Novelty of this study

Various studies have been conducted on patient attitudes toward deprescribing. However, few have investigated patients’ thoughts and wishes regarding prescribing. This study is the only one to comprehensively investigate prescription content, patient background, and patients’ thoughts on factors influencing attitudes toward deprescribing.

Five factors influencing attitudes toward Deprescribing

The five factors extracted in the logistic regression analysis are discussed below.

Age

A systematic review of attitudes toward deprescribing indicated that many older adults wish to reduce medications if clinicians agree [12]. Previous studies in Japan have reported that patients’ willingness to reduce medication increases with age [13]. In our results, the wish for deprescribing was also correlated with older age. Why does the wish for deprescribing increase with increasing age? With aging, diseases increases and the number of medications increases [17, 18]. Some studies have found that the number of medications affects adherence [19], suggesting that as the number of medications increases, patients experience difficulty in managing medications and become more positive about deprescribing. In our study, there were no significant differences in the number of medications or MRCI scores between elderly and non-elderly patients who requested deprescribing. However, significantly more elderly respondents selected “difficulty in managing medications,” “want to reduce the number and types of medications,” and “concern about side effects”. Even if the number of medications and the complexity of prescriptions are the same, the elderly may be less able to manage their medications than non-elderly patients, and more concerned about side effects due to a perceived decline in physical strength and physiological function, which may increase motivation for deprescribing.

Wish to reduce the number and types of medications

“Wish to reduce the number and types of medications” was a factor influencing attitudes toward deprescribing, while the number of medications was not. A meta-analysis reporting that patients’ and caregivers’ willingness to reduce medication was not affected by the number of medications [12] seems to support our results. Patients’ perception that they were “taking a lot of medications” was correct, but this did not affect the wish for deprescribing, suggesting that patients were aware of taking many medications but deemed deprescribing unnecessary if they felt that all were necessary.

Satisfaction with prescribing

In our study, a positive factor affecting satisfaction was the feeling that medication helped patients feel better while a negative one was experiencing emergency hospitalization within the past year, both influencing patient evaluation of medication efficacy. Medications they did not want changed may have been those felt to readily improve symptoms, such as antihypertensives and analgesics. However, the goodness of fit in multiple regression analysis was low (Table 8). Thus, these 2 factors are insufficient for explaining the satisfaction level. It has been reported that the efficacy, side-effect profile, and regimen of a medication can affect patient satisfaction [20,21,22] and were also factors considered in this study. Factors influencing satisfaction may differ from person to person.

Concern about side effects

We assumed that “Concern about side effects” indicated patient anxiety about continuing to take a medication. However, there was no difference between patients who wanted deprescribing and those who did not regarding the experience of side effects, current symptoms of concern, and evaluation of the health care provider’s explanation and confirmations. For patients who wished deprescribing, there was no difference between those who were concerned about side effects and those who were not (data not shown). Therefore, it is necessary to determine points of concern for each patient and make efforts to alleviate them by skillfully devising the explanation content.

Deprescribing preference by prescription medication type

It seems contradictory at first glance that having a medication that one does not want changed influences one’s attitude toward deprescribing. However, the response “There are medications that I do not want changed” can be seen as indicating a willingness to be actively involved in medication treatment. However, with a good understanding of their medications, patients may want to see them changed to those that are more effective in improving their symptoms. Respondents did not want to have antihypertensive drugs, sleeping pills, or painkillers changed because they likely benefitted from them. Dyslipidemia drugs, which were used for comparison, are often prescribed for the prevention of cardiovascular events, but it is difficult for patients to understand the necessity of taking them. For medications whose evaluation of efficacy is highly subjective, patients may not want them changed for fear of their condition worsening or reduced efficacy. The most common reason given for not wanting a change of “Because I have been taking it for a long time” supports this. Patients may wish to have medications whose efficacy is difficult to perceive reviewed. The results of this survey may reflect these mindsets.

