Deprescribing: barriers and enablers


Kristen Anderson

Community pharmacists can play a strong role in identifying patients who would benefit from a review of their medicines with a view to deprescribing, says one expert.

Kristen Anderson from the University of Queensland presented a poster at the National Medicines Symposium on “Negotiating ‘unmeasurable harms and benefits’ – General practitioners’ and consultant pharmacists’ barriers and enablers to deprescribing in primary care”.

She told the AJP that a great deal of work is being done on deprescribing for seniors in residential care, but it was also vital to look at deprescribing in the community setting.

“There’s a lot of literature out there showing the harms related to potentially inappropriate medicines or polypharmacy, so why is it that prescribers aren’t addressing this as a matter of urgency?” she says.

“So we undertook a systematic review of the literature and we found some really interesting things: barriers and enablers can broadly be categorised based on awareness, inertia, self-efficacy and feasibility.

“We then build on that work with this study, exploring Australian GPs’ and consultant pharmacists’ barriers and enablers to deprescribing in community-based older people in the local context.”

The study found that “feasible, locally relevant deprescribing initiatives need to take account of GPs’ and consultant pharmacists’ highly individualised decision making and variable barriers and enablers to prescribing change”.

Findings included:

  • Working through possibilities is a major theme, underpinned by GP/pharmacist characteristics, patient, drug, hospital, specialist factors and influences.
  • Information gaps hamper GPs, but especially consultant pharmacists, who lack tacit knowledge of a patient.
  • Fear of deprescribing consequences, time constraints and crowded clinical agendas promote GP’s therapeutic inertia.
  • Prominent enablers to deprescribing include clear clinical or situational triggers to review/change therapy.
  • For GPs, an ongoing patient relationship is critical to deprescribing.
  • The CEASE deprescribing framework developed by Scott et al1 is a useful tool for reflection and learning but not application at the point of care.

 

These findings were utilised to develop a “multifaceted intervention” which has just been piloted in general practice.

Anderson says that addressing polypharmacy at the community level, as well as in residential care, will only become more important as the population ages.

“We wanted to wind the clock forward, if you like, and think about some of the policy drivers around trying to keep people in their own homes – which is more affordable for the government and in fact is more consistent with what consumers want – and so we thought that there really needs to be something that can be driven by general practitioners, with the support of other health professionals. We felt that consultant pharmacists were well positioned there.

“I think community pharmacists are also very well placed to identify those individuals at high risk of medication misadventure.

“Often they’ve got real potential to be flagging these individuals, and to become part of the process and part of the solution, because things don’t happen in isolation – if any of these changes are to be made to older people’s medication regimens then community pharmacists very much need to be part of that process,” she says.

“And they need to facilitate that with the patient, with whom they have ongoing relationships, unlike consultant pharmacists who sometimes only see people once, and then don’t have the opportunity to follow up for a long time – unless that consultant pharmacist is in the ideal position of being attached to the community pharmacy, and having relationships with the local GPs too.

“That’s really the ideal: being connected with the patient and the GP, offering the ability to do a medicines review and having those links with the community pharmacy.”

 

  1. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Internal Medicine. 2015;175(5):827-34.

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