriate-polypharmacy-and-the-consequence-thereof.-this-study-aims-to-evaluate-healthcare-providers-hcps-attitudes-toward-and-experiences-with-deprescribing-practice.}}

Methods:~An institution-based cross-sectional study was conducted among
HCPs at the University of Gondar Referral Hospital, Ethiopia. Perception
of HCPs on deprescribing was measured by Linsky et al. validated tool.
This tool has five dimensions that could affect HCPs' decision to
discontinue medications intentionally. One-way ANOVA was used to test
the association between socio-demographic variables and their perception
of deprescribing decisions.~

{\label{methodsan-institution-based-cross-sectional-study-was-conducted-among-hcps-at-the-university-of-gondar-referral-hospital-ethiopia.-perception-of-hcps-on-deprescribing-was-measured-by-linsky-et-al.-validated-tool.-this-tool-has-five-dimensions-that-could-affect-hcps-decision-to-discontinue-medications-intentionally.-one-way-anova-was-used-to-test-the-association-between-socio-demographic-variables-and-their-perception-of-deprescribing-decisions.}}

\textbf{Results:~} Of 85 HCPs approached, about 82 HCPs with a 96.5\%
response rate were included in the final analysis of this study. Most
HCPs (87\%) were less likely or not at all to be affected by a strong
relationship between HCPs and their patients to make a deprescribing
decision. However, HCPs believed that formal education, significant
physical health conditions, objective response to clinical endpoint of
the medication (e.g., blood pressure), and on-the-job experience
profoundly influenced them to decide on deprescribing. According to the
post-hoc analysis of one-way ANOVA, clinical pharmacists seemed to have
a better attitude toward deprescribing decisions compared to physicians.
(\emph{p} ~= 0.025).

\textbf{Conclusion} : HCPs' decision to discontinue a medication could
be multifactorial, and HCPs could be influenced by education level and
their experience to discontinue a medication intentionally. A
therapy-specific deprescribing algorithm, multidisciplinary
collaboration, and continuous education development should be instituted
to guide HCPs in the deprescribing decision process.

\textbf{Keywords:} Deprescribing, polypharmacy, medication
discontinuation, prescriber, Ethiopia.

What's known

\begin{itemize}
\tightlist
\item
  Deprescribing is a clinical practice to optimise medication use
  through reducing inappropriate medication and medication burden,
  thereby improving clinical outcome.
\item
  Taking decisions to deprescribe is a complex process for healthcare
  providers (HCPs). However, factors influencing the deprescribing
  decision for HCPs are not well understood in a resource-limited
  setting.
\end{itemize}

What's new

\begin{itemize}
\tightlist
\item
  HCPs' decision to deprescribe were influenced by their education level
  and experience.
\item
  Clinical pharmacists seemed to have a better attitude toward
  deprescribing decisions compared to physicians.
\end{itemize}

\textbf{Introduction}

The use of five or more medications can be considered as polypharmacy.
Polypharmacy is mostly associated with adverse drug events (ADEs),
leading to heightened morbidity, mortality, and healthcare cost (1-3).
ADEs due to polypharmacy are prevailing and occur in approximately 25\%
of outpatients (3).

Medication discontinuation or deprescribing is one of the interventions
to reduce inappropriate polypharmacy and its associated ADEs. It is a
process of detecting and stopping medications when the actual or
potential harms exceed the actual or potential benefits taking into
consideration a variety of factors including the individual patient's
therapeutic care plans, level of functioning and needs (4, 5).
Discontinuation of inappropriate polypharmacy has several benefits to
the patient, such as reducing costs associated with medicines and their
ADEs, improving adherence, and overall quality of life (6). This is
especially true in developing countries including Ethiopia, where the
primary source of drug expenditure is patients' out of pocket money, and
a significant percentage of the population purchase medicines from
private drug retail outlets (7).

