PURPOSE Avoidable hospitalizations due to adverse drug events and high-risk prescribing are common in older people. Primary care physicians prescribe most on-going medicines. Deprescribing has long been essential to best prescribing practice. We sought to explore the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.
METHODSWe used a snowball sampling technique to identify potential participants. Physicians were selected on the basis of years in practice, employment status, and practice setting, with an additional focus on information-rich participants. Twenty-four semistructured interviews were audio-recorded, transcribed verbatim, and analyzed to identify emergent themes.
RESULTSPhysicians described deprescribing as "swimming against the tide" of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management.
CONCLUSIONSInterventions to support safer prescribing in everyday practice should consider the sociocultural, personal, relational, and organizational constraints on deprescribing. Regulations and policies should be designed to support physicians in practicing according to their professional ethical values.
Although there is extensive documentation of minority overrepresentation in special education, knowledge of the factors that create the context within which disproportionality occurs is limited. To gain an understanding of the local processes that may contribute to special education disproportionality, we interviewed 66 educators about their perspectives on urban education, special education, available and needed resources, and the specific topics of diversity and disproportionality. A number of clear themes emerged. Teachers and schools feel unprepared to meet the needs of economically disadvantaged students. Classroom behavior appears to be an especially challenging issue for many teachers, and cultural gaps and misunderstandings may intensify behavioral challenges. Special education is perceived by many teachers as the only resource available for helping students who are not succeeding. Finally, there was a surprising reticence among many respondents to discuss issues of race. These results paint a surprisingly complex picture of the factors that may cause and maintain minority disproportionality in special education. Together, they suggest that successful remediation efforts will avoid simplistic or linear solutions, increase resources to address learning and behavior problems in general education, and seek methods to use data on racial disparity as a stimulus toward reflection and action.
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