Table 4 Scoping Review – Barriers to Effective Prescribing in Older Adults
Domain | Constructs | Barriers to Effective Prescribing |
|---|---|---|
Knowledge | • Scientific knowledge • Procedural knowledge • Knowledge of task environment | [Physician] Medical complexity • Multimorbidity, potential interactions between diseases and medications • Polypharmacy, which increases difficulty in rationalizing and deprescribing medications • Increased risk of ADEs or drug-drug interactions • Difficulty in distinguishing between new complaints and medication side effects • Clinical uncertainty • Uncertainty in weighing unmeasurable harms and benefits [Physician] Lack of knowledge or awareness • Lack of awareness of PIP or PIMs • Poor insight into the term and the process of deprescribing • Lack of awareness of prescribing cost differences between care settings • Physicians’ shortcomings in their pharmacological knowledge • Doubts associated with potential ADEs and treatment of older adults • Lack of formal education on prescribing for older adults • Lack of up-to-date knowledge [Patient] Lack of knowledge / poor healthcare literacy • Patients do not understand what medications they are taking • Patients do not inform GPs about their medication intake or side effects • Patients may be more likely to report symptoms to hospital specialists rather than GPs • Unintentional withholding of ADEs because they attribute these to ageing rather than side effects of medications |
Skills | • Skills • Skills development • Competence • Ability • Interpersonal skills • Practice • Skill assessment | [Physician] Lack of skills and confidence • Physician not comfortable with deprescribing (e.g. particularly when not the original prescriber) • Lack of confidence and clinical experience in managing older adult patients • Lack of research, education and training to care for this specific group of patients [Physician] Challenges to discussion with patients • Physicians are reluctant to talk to patients about their life expectancy • Problems with incorporating patients’ prognoses into decisions about therapy appropriateness • Difficulty in communicating risk to patients [Patient] Non-adherence to medications or visits • Lack of adherence to medications, or self-titration of medications • Usage of over-the-counter and traditional medications (e.g. often without informing the primary physician) • Non-adherence to clinic visits • Choosing to ‘doctor hop’ or ‘pharmacy hop’ |
Social/Professional Role and Identity | • Professional identify • Professional role • Social identity • Identity / group identity • Professional boundaries • Professional confidence • Leadership • Organizational commitment | [Physician] Paternalistic doctor-patient relationship • Physicians imposing their own beliefs onto the patient without consideration for the latter [Physician] [System] Role dilemma • Dilemma between economic responsibility for both patients and society [Physician] Concerns on inter-professional relationships • Risk/fear of conflict or damaging the relationship between various healthcare providers • Unwillingness to change recommendations from secondary/tertiary care • Reluctance to interfere with and/or hesitation to discontinue medications that have been prescribed by a colleague or specialist • GPs may feel a lack of appreciation by secondary/tertiary care colleagues for their role as a GP • Respect for hierarchy [Physician] Perceptions of pharmacists’ expertise • Varying perceptions of pharmacists’ recommendations |
Beliefs about Capabilities | • Self-confidence • Self-esteem • Self-efficacy • Perceived competence • Beliefs | [Physician] Self-efficacy issues • Lack of confidence and experience [Physician] Discrepant beliefs and practice • Influence from prescriber’s own beliefs, clinical experience and prescribing habits • Respecting prescriber’s right to autonomy [Patient] Patients’ own expectations and beliefs • Unrealistic expectations and/or demands from patients and families • Personal beliefs, demands and expectations about their own care and medications • Discrepancies between the patients’ preferences and best practice recommendations • Patients are reluctant or disinclined to stop medications that they have used for a long time • Resistant to change and/or poor acceptance of alternatives • Resistant to non-pharmacological treatment alternatives • Some patients ‘love taking medications’ • Demanding specific medications and when refused, obtaining them from different physicians • Patient’s and family’s wishes for medications • Passive approach adopted by patients |
Optimism | • Optimism • Pessimism | – |
Beliefs about Consequences | • Beliefs • Outcome expectancies • Characteristics of outcome expectancies • Anticipated regret • Consequents | [Physician] Clinical • Feeling a sense of fear towards older patients in general owing to their frailty and comorbidities • Fear of causing potential harm by deprescribing • Fear of the unknown • Viewing the deprescribing process as a risk to be avoided • Anxiety when the GP’s own conviction conflicts with either that of a specialty of the guidelines • Fear of ‘giving up on the patient’ • Fear of withdrawal effects (e.g. cessation of opioids and benzodiazepines) [Physician] Social • Fear of offending other doctors [Physician] [System] Legal • Fear of damage to reputation, accountability for adverse outcomes, malpractice or litigation • Litigation fears concerning withholding preventive medications • Fear of medicolegal repercussions or negative responses from patients and their next of kin if rationalizing medications led to clinical events [Patient] Patients’ own expectations and beliefs • Unrealistic expectations and/or demands from patients and families • Personal beliefs, demands and expectations about their own care and medications • Discrepancies between the patients’ preferences and best practice recommendations • Resistance to non-pharmacological treatment alternatives • Demanding specific medications and when refused, obtaining them from different physicians • Patient’s and family’s wishes for medications • Passive approach adopted by patients |
Reinforcement | • Rewards, incentives • Punishment • Reinforcements • Contingencies, sanctions | - Similar to ‘Legal’ concerns in the above ‘Beliefs about Consequences’ domain - |
Intentions | • Stability of intentions • Stages of change model • Transtheoretical model and stages of change | [Physician] Inertia and maintaining the status quo • Differing treatment decisions or changes to the next visit • Easier to maintain the status quo rather than interfere with drug regimes in a stable patient |