In addition to the economic implication associated with the prescription
of multiple medications, polypharmacy is becoming common, resulting in
ADEs in Ethiopia (8). This problem is more pronounced in older Ethiopian
patients leading to poor quality of life due to polypharmacy (9).
Fortunately, Ethiopian older patients seem to be willing and cooperative
to discontinue one or more of their medications as long as their doctors
said it was possible. This could potentially facilitate decision making
for healthcare providers (HCPs) during the deprescribing process (10).

Unlike medication adherence and medication reconciliation, the concept
of deprescribing receive little attention in literature worldwide (11).
Though HCPs are keen on deprescribing in developed countries (12),
factors like clinical uncertainty and multidisciplinary shared
responsibility, could severely hamper their ability to proactivity
deprescribe (13). However, data on the perception of physicians,
clinical pharmacists, and nursing practitioners regarding proactive
medication discontinuation and lessening of inappropriate polypharmacy
are lacking in the developing and resource-limited countries, including
Ethiopia. Hence, we undertook the present institutional-based survey to
document the experiences, attitudes, and beliefs of HCPs toward
intentional medication discontinuation.

\textbf{Methods}

\textbf{Study design and setting}

An institution-based prospective observational study was conducted at
the University of Gondar Referral Hospital, Ethiopia. It is the only
referral hospital located in Gondar city and serves as both a teaching
and referral centre for the majority of the population in the Amhara
region. The study was conducted from 1 October to 30 November 2018.

Healthcare providers, including physicians, nurses, and clinical
pharmacists, were recruited in this study. Simple random sampling
technique was employed to recruit eligible participants. Participants
who refused to participate or with incomplete response were not included
in the study. Of 85 HCPs, 82 had a complete response and considered in
the final analysis.

\textbf{Study instrument}

The primary outcome of the study is the experiences, attitudes, and
beliefs of HCPs towards intentional medication discontinuation, to be
measured using a validated tool, ``Prescribers' perceptions of
medication discontinuation: survey instrument development and
validation'' (14). The questionnaire has five significant groups related
to constructs of clinical deprescribing decisions of HCPs, namely
`medication characteristics' (seven items), `current patient clinical
factors' (five items), `Predictions of future health states' (three
items), `Patients' resources to manage their own health' (four items)
and `Education and experience (four items).

\textbf{Data collection}

Before the actual data collection, data collectors were trained on how
to collect the necessary data. A single-day training was given to the
research staff on the research protocol. A pre-test was done, and three
of the investigators carried out the data collection.

The study was approved by the ethics review committee of the school of
pharmacy, University of Gondar. Informed consent was sought from the
study participants prior to data collection and confidentiality and
anonymity of subjects were maintained by not recording identifying
details, such as name or any other personal identifiers.

\textbf{Statistical analysis}

The data were exported to Statistical Package for Social Science (SPSS)
window version 25 for analysis. Descriptive statistics were employed to
summarise the participant characteristics and outcome measures in
percentages and numbers. One-way ANOVA was applied to determine the
significant mean difference between socio-demographic characteristics of
the HCPs based on their level of perceptions to medication
discontinuation.

\textbf{Result}

\subsection*{Socio-demographic characteristics of the
participants}

{\label{socio-demographic-characteristics-of-the-participants}}

A total of 85 HCPs were interviewed, 82 were included in the analysis,
and three participants were excluded due to incompleteness with 96.5\%
response rate. The mean age of the study participants was 25 years \selectlanguage{ngerman}±
3.01 years. Nearly two-thirds (57.3\%) of the participants were males
and Amhara in ethnicity (54.9\%). The average work experience of the
study participants was 2.23 years ± 2.62 years (Table 1).

\subsection*{Participants' perception toward medication
discontinuation}

{\label{participants-perception-toward-medication-discontinuation}}

The overall perception was described by parameters for the perception of
medication discontinuation. Participants were considered to be
influenced if they score a mean value higher than 1.5 points. Most of
the participants (n=73, 89\%) have scored less than 1.5 points and are
less influenced by the overall five domains. The overall mean level of
influence among participants was 1.18 point.

