Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

Abstract

ObjectiveTo synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults.DesignA qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings.SettingAll healthcare settings.ParticipantsMedical and non-medical prescribers of medicines to adults.OutcomesPrescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults.Results21 studies were included; most explored primary care physicians’ perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported.ConclusionsA multitude of highly interdependent factors shape prescribers’ behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.

A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice.

“…For example, a 2013 Cochrane review [60] found that chronic antipsychotics used for neuropsychiatric symptoms of dementia can be safely withdrawn without detrimental effects on behaviour, and a recent randomized clinical trial found that withdrawal of statins in the setting of a life-limiting illness resulted in improved quality of life and reduced medication costs [61]. While it is still unknown what is the most effective way to implement deprescribing in practice [62], this term and a consistent definition will have important implications for both research and practice. While Woodward's seminal article [1] is the most highly cited, its definition consists of principles/steps for conducting deprescribing and only included four of the eight characteristics that were identified across all the included articles and therefore has not been employed consistently (even among the articles which cited it).…”

A pilot study of a Medication Rationalization (MERA) intervention

“…Previous deprescribing interventions have sometimes had little or no effect, 33 and there are multiple factors that shape both prescriber 34 and patient 35 barriers to deprescribing including complexity and time limitations, an underappreciation of the scale of polypharmacy-related harms, the increasing intensity of medical care in general, the fear of precipitating an acute event, and the conceptual difficulty involved in balancing risks and benefits. 3,13 Only 21% of the Choosing Wisely campaign's current recommendations refer to stopping specific medications.…”

Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice

“…Most research has focused on deprescribing in residential care settings, complex case examples, and understanding the views of patients. [21][22][23][24][25][26][27][28][29][30][31] We sought to explore the views of primary care physicians on the barriers to and facilitators of deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.…”