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      Challenges and Enablers of Deprescribing: A General Practitioner Perspective

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          Abstract

          Aims

          Deprescribing is the process of reducing or discontinuing medicines that are unnecessary or deemed to be harmful. We aimed to investigate general practitioner (GP) perceived challenges to deprescribing in residential care and the possible enablers that support GPs to implement deprescribing.

          Methods

          A qualitative study was undertaken using semi-structured, face-to-face interviews from two cities in New Zealand and a purpose-developed pilot-tested interview schedule. Interviews were recorded with permission and transcribed verbatim. Transcripts were read and re-read and themes were identified with iterative building of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out with the assistance of a Theoretical Domains Framework (TDF) and constant comparison techniques. Several themes were identified. Challenges and enablers of deprescribing were determined based on participants’ answers.

          Results

          Ten GPs agreed to participate. Four themes were identified to define the issues around prescribing for older people, from the GPs’ perspectives. Theme 1, the ‘recognition of the problem’, discusses the difficulties involved with prescribing for older people. Theme 2 outlines the identified behaviour change factors relevant to the problem. Deprescribing challenges were drawn from these factors and summarised in Theme 3 under three major headings; ‘prescribing factors’, ‘social influences’ and ‘policy and processes’. Deprescribing enablers, based on the opinions and professional experience of GPs, were retrieved and summarised in Theme 4.

          Conclusion

          The process of deprescribing is laced with many challenges for GPs. The uncertainty of research evidence in older people and social factors such as specialists’ and nurses’ influences were among the major challenges identified. Deprescribing enablers encompassed support for GPs’ awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team.

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          Most cited references22

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

          Objective To synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults. Design A 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. Setting All healthcare settings. Participants Medical and non-medical prescribers of medicines to adults. Outcomes Prescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults. Results 21 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. Conclusions A 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.
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            Potential pitfalls of disease-specific guidelines for patients with multiple conditions.

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              Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.

              Polypharmacy and inappropriate medication use is a problem in elderly patients, who are more likely to experience adverse effects from multiple treatments and less likely to obtain the same therapeutic benefit as younger populations. The Good Palliative-Geriatric Practice algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home inpatients. This study reports the feasibility of this approach in community-dwelling older patients. The Good Palliative-Geriatric Practice algorithm was applied to a cohort of 70 community-dwelling older patients to recommend drug discontinuations. Success rates of discontinuation, morbidity, mortality, and changes in health status were recorded. The mean (SD) age of the 70 patients was 82.8 (6.9) years. Forty-three patients (61%) had 3 or more and 26% had 5 or more comorbidities. The mean follow-up was 19 months. Participants used a mean (SD) of 7.7 (3.7) medications. Protocol indicated that discontinuation was recommended for 311 medications in 64 patients (58% of drugs; mean [SD], 4.4 [2.5] drugs per patient overall, 4.9 per patient who had discontinuation). Of the discontinued drug therapies, 2% were restarted because of recurrence of the original indication. Taking nonconsent and failures together, successful discontinuation was achieved in 81%. Ten elderly patients (14%) died after a mean follow-up of 13 months, with the mean age at death of 89 years. No significant adverse events or deaths were attributable to discontinuation, and 88% of patients reported global improvement in health. It is feasible to decrease medication burden in community-dwelling elderly patients. This tool would be suitable for larger randomized controlled trials in different clinical settings.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 April 2016
                2016
                : 11
                : 4
                : e0151066
                Affiliations
                [1 ]School of Pharmacy, University of Otago, Dunedin, New Zealand
                [2 ]David Braley Chair in Family Medicine, McMaster University, Hamilton, Canada and University of Otago, Christchurch, New Zealand
                Royal College of Surgeons, IRELAND
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: NJA PSN DM JMT. Performed the experiments: NJA. Analyzed the data: NJA JMT. Contributed reagents/materials/analysis tools: NJA PSN DM JMT. Wrote the paper: NJA PSN DM JMT.

                Article
                PONE-D-15-52977
                10.1371/journal.pone.0151066
                4836702
                27093289
                5c11a2fb-8c1c-4abe-90fa-8b79ec4787a0
                © 2016 Ailabouni et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 7 December 2015
                : 23 February 2016
                Page count
                Figures: 1, Tables: 3, Pages: 20
                Funding
                Funded by: New Zealand Lottery Health Research
                Award Recipient :
                Funded by: NZPERF
                Award Recipient :
                New Zealand Lottery Health Research provided the scholarship for this PhD ( http://www.communitymatters.govt.nz/Funding-and-grants---Lottery-grants---Lottery-Health-Research); and the New Zealand Pharmacy Education and Research Foundation (NZPERF) provided funding for the employment of a transcriber for the interviews in this study ( http://www.psnz.org.nz/Category?Action=View&Category_id=155). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Medical Doctors
                Physicians
                People and Places
                Population Groupings
                Professions
                Medical Doctors
                Physicians
                People and Places
                Population Groupings
                Professions
                Pharmacists
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Nurses
                People and Places
                Population Groupings
                Professions
                Nurses
                People and Places
                Population Groupings
                Age Groups
                Elderly
                Social Sciences
                Sociology
                Communications
                Social Communication
                Medicine and Health Sciences
                Geriatrics
                Research and Analysis Methods
                Research Design
                Qualitative Studies
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Treatment Guidelines
                Custom metadata
                Raw data includes identification of GPs who had participated in this study. As part of the ethics application, it was agreed that the GPs will not be identified and the details will be kept confidential. Therefore, raw data files of transcripts and audio recordings of interviews are kept on a secure university based network. Any queries regarding the data can be answered by contacting the corresponding author, NA, or other authors, if necessary.

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