Among the parameters, patient-HCP relationship strength under the domain
of `patients' resource scale' was found to be the lowest influencing
level (0.66 points). Almost half of the participants were highly
influenced to deprescribe with the occurrence of significant physical
health condition (1.55) and objective response to the clinical endpoint
of the medication (e.g., blood pressure approaches treatment target)
(1.43).

In the domain of ``predictions of future health states'', very few HCPs
(n=1518.3\%) perceive their medication discontinuation decision is more
likely to be influenced when it is patient's concern that symptoms will
return if the medication is stopped. Majority of the participants (n=55,
67\%) deem formal education is more important to their current level of
comfort with making deprescribing decisions. In contrast, almost half of
the participants (n=42, 51.2\%) mentioned on-the-job experience as a
more important factor (Table 2).

\subsection*{The difference in perception level among participants
towards medication
discontinuation}

{\label{the-difference-in-perception-level-among-participants-towards-medication-discontinuation}}

The difference in the mean perception levels of participants was
determined based on socio-demographic characteristics. Based on One-way
ANOVA test performed on socio-demographic characteristics, significant
difference concerning perception to medication discontinuation were
found with different age groups (\emph{p} = 0.024) and the participants'
educational qualification (\emph{p} = 0.029) as shown Table 3. Post-hoc
analysis indicated that participants with a qualification of clinical
pharmacy (mean=0.313) had good perception level towards medication
discontinuation compared to participants with physician qualification
(mean=0.262), (\emph{p} = 0.025).

\textbf{Discussion}

To the best of our knowledge, there appear no studies done to
investigate HCPs' insight on deprescribing in Africa, and this study
assessed HCPs' perceptions and experiences with medication
discontinuation decisions in Ethiopia. Polypharmacy increases the chance
of interactions and inappropriate medications (5, 6, 8) leading to
adverse drug reactions and hospital admission (15, 16). As a result,
polypharmacy makes prescribing medication be more difficult and
complicated (1). Till date, all other studies (17-24) employed
qualitative methods to explore HCPs' perceived barriers to deprescribing
practice. To our knowledge, this is the first quantitative study to
evaluate factors influencing HCPs' deprescribing decisions in
resource-limited settings like Ethiopia.

Overall, consideration of medication discontinuation is less influenced
by the overall five domains in most of the participants for 73 (89\%)
having a mean influence level of less than 1.5. This may be due to the
fact that participants' deprescribing practice may be suffering from
other challenges unaddressed in this quantitative study. In other
studies (18, 25), barriers affecting deprescribing practice have been
broadly classified into intrinsic factors to the HCPs (beliefs,
attitudes, knowledge, skills, and behaviour) and extrinsic factors to
the HCPs such as patient, work setting, health care system and culture
(18, 25).

In the current study, the occurrence of significant physical health
conditions profoundly influenced HCPs to discontinue patients'
medication. They also feel confident to make a deprescribing decision
with the patient's clinical endpoints such as blood pressure. However,
HCPs' level of comfort to decide medication discontinuation is least
influenced by the strong relationship they have with their patients. A
systematic review by Anderson K. et al. identified intrinsic problems,
prescribing inertia (failure to deprescribe inappropriate medication
despite the awareness of its presence), and low self-efficacy. The busy
workflow and feasibility aspects were also acknowledged as external
barriers in routine clinical practice (25).

Similarly, a qualitative study done in Australia and Sweden demonstrated
that environmental factors, skills and abilities, and intentions could
influence HCPs' behaviour to deprescribe. The study explained that
intentions to deprescribe could also be affected by the HCP's attitude,
norms, and self-efficacy (18). Patients centred decision-making process
should be a part of deprescription practice. Involving patients in
deprescription necessitates their readiness to discontinue their
medications. A study done in Ethiopia showed that older patients were
willing to discontinue their medication as long as their doctor believed
it was possible (10). This could enable HCPs to cooperate with their
patients in deprescription decisions effectively.

Formal education and on-the-job experience were frequently reported to
be more important for HCPs to consider medication discontinuation in our
study. In Bolmsjö BB et al. study has also explored that skills and
knowledge are mostly lacking (18), and suggested a need for more
education for evidence-based deprescribing (26).

