Background
Methods
Data analysis
Results
Aged care and primary health care in Australia and Sweden
Australia | Sweden | |
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Population ≥65 years | 15 % [21] | 20 % [22] |
Population ≥65 in ACF | 7.8 % [23] | 5 % [22] |
Number of medications per ACF resident | 7–10 [3, 4, 24] | 7–10 [25, 26] (>70 % have one or more PIM) |
ACF providers | • Private not-for-profit [27] • Private for-profit [27] | • Municipality (responsible) • Private (paid by municipality) [28] |
General practice structure | • Single/multiple GP private practices [29] • Small − medium business model [29] | • Team-based primary care facilities • Most public (owned by the county councils) • Few private (mostly owned by companies or cooperatives) [30] |
GPs in ACF | • Continuity model: GP follows long-term patient to ACF [31] • ACF panel model: GP provides care for >2 patients in nearby ACF [31] • GPwSI ACF model: GP provides regular scheduled service to large number of ACF residents [31] • LGPT model: GP part of team-based care [31] • ACF-based model: Single GP partners with single ACF [31] | • County councils responsible for residents’ medical care; generally weekly visit to ACF by one GP from the local primary care unit [28] |
Funding for primary health care | • Government funded (both state-, territory- and local-) • Fee-for-service paid directly by patients and clients • Private health insurers • Private charities [32] | • Funded through national and local taxation [30]. |
GP funding structure | • Fee-for-service paid directly by patients, and/or • Reimbursement by Government Medicare Benefits Schedule [29] | Different funding in the 20 different county councils [33]. In Skåne where interviewed GPs worked [34]: • Based on capitation for registered patients. • Complemented with estimated ‘illness burden’ indexation • Performance-based payments |
Medication reviews for ACF residents | • Pharmaceutical review outsourced by ACF to private company or local pharmacist. • Compulsory biennially as part of ACF accreditation process [35]. • GP may request local pharmacist to undertake medication review at any time [35]. • Funded by Government Medicare Benefits Schedule; maximum 1 review in 12 month period. | • Undertaken by county council employed pharmacists undertaken at any time, at least once a year, aiming to increase quality of medications and reduce PIMS [36]. |
Intention to deprescribe
1. Self-efficacy | I deprescribe |
“I cease Warfarin [for] all my nursing home patients without exception because I think it’s actively dangerous to be on Warfarin.” (AusGP4)
“As soon as a problem arises, I take a look at the medication list and figure out which one to deprescribe.” (SweGP10)
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Insecurity |
“Say someone was [on] Parkinsonism drugs - I would be less confident stopping it because… I do initiate anti-Parkinsonism drugs, but not at the higher end of them.” (AusGP6)
“And where it can be hard to gain support for examinations and follow-ups and help with observations and so… they like to call for sedatives, when instead there is a need of attendance and measures other than medications.” (SweGP10)
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Evidence and know-how |
“From a University point of view, if you could train the undergraduate to be interested in coming to the nursing home. This is the greatest point…” (AusGP8)
“I have only had one course on elderly and medications, and that was long ago. But I still use the notes from that class.” (SweGP1)
“Is it right or wrong to deprescribe this medication? You are pretty alone in the decision actually. I would like some kind of mentorship or someone to talk to.” (SweGP3)
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2. Norms | Unrealistic expectations |
“And, I think, sometimes the specialists are a bit unrealistic. Sometimes they’re a little bit unrealistic about what’s actually going on - on the actual coalface, I think.” (AusGP4)
“I don’t think they need some of the medications, but it is all psychology, the psychology of the patient and of the staff. They believe somehow that somethings would get better with pills.” (SweGP5)
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The Almighty doctor | “So they’re [relative] feeling guilty about the fact that they’ve [their parent] gone into the nursing home…So the…family want them to keep on going and going and going, so you do everything possible to keep them [resident] alive.” (AusGP6)
“There is a focus on the doctor. And I have very little chance to help the patient because what the patient actually is in need of is basic care …but this may lead to that a patient gets many medications” (SweGP11)
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3. Attitudes | Facilitating a good quality of life |
“I think the medications which keep them comfortable are important, like pain medications can help them. And those ones which are related to heart.” (AusGP5)
“…the first priority is definitely to reduce suffering, reduce anxiety…try to make life meaningful for the patient. Diseases are secondary.” (SweGP4)
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Interest and disinterest in aged care |
“I think that’s a big barrier for us to be able to get other doctors [to] actually provide services there [in the aged care facility].” (AusGP6)
“It [aged care work] is sort of a relief compared to the ordinary work at the primary health care centre, you get away from the primary health care centre for a while every week and it is freer time, not the scheduled appointments all the time, but you go there and sometimes you visit the patients and sometimes you just discuss the patients. It is more free and a different way of working with patients.” (SweGP12)
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Self-efficacy in deprescribing
“After 20 years I know exactly what I want to do. I don’t have a problem with saying, yep, the Statin goes, the Aspirin goes, the Warfarin goes.” (AusGP4)“When a patient first arrives to the nursing home, it is no longer ‘what to prescribe?’, but ‘what to deprescribe?’” (SweGP5)
“I am pretty confident in what I am doing and what I don’t want to do. If there is a prescription that I don’t agree with, I won’t prescribe it…But when it comes to the discussion about non-pharmacological issues, such as nursing care instead of medications, it is hard to gain support from the nursing staff.” (SweGP6)
“They seem to have a pretty crappy end stage level of Parkinson’s, but maybe it would be worse if I stopped these tablets and so I’ll get anxious about that.” (AusGP6)“Sometimes I try to call a geriatrician, but there is no easy way to contact them. It all ends up with me writing a letter to try to get a hold of someone, because via telephone it is just hopeless.” (SweGP9)
