Principal findings and comparison with literature
About two-thirds of Indonesian older adults with T2D were willing to stop one or more medicines in general if their GP or specialist said it was possible. This willingness was significantly lower when the pharmacist would propose deprescribing. There was, however, variation in how participants perceived appropriateness and concerns about stopping specific cardiometabolic medicines. Furthermore, participants perceiving more burden of their medicines and having less concerns about stopping were more willing to stop their medicines if their doctor would propose this. Surprisingly, if such a proposal would come from the pharmacists, participants with very limited education were more willing to stop in comparison to those with higher education.
Our findings about the general satisfaction with the medications and willingness to stop medicines are in line with previous studies using the rPATD questionnaire in other Asian countries, where around 80% of older patients were satisfied with their current medications and about two-thirds were willing to stop one or more of their regular medicines if the doctor said it was possible [20, 21]. This willingness is, however, much lower than the 88% willingness observed among primary care patients with T2D in The Netherlands [11]. In general, patients from LMICs, including also those from Indonesia in our study, appear less willing to stop medication compared to high-income countries [9]. Whether this is due to differences in the healthcare system or culture is not clear. Contrary to our expectation, we did not observe any relationship between willingness and the use of CAM. Another study showed that it is common for T2D patients in Indonesia to use CAM in addition to their regular diabetes treatment [22]. This may suggest that they believe that both are needed, without a clear preference of using CAM over regular medicines.
The observed difference between The Netherlands and Indonesia may partly be due to differences in the patient population. We included patients of 60 years and older because life expectancy is lower in Indonesia as compared to countries like the Netherlands. Possibly, not all the participants in our study were people who are eligible for deprescribing, since patients with lower ages can still benefit from continuing their current treatment. On the other hand, we observed no association between age and willingness within our study population. Of note, almost half or our participants used only one glucose-lowering medicine, less than 60% used SU or insulin, and just over 20% used a combination of glucose-lowering, blood pressure-lowering and lipid-lowering medication. This suggests a relatively low need for deprescribing of such drugs. Nonetheless, around a third of our participants did feel burdened by a large number of drugs, which is similar to the findings in the Netherlands [11]. As expected, people perceiving more burden were more willing to stop one or more of the medicines if proposed by their doctor. Surprisingly, people using more than one glucose-lowering medicine were less willing to stop their medicines if proposed by their doctor, whereas these people would be more likely the ones who are eligible for deprescribing. This association became non-significant in the multiple regression model for the specialist. It might be that participants who require more intensive glucose-lowering treatment would trust the specialist more than the GP for reducing such medication.
Looking at the attitudes towards deprescribing, we observed the expected associations between perceived burden of medicines, appropriateness of medicines, and concerns about stopping medicines with a patient’s willingness to stop if a doctor would propose this. However, we observed no such associations with willingness if the pharmacist would say that stopping was possible. This suggests that accepting such proposals from the pharmacist is not related to the patients’ attitudes towards deprescribing. Instead, accepting such proposals appeared mostly related to a patient’s educational level. In general, we identified that the pharmacist appeared to be less trusted to propose changes in medication in Indonesia, particularly among more educated people. Although pharmacists are allowed to give such recommendations to a GP or a specialist, it might be considered inappropriate to make such a suggestion directly to a patient [22, 23]. A previous study in Indonesia about patients’ perceptions of the importance of pharmacist service that can improve medication adherence showed that most patients preferred regular face-to-face consultation over other more intensive pharmacist services, like medication reviews [24]. Educational level appeared to influence the patients’ preference for specific services, with people with primary education being more in favour of medication reviews conducted by pharmacists [24]. Of note, a quarter of the patients had never received any of the pharmacist services, indicating that they may see the pharmacist mostly as someone dispensing and preparing the medications. This may lead to not preferring any other pharmacist services than the short face-to-face consultation when collecting the medication [25]. In a study conducted in the USA, one in five patients indicated never communicating with the pharmacist, but when such communication was perceived effective it was associated with a higher willingness to accept deprescribing [14]. A study in Singapore found that only half of the patients felt comfortable with pharmacists being involved in the deprescribing process in primary care [26], while more than 70% of patients in Croatia had a positive opinion on pharmacists’ involvement in deprescribing [12].. In some high-income countries, there is already involvement of the pharmacist in the deprescribing process, such as taking part in medication reviews that include the option of stopping certain medication, also giving guidance on how to taper and stop specific medicines, and participating in the shared-decision making process [27,28,29].