The current study showed that clinical pharmacists had good perception
level towards medication discontinuation as compared to physicians.
Physicians may not be well acquainted with the deprescribing process and
its benefit due partly to the lack of adequate evidence \selectlanguage{english}to change the
usual clinical practise (18). Physicians' decisions for deprescribing
could be supported by other HCPs recommendations like pharmacists (27).
Thus, inter-professional communication could improve decision making and
facilitate successful deprescribing practise since different HCPs may
have different barriers and priorities for deprescribing interventions
(24, 28).

A study by Forsetlund et al. have shown that interventions, including
education and pharmacist-led medication review could lessen harmful
medications under certain circumstances (29). A recent study conducted
in Canada suggested that pharmacist-led deprescribing focused medication
review minimised unnecessary and potentially harmful medications (30).
There have been several tools to support HCPs to assuredly deprescribe
harmful or unwanted medications (31). However, it is unknown as to which
tools are more important to effectively deprescribing and improving
patient outcomes particular to the Ethiopian context. As an initial
step, developing therapy-specific algorithm could assist HCPs with
deprescribing decisions.

\textbf{Future implications for clinicians and policymakers in Ethiopia}

There is a paucity of studies related to deprescribing prescribing in
Ethiopia. In a limited-resource setting, inappropriate polypharmacy
poses poor clinical outcomes, including ADEs and a high economic burden
on the patients and the country at large. Polypharmacy is prevailing in
Ethiopian patients, particularly in the older population and patients
with cardiovascular disease (9, 32). This could be due partly because,
as to the recent studies done in Ethiopia, inappropriate prescribing of
medications has been pervasive in chronic patients such as patients with
antithrombotic therapy and patients with cardiovascular disease (33, 34)
.

Patients with inappropriate polypharmacy could also contribute to
suboptimal medication adherence as patients get trouble with remembering
to take multiple medications. The problem worsens when HCPs fail to make
the deprescribing decision for inappropriate medications, particularly
for older patients. Moreover, in a limited resource setting like
Ethiopia, medication unavailability, and out-of-pocket expenditure are
significant challenges in healthcare (35). The country cannot afford the
underutilisation of medications due to non-adherence, and wastage of
medications due to the inappropriate commission of medications.
Deprescription could optimise medication use and reduce inappropriate
polypharmacy, thereby improving medication adherence and utilising the
available medications cost-effectively in resource-limited settings.
Stakeholders such as the Ethiopian Ministry of Health and professional
associations should consider deprescription practice to integrate it
into the clinical practice. They could also take the lead and organise
to develop therapy-specific guidelines for deprescribing algorithm and
providing continuous professional development to HCPs.

\section*{Limitation}

{\label{limitation}}

The findings of this study have some limitations. Only 82 participants
were enrolled, and a small proportion of pharmacists and nurses
participated in the study. The study was also conducted in a single
centre in the University of Gondar Referral Hospital, Ethiopia.
Consequently, this study could suffer from generalizability.

{\label{the-findings-of-this-study-have-some-limitations.-only-82-participants-were-enrolled-and-a-small-proportion-of-pharmacists-and-nurses-participated-in-the-study.-the-study-was-also-conducted-in-a-single-centre-in-the-university-of-gondar-referral-hospital-ethiopia.-consequently-this-study-could-suffer-from-generalizability.}}

\section*{Conclusion}

{\label{conclusion}}

This study could inform clinicians and stakeholder on the impediments
and enablers for deprescribing decisions among HCPs. The deprescribing
practice seems to depend on the type of HCPs, and with their education
level and experience. Treatment specific deprescribing guidelines and
algorithms, multidisciplinary collaboration and continuous education
development should be sought to guide HCPs for evidence-based
deprescribing decision process. Pharmacists-led medication review could
lessen potentially inappropriate medication. Future studies should focus
on impediments and enablers to deprescribing specific to the context in
Ethiopia. Further interventions studies are needed with
multidisciplinary approach.

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\selectlanguage{english}
\FloatBarrier
\end{document}