Goals | • Goal / target setting • Goal priority • Action planning | – |
Memory, Attention and Decision Processes | • Memory • Attention • Attention control • Decision making • Cognitive overload / tiredness | [Physician] Prescribing challenges • Feeling forced to prescribe • Limited availability of alternatives to medications • Inability to gauge the efficacy effectiveness of a drug for individual patients • Ethical concerns around denying treatments • Need to meet patient expectations • Managing complex drug regimens and side effects • Hesitancy in changing medications that have been prescribed in their current dosage for a long period, or when prescribed by a medical specialist |
Environmental Context and Resources | • Environmental stressors • Resources / material resources • Organizational culture / climate • Salient events / critical incidents • Person to environment interaction • Barriers and facilitators | [Physician] [System] Time constraints • Lack of time to perform medication reviews during the clinic consultation visit • Crowded clinics and high workload, unable to spend too much time with a single patient • Competing demands of practice (e.g. prioritizing other aspects of care rather than deprescribing) • Insufficient time and reimbursement (e.g. to perform medication reviews) [Physician] [System] Lack of resources • Lack of access to a pharmacist (e.g. to assist with medication review) • Limited alternative medications • Limited prescribing support (e.g. formularies and computer decision support have limited adaptability and flexibility with multiple conditions) • Lack of resources to assist family caregivers with challenging symptoms (e.g. incontinence) [System] Lack of inter-professional communication and support • Lack of communication between prescribers before adding on new drugs • Lack of support from secondary/tertiary care especially with the management of complex patients in general practice [Physician] [System] Challenges with evidence-based guidelines • Feeling pressured by guidelines to prescribe medications - including preventive drugs • Less comfortable in deprescribing guideline-recommended therapeutic medications, as compared to deprescribing preventive medications, in patients with poor life expectancy • Easier to pile on the recommendations of one guideline onto another instead of prioritizing • Difficulty in implementing guidelines to older adults with multimorbidity • Exclusion of older adults with multimorbidity in clinical trials • Lack of data for outcomes most important to patients (e.g. improvement in pain control) • Difficulty in applying guidelines because of the heterogeneity of the patients [System] Fragmentation of care • Multiple healthcare providers or prescribers • Patients follow up with multiple hospitals and receive medications from multiple providers • Increased specialization in healthcare • Choosing to focus on subspecialty-based care instead of overall management • Fragmentation of care, lack of a specific or unified physician to follow up with • Lack of ownership to assume responsibility for optimizing a specific patient’s care plans [System] Poor coordination of care • Lack of coordination/communication between transitions and various levels of care • Lack of access to patients’ clinical data from other healthcare settings • Tough job for coordinating physician • Specialists’ lack of a holistic or geriatric view on older adult patients • Lack of relational continuity of care (e.g. lack of specific/unified physician to follow with) • Attribution of medication management responsibility to other physicians [System] Information access and documentation • Lack of coordination of information before adding on new drugs • Lack of or inadequate documentation • Incomplete medication reviews and/or outdated medication lists • Lack of access to information on patients’ current medications • Poor acquisition and documentation of patients’ medication lists • Difficulty in obtaining colleagues’ reasons for prescription • Data lost in the transition from written notes to electronic prescriptions • Lack of access to expert advice and user-friendly decision support (e.g. computer prompts or alerts to notify prescribers of PIMs) [System] Policy and regulatory issues • Insufficient reimbursement • Influences of prescribing policy (e.g. perception of managerial meddling and cost cutting) • Quality measure-driven care [System] Cost issues • Limited options on insurance formularies [System] Influences of the pharmaceutical industry • Widespread marketing of medications in mainstream media • Difficulty in managing direct-to-consumer commercials about drugs and their impact on patients • Physicians themselves may be influenced by pharmaceutical drug representatives |
Social Influences | • Social pressure and norms • Group conformity / identity • Social comparisons • Group norms • Social support • Power • Intergroup conflict • Alienation • Modelling | [Patient] Social factors • Patient’s social context and access to healthcare and resources • Patients who change living or care arrangements may be accompanied by different caregivers to visits, which may result in inconsistent reports from the family and/or lack of continuity of care • Socioeconomic status [Physician] Health beliefs and culture • Culture to prescribe more • Prescribing validates illness |
Emotion | • Fear • Anxiety • Affect • Stress • Depression • Burnout | [Physician] Anxiety or fear • Feeling a sense of fear towards older patients in general owing to their frailty and comorbidities • Fear of causing potential harm by deprescribing • Fear of the unknown • Viewing the deprescribing process as a risk to be avoided • Anxiety when the GP’s own conviction conflicts with either that of a specialty or the guidelines • Fear of damage to reputation, accountability for adverse outcomes, malpractice or litigation • Fear of ‘giving up on the patient’ • Fear of offending other doctors • Fear of withdrawal effects (e.g. cessation of opioids and benzodiazepines) • Litigation fears concerning withholding preventative medications • Fear of medico-legal repercussions or negative responses from patients and their next of kin if rationalizing medications led to clinical events [Physician] Fear of damaging the patient-doctor relationship • Choosing the maintain the patient-doctor relationship rather than enforce changes or recommendations and threatening that relationship |
Behavioural Regulation | • Self-monitoring • Breaking habit • Action planning | – |