| Sažetak | Deprescribing is the planned and supervised process of dose reduction or tapering, and stopping of medication,
which might be causing harm, or is no longer of benefit to the patient, with the goal of managing polypharmacy
and improving outcomes. This research aimed to explore the need for, and the barriers and facilitators of
deprescribing in primary care in a healthcare system where it has not been researched, implemented, or provided.
Four phases of research were carried out. The systematic review performed in the first phase of this research shows
community-based pharmacists can successfully lead deprescribing interventions and are valuable partners in
deprescribing. Second phase of research unveils the finding that the majority of adults 40 years and older (84%)
would be willing to deprescribe one or more medications, with older adults (65 years and older) being more willing
to have medications deprescribed than younger adults (χ2 (1) = 4.06; p = 0.044). Furthermore, majority of
participating adults (71%) would feel comfortable with pharmacist’s involvement in deprescribing, and 69%
believes pharmacists have competencies to suggest deprescribing to physicians. Positive opinion on pharmacists'
involvement was assessed as a predictive factor for positive attitude towards deprescribing (aOR = 2.351, 95% CI
= 1.176 – 4.699; p = 0.016). Comprehensive Healthcare providers’ OPinions, Preferences, and attitudEs towards
Deprescribing (CHOPPED) questionnaire was developed in the third phase of research, to aid in exploration of
healthcare providers’ determinants important for implementing and providing deprescribing regardless of their
familiarization with deprescribing. Using the CHOPPED questionnaire, it was found that the majority of healthcare
providers (87%) would suggest deprescribing to a patient if appropriate. For pharmacists, the most important
facilitators were extrinsic factors (collaboration facilitators and healthcare facilitators factors), while for physicians
intrinsic (knowledge and awareness) and patient-related factors were more prominent. Moreover, a case vignette
study elucidated pharmacists can identify potential deprescribing targets and suggest deprescribing rationales
which physicians would accept. Collaborative deprescribing targets should be medicines both healthcare providers
share most agreement on, such as nonsteroidal anti-inflammatories (NSAID), opioids (OPI) or diuretics. In a crosssectional
stud conducted in community pharmacies across Croatia, which enrolled 388 patients older than 65 years,
55.2% of participants were identified as potential candidates for deprescribing of one or more medications; 31.1%
of proton pump inhibitors (PPI) users, 74.8% of NSAID, 75.0% of OPI, and 96.1% of benzodiazepine (BZN) users
met at least one deprescribing criterion. Several predictive factors were identified for increased need for
deprescribing, including identifying as a woman (aOR = 2.58; 95% CI =1.59 - 4.18; p < 0.001), poor self-reported
health (aOR = 5.14; 95% CI = 1.73-15.25; p < 0.001), and polypharmacy (aOR = 1.29; 95% CI = 1.17 - 1.44; p <
0.001). Formative evaluation, as a result of this doctoral research, can lead to an implementation strategy facilitated
by CHOPPED questionnaire and interventional protocol (Collaborating for Older aduLts to Deprescribe in
primarY care” (COLDY)), proposed in this doctoral thesis, which can help engage healthcare providers in
collaborative patient care with the goal of promoting deprescribing to enhance patient safety and optimise
pharmacotherapy. |
| Sažetak (engleski) | Depreskripcija terapije je planirani proces smanjivanja doze ili potpunog ukidanja lijeka iz farmakoterapije, za
koji je rizik korištenja veći od potencijalne koristi ili za kojim više nema potrebe odnosno dokazane učinkovitosti.
Ovo istraživanje za cilj je imalo istražiti potrebe, prepreke i poticatelje depreskripcije u primarnoj zdravstvenoj
zaštiti u zdravstvenom sustavu u kojem dosada nije istraživana, implementirana ili provođena. Istraživanje je
provedeno u četiri faze. Sustavni pregled proveden u prvoj prvi fazi istraživanja pokazuje da javni ljekarnici mogu
uspješno predvoditi depreskripcijske intervencije te da su vrijedni suučesnici u depreskripciji. Druga faza
istraživanja otkriva da bi većina osoba 40 godina i starijih (84%) pristala na depreskripciju jednog ili više lijekova.
Osobe starije životne dobi (starije od 65 godina života) sklonije su prihvatiti depreskripciju terapije u usporedbi s
mlađim odraslim osobama (χ2 (1) = 4.06; p = 0.044). Nadalje, većina ispitanika (71%) osjećala bi se ugodno ako
bi ljekarnik bio uključen u proces depreskripcije, a 69% njih dodatno smatra da ljekarnik ima dovoljno
kompetencija predložiti depreskripciju. Pozitivno mišljenje o uključenosti ljekarnika u proces depreskripcije
terapije utvrđeno je kao prediktivni čimbenik spremnosti na depreskripciju (aOR = 2,351, 95% CI = 1,176 – 4,699;
p = 0,016). Sveobuhvatni CHOPPED upitnik (engl. Comprehensive Healthcare providers’ OPinions, Preferences,
and attitudEs towards Deprescribing) razvijen u trećoj fazi istraživanja omogućuje ispitivanje čimbenika
depreskripcije među zdravstvenim radnicima koji su važni za implementaciju i provođenje depreskripcije. Većina
zdravstvenih radnika (87%) predložila bi depreskripciju terapije pacijentu. Za ljekarnike najvažniji poticatelji
depreskripcije su ekstrinzični čimbenici (čimbenik poticatelja suradnje i čimbenik poticatelja zdravstvenog
sustava), dok su za liječnike primarne zdravstvene zaštite najvažniji intrinzični čimbenici (znanje, osviještenost)
te čimbenici povezani s pacijentom. Rezultati studije prikaza slučaja pokazuju da ljekarnici imaju potrebne
kompetencije prepoznati potencijalno neprikladne lijekova a liječnici su spremni prihvatiti ljekarnikov
depreskripcijski prijedlog (diuretici, nesteroidni protuupalni lijekovi, opioidni analgetici i benzodiazepini). U
posljednjoj fazi istraživanja, koje je uključila 388 osoba starije životne dobi, otkriveno je da je više od polovice
ispitanika (55,2%) kandidat za depreskripciju jednog ili više lijekova, od toga 31,1% korisnika inhibitora protonske
crpke, 74,8% korisnika nesteroidnih protuupalnih lijekova, 75% korisnika opioidnih analgetika, te 96% korisnika
benzodiazepina. Ženski spol (aOR = 2,58; 95% CI =1,59 – 4,18; p < 0,001), politerapija (aOR = 1,29; 95% CI =
1,17 – 1,44; p < 0,001) i loša samoprocjena zdravlja (aOR = 5,14; 95% CI = 1,73-15,25; p < 0,001) prediktivni su
čimbenici za povećanu potrebu za depreskripcijom terapije. Formativna procjena, kao rezultat četiriju faza ovog
doktorskog istraživanja, omogućuje kreiranje implementacijske strategije potpomognute CHOPPED upitnikom,
kao i intervencijskog protokola za kolaborativni pristup depreskripciji terapije osoba starije životne dobi u
primarnoj zdravstvenoj zaštiti (engl. Collaborating for Older aduLts to Deprescribe in primarY care (COLDY))
koje će omogućiti će provođenje depreskripcijske s ciljem optimizacije farmakoterapije i poboljšanja ishoda. |
