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

Karolina Kuberska, Fiona Scheibl, Carol Sinnott, James P Sheppard, Mark Lown, Marney Williams, Rupert A Payne, Jonathan Mant, Richard J McManus, Jenni Burt*

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

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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 practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

Original languageEnglish
Pages (from-to)e498-e507
Number of pages11
JournalThe British journal of general practice : the journal of the Royal College of General Practitioners
Volume71
Issue number708
Early online date24 Jun 2021
DOIs
Publication statusPublished - Jul 2021

Bibliographical note

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.

Keywords

  • general practice
  • polypharmacy
  • hypertension
  • deprescriptions
  • aged, 80 and over
  • qualitative research

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