Some variation in attitudes related to the appropriateness of medicines and concerns about stopping was seen according to the type of cardiometabolic medicines. In general, it seemed that particularly more of the patients using lipid-lowering medicines would like to try stopping or having their doctor to reduce the dose of this medicine. This may in part be related to a lower perceived need for these medicines and also to differences in perceived disease severity [30]. This is in line with a similar study comparing appropriateness and concerns of cardiometabolic medicines in the Netherlands, where statins were considered less appropriate than blood pressure-lowering medicines and also in comparison to insulin [11]. This indicates that patients with T2D may be more open to stopping statins than their glucose-lowering or blood pressure-lowering medicines.
This study confirmed that there are no clear and consistent associations of patients’ demographics in relation to willingness to stop medicines, as was also found in the previous reviews [8,9,10]. Sex and age do not seem relevant, but education and number of drugs used may influence willingness although not always too the same extent [8,9,10]. In our study, the total number of drugs used appeared to be low, which may explain the lack of association with willingness. It was suggested before that the influence of total number of medication might only be seen among populations that use more drugs [9].
Strengths and limitations
A clear strength of our study is the high response rate. Surprisingly, there was a relatively high number of women participants. A previous survey study among T2D patients in primary care centers in several big cities in Indonesia showed a similar pattern with more women included [31]. It was speculated that this could be because women in Indonesia are more obedient to getting their T2D check-ups regularly than men. Participants were recruited from 11 primary care centers, reflecting a broad city population in Indonesia. However, the results may not reflect the general responses of the overall Indonesian population since patient attitudes may be different in more remote areas. We did not adjust for clustering but observed no clear differences in willingness across the centers (data not shown). Furthermore, the inclusion of participants was somewhat hampered due to COVID restrictions in Indonesia during the study period. When looking at attitudes towards deprescribing of specific cardiometabolic medicines, we did not formally tested for differences since our design would result in a mix of within and between patient comparisons. Finally, all patient-related factors were self reported. Particularly when reporting on the total number of medicines patients use, recall bias and uncertainty about which drugs to include may result in an underestimation of the actual number and type of medicines taken.
Implications for practice and research
Deprescribing of cardiometabolic medicines is still a new intervention in LMICs. Both patients and HCPs play a role in implementing successful deprescribing. When GPs and specialists want to start deprescribing cardiometabolic medicines among older T2D patients, it is important that they pay attention to concerns of these patients, such as being worried about missing out on future benefits. Also, addressing the perceived appropriateness of specific medicines should be also considered. This appears particularly important for patients using more than one glucose-lowering medicine. Tailoring the deprescribing approach to the individual patient requires talking with the patient about the medication. Shared decision making between patients and HCPs is considered a fundamental part of the deprescribing process [32]. This may require a change in culture in countries like Indonesia and may also take more time investment of HCPs, which can be problematic especially for countries that lack funding for such specific program development.
It seems that many patients in Indonesia are not yet ready for accepting pharmacists to be involved in the deprescribing process. Currently, there is no regulation that gives pharmacists a specific task in this process [22, 23]. A lack of trust from patients but also little existing collaboration of pharmacists with other HCPs may hamper the realization of medication optimization at the primary healthcare level in Indonesia. Pharmacists in Indonesia may also need more training to gain trust. A qualitative study conducted in Iran concluded that to gain trust from the patients and establish an effective relationship with patients, pharmacists need to improve their communication skills and implement the principles of professionalism [33]. In addition, collaboration among HCPs in primary care needs to be enhanced. Developing mutual trustworthiness, initiating a relationship by conducting good communication during the early stages of the relationship, and maintaining high-quality pharmacist contributions have been mentioned as relevant for a successful collaboration [34].
Future research could investigate other patients’ characteristics that might be associated with willingness, such as relationship with the HCPs, frailty, medication adherence, or family support. Furthermore, it would be interesting to conduct research in Indonesia or other LMIC to explore HCP’s opinions regarding deprescribing in T2D patients, as has been done in other countries [27, 28].
