General practitioners' views on ( long- term) prescription and use of problematic and potentially inappropriate medication for oldest- old patients- A qualitative interview study with GPs ( CIM- TRIAD study)

Background: Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/ or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest- old patients is high despite the existence of lists of PIM (e. g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners' views on PIM and aspects affecting the (long- term) use of PIM. Methods: As part of the CIM- TRIAD study, we conducted semi- structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient- specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. Results: The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners' point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e. g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e. g. benzodiazepines on alternative private prescription), medication- (e. g. subjective perception that PIM has no alternative), general practitioner- (e. g. general practitioner relies on specialists), patient( e. g. demanding high- user, positive subjective benefit- risk- ratio) and system- related aspects (e. g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. Conclusions: While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e. g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, positive lists, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists