Primary Care Physicians’ Views on the Barriers to and Facilitators of Deprescribing in Everyday Practice
| Barriers and Facilitators | Example Quotations | |
|---|---|---|
| Sociocultural factors | Patient expectations | I think there seems to be an expectation that if they’ve got a problem they’ll be given another pill to fix it. (GP-9) There are people who see medication as the barrier between them and the grave. (GP-7) |
| Medical culture of prescribing | I guess it’s easy to keep adding in medications without looking at whether they need all the medications they’re already on. (GP-21) Prescribing is something that’s taught a lot, you know. Deprescribing isn’t really something that’s been talked about from the get-go. It’s not something that’s come up. As a GP trainee, it’s not something that we’ve had a session on. (GP-9) | |
| Personal and relational factors | Uncertainty | We all want to do the right thing, but… We don’t know what the combinations of many conditions and all the medications for each of their conditions, what kind of extra risk that poses. (GP-8) |
| Fear of damage to reputation, accountability for adverse outcomes, moral blame and shame | You could be viewed as being neglectful, as being a bad doctor, as being not competent, if you’re taking medications away and someone has an event. (GP-5) We end up putting people on more stuff than I’m really comfortable with, but it’s hard to defend not complying with the guidelines. (GP-15) If [the patient] had a heart attack and the doctor in the hospital said “Oh it’s because your [doctor] stopped your statin,” then [the doctor] would feel terrible, and so he doesn’t stop them even though he thinks he should. (GP-2) The risk that you take on yourself…if the person, say, has a heart attack and you stopped their statin. So, there’s that psychological stuff that goes on. (GP-5) | |
| Research, education and training | I think we need more research, more collaborations. (GP-3) I think education would be very helpful for us, in sort of just giving us more confidence. (GP-17) | |
| Maintaining relationships with patients and colleagues | It can come off looking like you no longer care about the patient, you know, “You’re old enough to die now so it doesn’t really matter.” (GP-14) Sometimes people will say, “Why shouldn’t I have the same treatment that a younger person would have? You’re just writing me off.” (GP-16) It’s quite difficult to say, “How about we reduce [a medicine]?” when it’s only just been started by somebody else, like a hospital doctor or something. (GP-6) The reason you don’t stop things is you think they [specialists] know better than you. (GP-2) | |
| Ethical duty: beneficence | I think you’ve got to do what’s right for your patient, regardless. (GP-13) | |
| Organizational factors | Fast pace and competing demands of practice | There is no time … [You’ve got] complicated, complex patients and you never have more than 15 minutes and sometimes its double booked. There’s never time to spend on this. (GP-2) Patients are not coming in for a deprescribing conversation; they’re coming in for something else like a repeat or to talk about their aching joints. So the deprescribing conversation is an added thing to the consultation. (GP-5) A lot of the time the opportunities for deprescribing are lost by either repeat prescription generation without seeing the patient or doing their repeat medications in an appointment where they’ve come in to talk about something else. (GP-9) With the best will in the world we get really busy, we get distracted and we mean to do things that we don’t do. (GP-3) |
| Targeted funding | You need some funded time with the patient so that you can bring the patient in and say “This is a special appointment that’s not to talk about your current medical problems, it’s specifically about managing your medicines better.” (GP-4) | |
| Computer prompts and alerts | An alert would give you a little bit of courage to do it, or give you more reassurance, or give you a way to bring it up with the patient like, “Look, you see, the computer has noticed you’re on too many medications, maybe we can reduce it.” (GP-2) Memory support… Prompts are good, helpful. (GP-3) | |
| Fragmentation of care | As a locum, it’s difficult because you don’t know the indications, you don’t know the patient very well, you don’t know the history. Has someone tried to stop them before and it hasn’t gone well and had to be restarted? (GP-2) [Deprescribing is difficult] if they don’t know me well, haven’t built up that trust. (GP-12) | |
| Information flow between prescribers | The electronic portals might be something that will make it easier in the future, centralized storage of information that everyone can access. (GP-9) | |
| Access to expert advice and user-friendly decision support | I like to ring someone up and just ask them what I should do. I would like to be able to ring a cardiologist or geriatrician. I often email a pharmacist. (GP-2) I’ve recently come across an app, which I have on my iPad [MedStopper], and you can put in the medication list there and it will prioritize them for you. So, that’s a really neat little tool. (GP-11) | |
| Guidelines | Most guidelines are suggesting you add medicines rather than take them away. (GP-7) In each guideline for each condition, have a section on when it would be appropriate to reduce or stop each medication. (GP-2) I think we need multi-morbidity guidelines, the commonest multi-morbidities like chronic pain from arthritis and heart failure and diabetes together. (GP-8) | |
| Communication of risk | They’re used to being on these medications; whatever they’re feeling in their lives and the way that they’re experiencing their lives, this is their usual way of feeling and they’re used to it. You think that perhaps taking off the statin will make them feel better, but that’s a very subtle thing to try and tell them because most of the time they’re not actually feeling bad, or they don’t know they’re feeling bad. (GP-1) Communicating risk to patients, it’s very difficult. (GP-14) | |
| Access to non-pharmaceutical options | It’s harder to access other services. Non-pharmaceutical options are often a lot harder to access than medications. (GP-9) | |
| Patient activation | A recall that sends out something to the patient every year and says, “Next time you’re at the doctor make sure to look over the pills.” (GP-8) [A letter] to warm the patient up … (GP-3) | |