Exploring macrocognitive functions in the deprescribing of anti-hypertensive medication: an interview study with GPs and older patients

Problem

Polypharmacy is an increasing challenge for primary care, with mounting concern about overtreatment and patient outcomes. Recent evidence suggests that multiple antihypertensive prescriptions may be harmful in older people. However, decisions about rationalising medication are challenging for both patients and GPs. For GPs, cultural imperatives are in favour of prescribing, and there is a lack of guidance on why, how, and when to deprescribe. For patients, long-term medication regimens are embedded within their daily lives, and changes may be avoided unless vital. As such, the safest course for both GPs and patients is often medication continuation, even if a regimen may be sub-optimal. The aim of this study was to explore the challenges facing GPs and older patients in considering the deprescribing of antihypertensives, drawing on macrocognitive approaches.

Approach

We conducted face-to-face interviews with GPs and patients from seven diverse practices in the East of England. GPs were purposively sampled to ensure variation in gender and years of practice. Patients were invited to participate if they were aged >80, and on two or more antihypertensive medications. With GPs, we used chart-stimulated recall techniques to explore their approach to treatment for older multimorbid hypertensive patients. With patients, we used diagrammatic elicitation techniques to encourage discussion on the implications of withdrawing antihypertensive medications. We initially used an inductive thematic analysis approach; we subsequently undertook deductive coding for macrocognitive functions (including naturalistic decision-making, sense-making, planning and adaptation). Macrocognitive approaches are concerned with exploring mental activities as they happen “in the wild” – the complex, often messy, way in which we perform tasks, including medication management.

Findings

We undertook interviews with 15 GPs and 16 patients. GPs used tacit knowledge and prior experience to rapidly make decisions about the appropriateness of considering anti-hypertensive discontinuation in patients. GPs were typically reluctant to deprescribe in the absence of guidance, wishing to be ‘better safe than sorry’. However, more experienced GPs were able to draw on a deeper repertoire of previous encounters and outcomes to facilitate a more individualized approach to treatment decisions, and a greater willingness to discontinue medication. For many patients, antihypertensives were interwoven with their daily routines, with diverse strategies and artefacts supporting their taking of these medicines. Stopping anti-hypertensive medication presented a challenge to the narratives behind why such medications were embedded in their lives. As such, readiness to change varied widely according to patients’ mental models and projected futures.

Consequences

Medication management and deprescribing decisions are achieved within a complex framework of cognitive functions that are built over many years of experience, for both patients and GPs. Our findings support recent calls for the need to broaden definitions of ‘knowledge’ and evidence which underpin clinical-decision making