Barriers and enablers for deprescribing
There is no ‘one-size-fits-all’ deprescribing intervention and a good understanding of the barriers and enablers to effective deprescribing is needed, according to Debi Bhattacharya, Professor of Behavioural Medicine at the University of Leicester, UK.
“There are there are numerous barriers and enablers – things that will help practitioners and patients to proactively stop a medicine and what we need to do is to design strategies that address these barriers and the enablers. …. There’s no one-size-fits all”, says Professor Bhattacharya. The barriers and enablers are often context-specific. For example, an opioid deprescribing project in an Integrated Care Service (ICS) is very different from deprescribing for older people in a hospital setting. The research community needs to understand the key barriers and enablers in different contexts and then harness behavioural science to address proactive deprescribing, she says.
Who should lead deprescribing?
“In 2018 we surveyed 150 Hospital inpatients and their family members; they said that they wanted the deprescribing discussion to be initiated by a doctor. When we spoke to hospital pharmacists, they also said that they would prefer that the discussion was initiated by the doctor and that they were happy to identify medicines that might require stopping”, she says. In contrast, an opioid deprescribing project in primary care is being largely led by pharmacists, who are also initiating the deprescribing discussions.
Many prescribers harbour “a misconception that patients are resistant or will be resistant to proactively having their medicine stopped and that is a significant barrier to pharmacists, geriatricians [and] doctors across the board initiating deprescribing discussions. So, we know that this is a misconception because when we surveyed 150 people they actually said, “We’re horrified that that you would keep us on medicines that that might not be the right thing for us” – so there is definitely an appetite for medicines to be stopped where the chance of harm outweighs benefit”, she says. However, when deprescribing interventions have been offered to patients in trials, in the majority of cases they’ve been rejected by the patient. “So, there is that disconnect between patients saying, ‘Actually we want to make sure that we’re only on the right medicines’ versus when they’re asked would they would they like to consider stopping, they opt not to”, she adds.
The results of a recent international survey of pharmacists, doctors and nurses involved in proactive deprescribing of medicines showed that one of the key challenges to proactive deprescribing was not having the time to have a meaningful discussion with the patient.
Typically, such discussions would bring together information about the patient’s goals and priorities and the clinical information about the balance of risks and benefits of the treatment in order to support the patient in making a decision. Practitioners reported that they did not have the time to do this and did not always have the skills to navigate that discussion. “So that may shed some light on this disconnect between patients absolutely wanting to only be on medicines where the chance of benefit outweighs harm versus being resistant to medicines being stopped when it’s proposed by a member of the healthcare team, she says.