We found various profiles of GPs' propensity to cooperate and share the management of prescriptions for patients with multimorbidity and polypharmacy with specialists and other health professionals. While most GPs recognized pharmacists' knowledge about medications and their adverse reactions, only a minority would agree to share prescription management with them.
GPs belonging to cooperative profiles (moderate and intensive) profiles had taken more CME courses than those in the low cooperation profile. GPs' propensity to initiate the deprescription of inappropriate medications was weakly correlated with their propensity to cooperate.
Comparison with literature
Qualitative studies have shown that some GPs feel that the involvement of many specialists in the management of these complicated patients results in the fragmentation of care. Combined with a lack of communication between physicians, this may lead to increase harm from polypharmacy [7, 15]. In these qualitative studies, many GPs call for better interprofessional communication and a fair balance between them and specialists when sharing prescribing activity [15, 16]. Our quantitative study confirmed that cooperation and confidence between physicians is not obvious for a majority of GPs (moderate and low cooperation profiles).
General practitioners would preferentially transfer to nurses, and sometimes pharmacists, advice to patients (lifestyle habits, monitoring of illnesses) and therapeutic education [19, 20].
Our results highlight the diversity of GPs' opinions about the role of pharmacists in the management of polypharmacy. Previous studies have demonstrated that pharmacists’ involvement in medication management may result in better clinical outcomes and improvement of prescribing patterns, especially for patients with polypharmacy [21–23]. Their involvement in patient counselling, therapeutic education or the training of other health professionals would have a positive impact on the patients follow-up, their treatment adherence and their quality of life [22]. In the same time, the frequent limitation of cooperation between GPs and pharmacists to clarification of prescriptions, drug-related information, or information about patient history reduces its potential benefits [24–26]. Moreover, contacts are occasional and mostly at the pharmacists' initiative. Nevertheless, pharmacists and GPs share the opinion that cooperation is easier when they have a local, long-lasting working relationship [25, 27].
Our finding that a majority of GPs were favorable to practice nurses ensuring consultations for patients with chronic diseases is encouraging. A recent Cochrane review showed that nurse practitioners achieved equal or better outcomes for chronic patients than primary care doctors, in terms of quality of care, patient health status, and patient satisfaction [28].
The younger age of GPs with a moderate cooperation profile, compared with the others, probably reflects the shaping of attitudes and behaviors regarding interprofessional cooperation by years of experience and professional environment: more experienced GPs may have adjusted their role, given what they have learned to expect from other health professionals in their environment.
The absence of association between GPs’ profiles and multiprofessional practice organization is surprising. But our study focused especially on the roles of specialists and pharmacists, who are rarely integrated in such organizations in France. Moreover, multiprofessional and group practices themselves have various profiles of organization and interprofessional collaboration [29, 30].
We found that GPs with profiles of moderate or selective cooperation had lesser deprescription propensities. At the same time, GPs with low and intensive cooperation profiles had similar behaviors towards deprescription. Qualitative studies have indicated that some GPs fear conflicts with other physicians or pharmacists when they initiate deprescription [15, 31]. One hypothesis is that GPs who cooperate intensively discuss and share the responsibility for the prescription management with other professionals and might thus feel themselves supported and confident when deprescribing. Inversely, GPs with a low cooperation profile may prefer to take on the responsibility for prescriptions management including when deprescribing. This may be problematic especially when they face therapeutic dilemmas, in which they could benefit from the advice and insight of colleagues and other professionals.