How to achieve patients’ wishes for prescribing

Overall, the above results suggest that patients want to feel well with fewer medications. In other words, patients want prescriptions that use the least number of medications, minimize side effects, and provide a stable therapeutic effect. They also suggest that the five factors influencing attitudes toward deprescribing depend on individual patient perception and background factors. Our findings indicate the necessity of close communication with patients and determining their needs to ensure that prescriptions are tailored to individual patients and achieve a high degree of satisfaction. In addition, we found that approximately 80% of the analysed subjects had a latent wish to reduce the number and types of medications and this was independent of the number of medications prescribed. This suggests that medical providers should proactively make appropriate prescribing suggestions regardless of the number of medications. Pharmacist medication reviews alone or in combination with adherence reviews have been reported to improve patient satisfaction equally [23]. Regular medication reviews and making recommendations for appropriate prescribing based on patient understanding may help address potential patient needs and increase satisfaction with prescribing. In light of these considerations, healthcare providers should keep the following practices in mind: 1. Listen more attentively to the patient’s thoughts through closer communication. 2. Regardless of the number of medications a patient is taking, proactively suggest changes to prescriptions that are commensurate with the patient’s ability to manage their medications, or appropriate medication reductions or prescription changes that improve the quality of medication therapy.

In Japanese clinical practice, patients are commonly selected for deprescribing based on a certain number of medications; e.g., five or more, so that it can be performed efficiently with limited manpower. However, this intervention is from the medical professional’s perspective. Our results showed that the perception of being on multiple medications and attitudes toward deprescribing varied from patient to patient. Including the patient’s perspective, it seems suboptimal to use number of medications as a basis for intervention. Focusing on patients’ medication management skills and thoughts on prescribing would be more in line with their wishes. A disadvantage, however, would be the time taken to gather information. A future issue will be how to efficiently conduct prescribing interventions from the patient’s standpoint. Recently, Kim et al. [24] reported that clinicians were able to elicit individual barriers and enablers to deprescribing from the patient’s perspective using a semi structured interview conversation tool. We hope that the development of such practical tools will increase in the future, in which the five factors obtained in the survey – “Age”, “Wish to reduce the number and types of medications”, “Satisfaction”, “Concerns about side effects,” and “Wish not to have certain medications changed”- are likely to be important factors.

Gap between willingness to reduce medications and to change medications

This study found that although about 80% of patients wanted to reduce the number and types of medications, more than half of them did not actually wish deprescribing. A high percentage of patients were reported to be willing to stop one or more medications if their doctor said it was possible [11, 12, 25], and Turner et al. reported that 86% of study participants indicated a willingness to reduce their medications in a preliminary survey, but only 41% were able to reduce them [26]. Our results suggest that although patients wanted to reduce their medications, they were hesitant to change prescriptions because of concerns about symptoms worsening or changes in their condition, or perhaps they wanted to reduce their medications but had given up the idea feeling that all medications prescribed by their physicians were necessary for treatment. However, since examination of this gap was not a major objective, a detailed analysis was not performed, so further research is needed in the future.

Strengths and weaknesses

In most related studies conducted to date, patients were enrolled through screening according to the use of multiple medications or the necessity of prescribing interventions. Our study also considered age, number of medications, and prescription content, which we believe allowed us to determine prescribing needs for all patients. However, there are several limitations. First, the number of patients included in the analysis was not so large. The results may have been a little less reliable than we had anticipated during the planning phase, since we were not able to collect the target number of patients. However, since the sample size required for a survey with a 10% margin of error and a 95% confidence level is generally less than 100 persons, the results of this study are considered to have a certain degree of acceptability and reliability. Second, the questionnaire was administered to patients whom the pharmacist in charge of the hospital ward determined to be able to request cooperation in view of the patient’s condition, i.e., patients in relatively good condition, making it possible that many patients proactive toward medication treatment were selected. Since patients were informed of the survey’ purpose and then their consent was obtained, giving consent to the survey itself may also have served to screen for patients who were proactive toward drug treatment and interested in deprescribing. In addition, since the questionnaire was administered face-to-face, it is possible that it did not elicit accurate responses to questions requiring an evaluation of healthcare providers. Furthermore, 30 interviewers were involved in this study. In general, the large number of interviewers can lead to variations or flaws in the data. To ensure data consistency and minimize deviations, we conducted an advanced orientation meeting for interviewers. Moreover, we minimized this concern by using a multiple-choice questionnaire during the interviews.