Barriers and facilitators to deprescribing in primary care: a systematic review.

Alison Jayne Doherty,Beth Shaw,Ruaraidh Hill,Anne-Marie Stephani,Paul Boland,Janet Reed,Lynn Hedgecoe,Nefyn Howard Williams,Andrew J Clegg,Lauren Walker

doi:10.3399/bjgpopen20x101096

Abstract

BackgroundManaging polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.AimTo identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.Design & settingA systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.MethodA search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.ResultsIn total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers’ and patients’ uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.ConclusionA whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Highlights

Polypharmacy, the use of multiple concurrent medications to manage multimorbidity, is a growing concern for healthcare systems globally.[16]
Author Keywords: primary care, review, deprescribing, polypharmacy, multimorbidity, primary health care, general practice. How this fits in Previous reviews have explored patient and/or prescriber barriers and facilitators to safe deprescribing in primary care.[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15]
It is thought to contribute to around 8% of unplanned (Scottish) hospital admissions in older people on multiple medicines,[16] and to the 47% increase in prescriptions dispensed in primary care (UK) over the decade from 2007 to 2017.25 Decreasing inappropriate polypharmacy has become a focus of national and international policy initiatives to improve health, reduce patient harm, and reduce healthcare costs.[24,26]

Summary

Introduction

Polypharmacy, the use of multiple concurrent medications to manage multimorbidity, is a growing concern for healthcare systems globally.[16] It affects some of the most vulnerable in society, often contributing to, and perpetuating, health inequality. Managing polypharmacy is a challenge for healthcare systems globally It is a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-r elated events. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. These are not fully accepted or routinely implemented

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