Deprescribing & its associated factors among middle & old-aged ambulatory patients with chronic disease (s): A hospital-based cross-sectional study

Materials & Methods

This cross-sectional study was conducted in the department of Pharmacy, Hospital Canselor Tuanku Muhriz (HCTM), Malaysia after obtaining approval from the Research Ethics Committee, Universiti Kebangsaan Malaysia.

Data collection was conducted from March 2024 to June 2024 utilising systematic random sampling, whereby every third person who entered the outpatient pharmacy in HCTM was approached. If the respondent did not fulfil the inclusion criteria or refused to participate, the next person who entered the outpatient pharmacy and met the study inclusion criteria was selected. Written informed consent was obtained from all participants.

Based on previous research by Ng et al⁸, which explored patients’ attitudes towards medication quantity and factors influencing their acceptance of deprescribing, 73 per cent of participants were willing to deprescribe; the required sample size was calculated using the one-proportion formula. With a five per cent alpha level and a precision rate of six per cent, a sample size of 211 was determined. To compensate for a 20 per cent non-response rate, a total of 254 participants were recruited.

The study included ambulatory adults aged ≥40 yr who received treatment in HCTM, took ≥1 chronic medication(s) with ≥1 chronic disease(s) and could understand Malay or English. Those with cognitive impairment (Mini-Mental State Examination ≤23) or dementia and incomplete questionnaires were excluded.

The Revised Patient Attitudes to Deprescribing (rPATD) questionnaire¹⁸ had 22 items with four domains namely, perceived burden of medication taking, belief in the appropriateness of deprescribing, concerns about stopping the medication, and level of involvement/knowledge of medications. Each item was rated on a 5-point scale, whereby a higher score indicated a greater burden, concern, involvement, and appropriateness of deprescribing. Additionally, one global question assessed satisfaction with current medications, while another served as the dependent variable, assessing willingness to deprescribe with the question: “If my doctor said it was possible, I would be willing to stop one or more of my regular medicines.” Responses of “strongly disagree,” “disagree,” and “unsure” were categorised as “unwilling to deprescribe,” while “agree” and “strongly agree” were categorised as “willing to deprescribe”¹¹.

SRH was assessed using a single question similar to Chan et al^17, asking participants to rate their health on a scale from “very good” (5) to “very bad” (1). Higher scores indicate better SRH. Trust towards physicians investigated by WFPTS-SF adopted from Dugan et al¹⁹, which consisted of five items and ranged from “strongly agree” (5) to “strongly disagree” (1). A higher score reflects higher physician trust.

First, the questionnaire was translated into Malay by two bilingual translators and then back translated by another bilingual panel to English to ensure conceptual equivalence. It was then tested for clarity with 10 adults. The content validation was conducted among six content experts, comprising five clinical pharmacists and one medical doctor, who manage NCD patients in their respective clinics. For content validation, the Item-Level Content Validity Index (I-CVI), Scale-Level Content Validity Index (S-CVI/Ave), and S-CVI/UA all met the minimum threshold of 0.83 across the domains of relevance, importance, and clarity, ranging from 0.83 to 1²⁰. Moreover, the Modified Kappa agreement among content experts was excellent, with K values ranging from 0.81 to 1²⁰. Internal reliability of all factors was acceptable, with Cronbach’s alpha ≥0.7 among 40 patients²¹.

Results

A total of 310 potential participants were approached, and 261 completed the questionnaire, which yielded a response rate of 84.19 per cent. The sociodemographic characteristics of the participants were summarised in table I. Among 261 participants, 59 per cent (n=154) were female, and 62.8 per cent (n=164) were Malay. A total of 47 per cent (n=122) of them were between 40-59 yr old, who were classified in the category of middle-aged. More than half of the participants completed their tertiary study (52.5%). Participants who participated in this study had a mean (±SD) medical conditions of 2.78 (±1.54) with a median of 4 prescribed medications by a physician.

The mean of willingness towards deprescribing was 4.12, with a standard deviation of 1.05, indicating a high willingness towards deprescribing. Among 261 patients, 83.2 per cent were willing to deprescribe their medications if their doctor said it was possible.

The association between patients’ willingness towards deprescribing and participants’ sociodemographic characteristics was presented in table II. Sociodemographic characteristics were not statistically associated with the willingness to stop medication(s).

Analysis of the total score of each domain in rPATD has been presented in table III. There were significant mean differences in the involvement (P=0.015), appropriateness (P=0.007) and concern score (P<0.001) among patients’ willingness towards deprescribing. However, no significant mean difference was observed between the groups (willing and unwilling) on the burden (P=0.621) and satisfaction (P=0.252) domains.

The overall score of SRH was 3.74 (±0.686) among the patients, as presented in table IV. The respondents willing to deprescribe showed higher SRH levels than their counterparts, but not statistically significant (P=0.358).

Besides, the overall score of WFPTS-SF was 21.06 out of 25 (Table IV), which indicated high overall trust towards physicians among patients. Patients who were willing to deprescribe showed a higher score in trust towards the physician compared to their counterparts, which showed significant differences (21.22 vs. 20.36, P=0.023).

