Barriers and enablers to deprescribing in long-term care facilities: a ‘best-fit’ framework synthesis of the qualitative evidence

Abstract

Introduction older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers’ (HCWs) engagement with deprescribing in LTCFs. Methods the ‘best-fit’ framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers. Results of 655 records identified, 14 met the inclusion criteria. The ‘best-fit’ framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an ‘established hierarchy’ within LTCFs, negatively affecting communication and insufficient resources which limited HCWs’ engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients’ condition to influence decisions. Discussion this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.

Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

“… Domains and constructs from the ‘Best-fit’ framework of barriers and enablers to deprescribing in long-term care facilities by Heinrich and colleagues [ 39 ]. (Italics) : Related constructs from other domains.…”

“…Written, informed consent was obtained from all participants. An interview guide was developed and tailored for each HCP group, guided by the TDF-informed framework of deprescribing barriers and enablers in long-term care facilities [ 39 ]. Each domain of the framework informed a question in the topic guide.…”

“…In the second stage, themes were mapped to domains of the deprescribing framework [ 39 ]. A second researcher reviewed the inductive themes, with supporting quotes and independently mapped these to the deprescribing framework.…”

Supporting deprescribing in long-term care: An approach using stakeholder engagement, behavioural science and implementation planning

“…Opportunities included alignment with existing care structures (e.g., legislated quarterly medication reviews, annual care conferences with families, integration into quality improvement plans) and leveraging existing tools and resources (e.g., evidence-based deprescribing algorithms and guidelines). Challenges consistent with those documented in published literature included obtaining buy-in from prescribers, 24 and variable willingness of residents 25 and families, caregivers to engage in decisions about medications. 26 Stakeholders also discussed the challenges of communication amongst health care providers (i.e., reliance on written communication due to variable schedules).…”

Identification of Potentially Inappropriate Medications in Frail Older Adults Residing in Long-Term Care: A Retrospective Chart Review Study

“…Considering the health benefits of deprescribing for LTC residents, including reduced PIMs, falls and all-cause mortality, STOPPFrail offers the additional advantage of being concise and having high interrater reliability between different HCPs [ 32 – 35 ]. This suggests that STOPPFrail could be an effective tool to support decision making and interprofessional collaboration, which have been identified as facilitators for deprescribing in LTC [ 36 ].…”