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GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice
GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background: optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines - tacit, internalised guidelines developed over time from multiple sources - may be of particular importance in such situations. 

Aim: to explore GPs' decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines. 

Design and setting: qualitative interview study set in English general practice. 

Method: thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension. 

Results: GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. 

Conclusion: in the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop 'mindlines' over time through practice-based experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

Aged 80, Deprescriptions, General practice, Hypertension, Over, Polypharmacy, Qualitative research
0960-1643
E498-E507
Kuberska, Karolina
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Scheibl, Fiona
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Sinnott, Carol
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Sheppard, James P.
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Lown, Mark
4742d5f8-bcf3-4e0b-811c-920e7d010c9b
Williams, Marney
aed0fd5f-500d-48d9-844f-814b08c037fd
Payne, Rupert A.
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Mant, Jonathan
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McManus, Richard J.
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Burt, Jenni
af1903e7-2bb8-464d-8e82-ec1076fdbb2e
Kuberska, Karolina
1a41639f-747d-4852-99a2-2566fcd93712
Scheibl, Fiona
abdc6e63-ee1d-4802-8e7c-626e43c19822
Sinnott, Carol
2bfb29a6-d890-4deb-a7cc-8730ff9676e3
Sheppard, James P.
5468331c-e231-4103-b407-28c8161cc6d7
Lown, Mark
4742d5f8-bcf3-4e0b-811c-920e7d010c9b
Williams, Marney
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Payne, Rupert A.
510c53d5-e691-41ed-8c2e-5cc77e40a75a
Mant, Jonathan
0d1a0061-0f04-45c7-b20a-15798b1f465c
McManus, Richard J.
481f6284-d599-4c77-8869-d1c6b63b9b02
Burt, Jenni
af1903e7-2bb8-464d-8e82-ec1076fdbb2e

Kuberska, Karolina, Scheibl, Fiona, Sinnott, Carol, Sheppard, James P., Lown, Mark, Williams, Marney, Payne, Rupert A., Mant, Jonathan, McManus, Richard J. and Burt, Jenni (2021) GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice. British Journal of General Practice, 71 (708), E498-E507. (doi:10.3399/bjgp21X714305).

Record type: Article

Abstract

Background: optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines - tacit, internalised guidelines developed over time from multiple sources - may be of particular importance in such situations. 

Aim: to explore GPs' decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines. 

Design and setting: qualitative interview study set in English general practice. 

Method: thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension. 

Results: GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. 

Conclusion: in the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop 'mindlines' over time through practice-based experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

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e-pub ahead of print date: 24 June 2021
Additional Information: Funding Information: This work received joint funding from the National Institute for Health Research (NIHR) Oxford Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust (reference: P2-501) and the NIHR School for Primary Care Research (SPCR; reference: 335) as a substudy of the OPtimising Treatment for MIld Systolic hypertension in the Elderly (OPTiMISE) antihypertensive medication reduction trial. Carol Sinnott has been funded by an NIHR Clinical Lectureship. James P Sheppard and Richard J McManus have been funded by an NIHR Professorship (reference: NIHR-RP-R2-12-015). James P Sheppard now receives funding from the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship (reference: 211182/Z/18/Z). Jonathan Mant and Richard J McManus are NIHR senior investigators. Karolina Kuberska, Carol Sinnott, and Jenni Burt are supported by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies (THIS) Institute. THIS Institute is supported by the Health Foundation — an independent charity committed to bringing about better health and health care for people in the UK. Funding Information: The authors thank the GPs who participated in this study, and staff from NIHR Eastern Clinical Research Network for their support. Publisher Copyright: © 2021 Royal College of General Practitioners. All rights reserved. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.
Keywords: Aged 80, Deprescriptions, General practice, Hypertension, Over, Polypharmacy, Qualitative research

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Local EPrints ID: 453459
URI: http://eprints.soton.ac.uk/id/eprint/453459
ISSN: 0960-1643
PURE UUID: 9f3399fd-41d6-4398-b9b8-3bdd5299522d
ORCID for Mark Lown: ORCID iD orcid.org/0000-0001-8309-568X

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Date deposited: 18 Jan 2022 17:33
Last modified: 28 Apr 2022 02:12

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Contributors

Author: Karolina Kuberska
Author: Fiona Scheibl
Author: Carol Sinnott
Author: James P. Sheppard
Author: Mark Lown ORCID iD
Author: Marney Williams
Author: Rupert A. Payne
Author: Jonathan Mant
Author: Richard J. McManus
Author: Jenni Burt

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