Exploring Sex, Gender, and Gender-Related Sociocultural Factors in Clinical Decision-Making for Older Adults Using a Prescribing Cascade Vignette: A Transnational Qualitative Study

Background: Despite growing awareness of sex differences in inappropriate prescribing among older adults, including the initiation of problematic prescribing cascades, the impact of gender bias remains largely unexplored. Objectives: We explored how a patient’s sex and gender-related sociocultural factors influence physicians’ prescribing decisions, potentially leading to prescribing cascades in older adults. A secondary objective was to explore whether and how physician sex affected prescribing decisions for female and male patients. Methods: Physicians in Canada and Italy were presented with a clinical vignette describing an older male or female patient on amlodipine presenting with peripheral edema. Physicians were interviewed using the ‘think-aloud’ method to describe their treatment considerations. Thematic multi-site analysis was used to analyze the data. Results: Of 30 physicians, only two considered prescribing a diuretic for an older female patient. Most physicians identified amlodipine as the cause of the edema and adjusted or substituted the medication, often making these treatment decisions without considering sex- and gender-related sociocultural factors. When prompted, physicians acknowledged the relevance of these factors, but their responses varied. Some adapted their treatment plans, noting the challenges of managing edema, particularly for female patients, whereas others did not incorporate these considerations. Interestingly, some physicians adjusted their plans based on gender-related factors yet still stated that gender did not influence their treatment decisions. No variations in treatment decisions based on physician sex were observed. Conclusion: The study reveals a gap between physicians’ recognition of gender-related sociocultural factors and their consistent integration into clinical decision-making, highlighting the need for more nuanced approaches in prescribing practices.