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Physicians’ perceived barriers and enablers for deprescribing among older patients at public primary care clinics: a qualitative study

Abstract

Background Increased harmful effects of medication resulting from polypharmacy, especially among older patients, is a significant concern globally. Hence, continuous medication review and withdrawal of inappropriate medications are essential to improve patient safety. Objective To explore physicians’ perceived barriers and enablers of deprescribing among older patients in the public primary healthcare setting. Setting Public primary care clinics in the northern states of Malaysia. Methods A semi-structured, face-to-face interview was conducted among physicians working in eight primary care clinics in northern Malaysia using a purposive sampling approach. Interviews were conducted using validated topic guides. All the responses were recorded, transcribed verbatim, validated, and analysed for the emerging themes using thematic analysis. Main outcome measure Physicians perceived barriers and enablers of deprescribing among geriatric patients. Results A total of eleven physicians were interviewed. Seven emerging themes were identified, which are categorised under barriers and enablers of deprescribing. The barriers were patient-specific, prescriber-specific, and healthcare provision and system. Prescriber deprescribing competencies, medication-specific outcomes, availability of empirical evidence, and pharmacist’s role were the enablers identified. Conclusion Patient-specific barriers were identified as a significant challenge for deprescribing. Improving competencies on deprescribing was the repeatedly adduced enabler by physicians. The development of targeted educational training can help to reduce the obstacles faced by prescribers.

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Acknowledgements

We wish to express our gratitude to the Health Director of Northeast Penang Island District (NPID), and all individual assisted in the study.

Funding

This study was not funded by any state, private, or non-profit funding agencies.

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Authors

Corresponding author

Correspondence to Balamurugan Tangiisuran.

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Conflicts of interest

There are no potential conflicts of interest for the authors to disclose.

Ethics approval

The research was approved by the Human Research Ethics Committee of Universiti Sains Malaysia (JEPeM Code: USM/JEPeM/18100603).

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Appendices

Appendix

COREQ (COnsolidated criteria for REporting Qualitative research) 32 item Checklist

See also Ref. [42]

Domain Comment Section reported in or not applicable (N/A)
Domain 1: Research team and reflexivity   
Personal characteristics   
1. Interviewer/facilitator The face-to-face interviews were done by VR, a clinical pharmacist trained to conduct this qualitative study Methods
2. Credentials Three academic pharmacists with doctorates in clinical pharmacy, a geriatrician, and VR, a clinical pharmacist who works in public primary care settings, made up the research team N/A
3. Occupation BT, AS, NAAD are Clinical Pharmacy Lecturers. SN is a geriatrician, and VR is a clinical pharmacist and the research student for this project N/A
4. Gender Three female-identifying researchers and two males. The interviewer was female-identifying N/A
5. Experience and training All of the researchers have experience in qualitative study design and analysis and geriatric medicine knowledge. In addition, VR had special training to conduct this study, which was required as part of her postgraduate studies N/A
Relationship with participants   
6. Relationship established BT, AS, NAAD, and SN have no previous relationship with the interviewers. VR has been working in a public primary care facility and has a working relationship with the two physicians interviewed in the pilot study. AS and NAAD was not involved in designing the study to ensure they are independent and unbiased N/A
7. Participant knowledge of the interviewer The credential of the interviewers and the research team were made available on the participant information sheet before informed consent taking N/A
8. Interviewer characteristics VJ is a postgraduate student trained to perform in-depth interview. She underwent qualitative research training and was trained to conduct interviews with the assistance of interview guides Methods
Domain 2: Study design   
Theoretical framework   
9. Methodological orientation and Theory A descriptive qualitative approach was adopted
Manual and line-by-line coding was performed to recognize anchoring phenomena and produce a list of themes and sub-themes accordingly
Methods
Participant selection   
10. Sampling Purposive sampling was used Methods
11. Method of approach Eligible participants were approached in person or by a personalized e-mail invitation, including participant information sheets and permission forms. The interviews were scheduled around the convenience and availability of the physicians at their different clinics Methods
12. Sample size Eleven interviews were conducted Results
13.Non-participation No dropout from all participants agreeing to take part N/A
Setting   
14. The setting of data collection All interviews with the physician were conducted at specified times according to the appointment in the consultation room, at their place of work, maintaining confidentiality and non-disruption Methods
15. Presence of nonparticipants None N/A
16. Description of sample Presented in Table 1 of the result section Results
Data collection   
17. Interview guide An interview guide was developed based on study objectives and validated by two experts, presented in Supplementary material Methods
18. Repeat interviews No  
19. Audio/visual recording All sessions were audio-recorded with permission Methods
20. Field notes No N/A
21. Duration The individual interview lasted an average of 61 min Results
22. Data saturation The sample continued until saturation was achieved and no new themes emerged Methods
23. Transcripts returned Transcripts were not returned to all participants for correction but were given to an independent reviewer to check the audio recording N/A
Domain 3: analysis and findings   
Data analysis   
24. Number of data coders Both VJ and BT coded the data Methods
25. Description of the coding tree A description of the coding tree Is not provided. Instead, only themes and subthemes generated are presented Methods
26. Derivation of themes Themes were derived from the data Methods
27.Software Analysis was done manually N/A
28. Participant checking Participants did not check but were checked by an independent reviewer team N/A
Reporting   
29. Quotations presented Yes, quotations are presented. Anonymized participants details are used for each quote Results
30. Data and findings consistent Yes, there is consistency between data and findings Results
31. Clarity of major themes Major themes are clearly illustrated Results
32. Clarity of minor themes Minor themes are also highlighted Results

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Tangiisuran, B., Rajendran, V., Sha’aban, A. et al. Physicians’ perceived barriers and enablers for deprescribing among older patients at public primary care clinics: a qualitative study. Int J Clin Pharm 44, 201–213 (2022). https://doi.org/10.1007/s11096-021-01336-w

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Keywords

  • Aging population
  • Drug regimen
  • Inappropriate medication
  • Older patients
  • Polypharmacy