“I’m not clever enough to have all the statistics in my head to be able to say, well, that Statin is stopping all that absolute relative blah de blah, which I don’t understand very well. So I can’t really educate the patient off the top of my head.” (AusGP4)“It would be a great help [with deprescribing] to have further training and to meet with GPs in the same situation.” (SweGP6)
“I think that the quality [of prescribing decisions] has increased greatly, and that is actually because of Hälsovalet [government incentives of medication reviews]… It makes my work with the elderly more pleasant.” (SweGP3)
“It’s one of those pieces of paper which goes in the shredder for me. If I haven’t got the time to negotiate – or to really think about the [medication review] because medico legally it’s a document which actually stitches you up.” (AusGP6)
Norms affecting GP-led deprescribing
“In our world there is a lot of fixation on diagnoses and diseases that should be cured. But in residential aged care there should be another perspective – having company, not being alone etc.” (SweGP4)“I honestly think 90 % of relatives don’t see the nursing homes as a palliative situation… Well, people with medical training can, perhaps, see it for what it is. Whereas relatives look at things often through rose-coloured glasses and they think it’s going to get better.” (AusGP1)
“So the anxiety that the staff [and] a lot of the relatives have about grandma dying, they’re displaced onto the nursing staff, so the nursing staff are worried about grandma and they’ve displaced it onto us and then that gets displaced onto… the geriatrician” (AusGP6)“I want to get away from giving medicines when the reason is that there are not enough nursing staff. There is a tendency for this, with too much focus on the doctor.” (SweGP11)
Attitudes towards deprescribing
“I want to give the patients a good quality of life, and I follow them in the continuum of ageing, with their progressive weakness and adapt medical interventions for this.” (SweGP10)
“Every time I am there I think to myself, ‘please don’t let me end up here’.” (SweGP5)“I have done much thinking about how I want to be treated in that situation, and I have talked to my relatives about it. If I get seriously ill and suffer from dementia, please don’t fight for prolonging my life to eternity” (SweGP2)
“So [the aim is to] to treat them, to keep them comfortable. And, again, those who have a good quality life, they can go out and visit their relatives, that is just like normal management.” (AusGP5)
“I’d be very, very happy to give that to anybody who wanted it, pay a significant amount of money to get that off my hands. I’m completely burnt out with it.” (AusGP4)“In my heart I know it would have made no difference, but I’ve had it where people – I’ve stopped the bisphosphonate or whatever and within the week they’ve fallen over and busted something. And the nurses… they go, ‘oh, look’.” (AusGP6)
“It is like a relief compared to the PHC centre, that you get to go away from the PHC centre every week and go to the nursing home, and it also gives you an opportunity to prioritise your work.” (SweGP12)
Environmental factors | Working within a complex system |
“So lack of uniformity of medication documentation is a barrier.” (AusGP3)
“I am pretty stressed when I am come back to the PHCC from the ACF. It limits me to not have the computer system to work with at the ACF, therefore I have to bring back a lot of work to administrate when I come back to the PHCC.” (SweGP6)
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Communication |
“You’re stopping people’s blood pressure medication and then to Digoxin and things like that. To me what that means is then unless you then identify a palliative care situation and everybody’s happy with that, is that means more monitoring, more faxes, more this, more that.” (AusGP3)
“I feel that it takes a lot of patience and ability to cooperate with the other staff at the ACF.” (SweGP2)
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Financial incentives to providing care |
“They will all complain bitterly about the doctors because we’re always - well, I am - always grumpy and never want to be there because you feel like you’re virtually doing charity work because you work hard.” (AusGP4)
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Skills and ability | Quality of human resources |
“The issue is as well is that the nursing staff have got to have the capacity to actually adhere to the plan.” (AusGP4)
“I would like more nursing staff, better educated nursing staff. It is my belief that we could save a lot of time and money that way.” (SweGP2)
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Quantity of human resources |
“The institution has to respect the [prescribing] policy and have enough skill to actually adhere to it.” (AusGP6)
“It is not optimal that a patient gets a sedative drug instead of someone that holds her hand, but it is as good as it can get because there is no other way. That is frustrating of course, and sad, that I can’t influence this in any way” (SweGP2) |
Environmental factors influencing deprescribing
“I hate the organisational barriers to actually being more efficient there. I think negotiating with the nursing home to get things done is extremely frustrating.” (AusGP6)“The paperwork from the municipality is often not summarized, it is time demanding work, getting it all together, and I don’t have time for that.” (SweGP4)
“Well, I cooperate with the nurse named X, and she is very good and that makes my work much easier and more pleasant. We can have a good dialogue and she… I feel that she has a good clinical sense and good intentions for the patient’s well-being.” (SweGP11)“I’ve got two or three nursing home staff who are fantastic. So I just don’t want make this out that they’re all terrible and that’s the reason I’m still there. If they leave I’m out of there. There’s no way I am staying.” (AusGP4)
“Because they [young doctors] don’t get paid enough.” (AusGP3)
Skills and abilities
“There is a need for better educated people who run the ACFs” (SweGP10)“But most [nursing staff] are very under skilled, very unintelligent and not able to make any decisions for themselves.” (AusGP1)
“And so – and some of the RNs are very skilled. But some of the RNs are hiding in the shadows, I reckon… “(AusGP6)
“It is frustrating with the lack of nursing staff, of course. But I can’t take responsibility for the municiptality’s employment system, it is all political.” (SweGP2)