Barriers and facilitators of implementing proactive deprescribing within primary care: a systematic review

Abstract

Objective Proactive deprescribing – identifying and discontinuing medicines where harms outweigh benefits – can minimise problematic polypharmacy, but has yet to be implemented into routine practice. Normalisation process theory (NPT) can provide a theory-informed understanding of the evidence base on what impedes or facilitates the normalisation of routine and safe deprescribing in primary care. This study systematically reviews the literature to identify barriers and facilitators to implementing routine safe deprescribing in primary care and their effect on normalisation potential using NPT. PubMed, MEDLINE, Embase, Web of Science, International Pharmaceutical Abstracts, CINAHL, PsycINFO and The Cochrane Library were searched (1996–2022). Studies of any design investigating the implementation of deprescribing in primary care were included. The Mixed Methods Appraisal Tool and the Quality Improvement Minimum Quality Criteria Set were used to appraise quality. Barriers and facilitators from included studies were extracted and mapped to the constructs of NPT. Key findings A total of 12,027 articles were identified, 56 articles included. In total, 178 barriers and 178 facilitators were extracted and condensed into 14 barriers and 16 facilitators. Common barriers were negative deprescribing perceptions and suboptimal deprescribing environments, while common facilitators were structured education and training on proactive deprescribing and utilising patient-centred approaches. Very few barriers and facilitators were associated with reflexive monitoring, highlighting a paucity of evidence on how deprescribing interventions are appraised. Summary Through NPT, multiple barriers and facilitators were identified that impede or facilitate the implementation and normalisation of deprescribing in primary care. However, more research is needed into the appraisal of deprescribing post-implementation.

Deprescribing medications among patients with multiple prescribers: A socioecological model

“…Prescribers attempting to deprescribe face challenges at the clinician–clinician interpersonal level as well. Differences in professional backgrounds and poor communication between providers may hinder deprescribing efforts 26,27 . Some prescribers may be hesitant to deprescribe when they are unfamiliar with other members of their patient's care team or have limited involvement with a patient's treatment regimen 28 .…”

Clinical decision‐making in benzodiazepine deprescribing by healthcare providers vs. AI‐assisted approach

“…5 The decision to consider and suggest stopping or withdrawing medication to the patient, poses a particularly challenging judgement for a clinician. 6,7 Clinicians need to take into consideration a multitude of factors, including the patient, the medication and the process itself. There are a number of tools available or being developed to aid in the deprescribing process.…”

“…In instances when prescribing is amiss, the deprescribing approach can be used to safely withdraw and stop inappropriate medications with intent to improve outcomes 5 . The decision to consider and suggest stopping or withdrawing medication to the patient, poses a particularly challenging judgement for a clinician 6,7 . Clinicians need to take into consideration a multitude of factors, including the patient, the medication and the process itself.…”

Survey content validation evaluating the dissemination and implementation of deprescribing guidelines

“…Robust and effective dissemination and implementation efforts are critical to ensuring that guideline recommendations reach end-users and enhancing the adoption of evidencebased interventions and practices. 6,[20][21][22][23][24][25] Deprescribing guideline dissemination strategies and subsequent guideline diffusion have not been extensively assessed in the literature. Although the implementation science literature provides evidence for effective implementation strategies, 26,27 there is a lack of consensus on an optimal strategy.…”

“…The development of a guideline does not necessarily lead to changes in clinical practice. Robust and effective dissemination and implementation efforts are critical to ensuring that guideline recommendations reach end‐users and enhancing the adoption of evidence‐based interventions and practices 6,20–25 . Deprescribing guideline dissemination strategies and subsequent guideline diffusion have not been extensively assessed in the literature.…”