Table V shows the results of MLR between the independent variables with the willingness towards deprescribing. The odds of willingness to stop medication(s) were significantly associated with a higher involvement score. The odds of willingness to deprescribe increased by 16 per cent with a one-unit increase in the high involvement score in rPATD (OR=1.16, 95% CI: 1.024-1.322). Similarly, a seventeen percent increase in odds was observed with a one-unit increase in perceived appropriateness in deprescribing (OR=1.17, 95% CI: 1.503-1.308). Moreover, higher trust in physicians was found to have a positive relationship with deprescribing (OR=1.259, 95% CI: 1.043-1.521). The patients’ willingness to deprescribe increased by 26 per cent with a one-unit increase in the WFPTS-SF score. However, those who scored higher in concern about deprescribing were less willing to deprescribe their medication (OR=0.75, 95% CI: 0.67-0.83).

Discussion

As per our knowledge, this is the first study in Malaysia involving the middle-aged individuals in assessing their willingness towards deprescribing. It is noted that the willingness of patients to deprescribe their medication(s) is relatively high (83.2%) among the respondents. The willingness to deprescribe medications among patients in HCTM was comparable to other countries, such as Australia (88%), Ethiopia (85%), Croatia (84%), Netherlands (88%), and Lebanon (89%)^7,11,22-24. The prevalence in this study is higher compared to another study from Malaysia that focused on government primary care health clinics and community pharmacies, which reported a prevalence of 67.5 per cent¹⁰. This discrepancy might be due to the higher health literacy among the participants of the current study, with over half (52.5%) having completed tertiary education, compared to 9.6 per cent in health clinics and 16.7 per cent in community pharmacies, as reported¹⁰. Therefore, they often have a better understanding of medications and medical conditions¹⁰.

The present study found no significant association between age groups, which contradicts the findings by Buzancics et al⁷ and Kua et al¹⁰. This might be attributed to increased health literacy and awareness among the community after the COVID-19 pandemic. Therefore, there is a greater emphasis on self-care and preventive health²⁵. This can be explained by the protection motivation theory, which posits that individuals who perceive a severe threat are more likely to take necessary actions to protect themselves, such as proactively seeking health information²⁶.

In the present study, sex appeared to be irrelevant to the willingness to deprescribe, which is consistent with the previous studies^{7,10,11,22,24}. This might be due to gender equality, which is now a fundamental human right, ensuring that access to rights and opportunities is unaffected by sex²¹. For example, both men and women had the same rights and opportunities to have an education, which helps develop their critical thinking and decision-making skills. As an upper-middle-income country, Malaysia has mandated primary and secondary education since 2015²⁷. Therefore, men and women have equal chances to have education, leading to comparable health literacy, and eventually, no significant difference in willingness towards deprescribing.

Patients’ willingness to participate in decision-making is crucial for implementing shared decision-making (SDM) in healthcare. Patients’ participation in SDM can predict their willingness to embrace new patient-centred services like deprescribing²⁸. This is supported by findings in this study, in which a higher involvement score in rPATD is associated with a higher willingness to deprescribe medication. SDM happens when healthcare providers and patients work together to make the best healthcare decision that is tailored to specific patients²⁸. When patients actively participate in care decisions, health outcomes improve significantly, reducing hospital bed days by 25 per cent, reducing admissions by 19 per cent, and achieving an 86 per cent patient satisfaction rate²⁸.

This study also highlighted that individuals were more willing to deprescribe if they perceive higher appropriateness in withdrawing medication(s). This finding aligns with studies in Croatia (P=0.039), Indonesia (P=0.03) and Lebanon (P=0.015)^7,23. A higher perception of appropriateness in withdrawing medications appeared to be influenced due to experiencing side effects or a lack of effectiveness²⁹.

While SDM is gradually replacing the paternalistic model globally, some Asians reportedly still find it distressing and burdensome³⁰. Although there is an increasing trend in the involvement in decision-making among the Asian community, it is still lower compared to Western society³⁰. Consequently, many clinical settings in Asia still favour the paternalistic approach, where physicians make decisions they deem best for the patient, and patients tend to follow advice³⁰. This aligned with the current study, which showed higher trust in physicians, leading to a higher willingness towards deprescribing. Thus, physicians should communicate the advantages of SDM to patients and actively encourage their participation in the decision-making process.

The willingness in deprescribing was not significantly associated with the burden score among patients, which was similar to other studies^7,11,24. The finding might be due to the current research setting in HCTM, which is a tertiary semi-government hospital where the government partially subsidises medications provided. Many patients initially perceive taking daily medications as burdensome. However, over time, these habits become automated behaviours as patients recognise the necessity of medications for managing their medical conditions³¹. Additionally, HCTM practices using fixed-dose combination drug therapy where possible, which reduces pill burden, improves adherence and decreases treatment burden.

When patients are satisfied with the treatment, they are more likely to comply with the medications and actively take care of their health. This, in turn, enhances perceived quality of life. Jneid et al³² reported that better treatment satisfaction positively affected the overall health-related QOL. Therefore, patients might feel they no longer need the medications and would like to discontinue the medications as they perceive their health has improved. This is shown in a few studies, including one from Lebanon²³. However, there is no significant difference between satisfaction and willingness towards deprescribing in this study, which warrants future investigations.

This study was not without limitations. It did not investigate the roles and responsibilities of other healthcare professionals other than physicians (e.g., clinical pharmacists). Furthermore, the findings of this single-centre study may not be generalisable to the entire Malaysian population. Moreover, the caregivers’ perception is not investigated in this study, which is significant given the cultural norm for family involvement in treatment decisions. Future research should address these limitations.

Understanding these elements will assist in the planning of deprescribing implementation to reduce possible adverse events or adverse events arising from polypharmacy, which has an increasing prevalence in Malaysia.