Illustrative quotations for enabler themes and subthemes
| Analytical and descriptive themes | Subtheme | Characteristics of studies from which subthemes were derived including: type of PIMs; age focus*; setting (number of references) | Illustrative quotations “Italicised text”=primary quote (ie, quote from a study participant from an included paper) ‘Non-italicised text’=secondary quote (ie, quote from study authors’ findings from an included paper) |
|---|---|---|---|
| Awareness | |||
| Review, observation, audit and feedback 46 47 49 | Misc PIMs (3); Older (2) and all ages (1); Primary (2) and secondary (1) care | As above46 | |
| Inertia | |||
| Prescriber beliefs/attitude | Fear of negative/unknown consequences of continuation 44 | PPIs (1); All ages (1); Primary care (1) | “Miracle all right, but too good of anything can be dangerous. Would just like to reiterate that, let me say they [PPIs] even work too well, what worries me is won't there be long-term missed cancers?”44 |
| Positive attitude towards deprescribing31 | Polypharm (1); Older age (1); Primary care (1) | “You can have a field day with crossing off medication: ‘sure, scrap half of it’”31 | |
| Stopping brings benefits 36 37 48 | Benzos (2) and Misc PIMs (1); Older (2) and all ages (1); Primary care (3) | “O ya, and she was delighted, I stopped some of her other medications because she was in front of me and I had a bit of time to do it”48 | |
| Prescriber behaviour | Devolve responsibility29 40 44 | Antidepressants (1), Misc PIMs (1), PPIs (1); Older (1) and all ages (2); Primary care (1) | ‘Some [GPs] preferred to wait until the patient went to hospital where they would be taken off their drugs without the GP being blamed. The GP might even write and ask a hospital doctor to do this’29 “Why not be honest and say, the NHS can't afford to keep giving you these drugs unless there's a very good reason. The patients understand that, and in this day and age they understand perfectly well about cost”44 |
| Self-efficacy | |||
| Skills/attitude | Confidence (to stop therapy/deviate from guidelines)33 45 | Polypharm (1), PPIs (1); Older patients (1) and all ages (1); Primary care (2) | “It's not as if the life of the patient is suddenly at risk because I take away a pill, yes. […] in the worst case heartburn may re-occur or there is upper abdominal discomfort, but that will not immediately cause a bleeding ulcer”45 “I sort of you know tone those goals down. I am not looking for a Hemaglobin A1C of 7 anymore…so I take the pressure off them and I start removing those medications especially the ones that cause hypoglycaemia”33 |
| Work experience, skills and training30 45 49 | Misc PIMs (1), Polypharm (1), PPIs (1); Older (2) and all ages (1); Primary (2) and secondary (1) care | “Yes, maybe problem oriented when you are new. Maybe now one thinks more about consequences, in another way”30 | |
| Information/decision support | Data to quantify benefits/harms30–32 48 | Misc PIMs (1), Polypharm (3); Older (4); Primary care (4) | “Because actually what you could do is to give him (patient) some more ‘hard core’ facts like: ‘If you refrain from treatment your chance of stroke is 20%…”30 |
| Dialogue with patients29 30 31 44 46 | Misc PIMs (2), Polypharm (2), PPIs (1); Older (2) and all ages (3); Primary care (5) | ‘Discussion during the research interview made some patients more willing to consider a change in medication’29 ‘Adequate discussion with patients was widely recognised as one of the keys to influencing change, but although practiced by some GPs it was not always successful’46 | |
| Access to specialists 40 41 44 49 | Antidepressants (1), Benzos (1), Misc PIMs (1), PPIs (1); Older (2) and all ages (2); Primary (3) and secondary (1) care | ‘They (low benzodiazepine prescribing family physicians) desired better co-operation and clear instructions from psychiatrists’ 41 | |
| Feasibility | |||
| Patient | Receptivity/motivation to change 33 37 46 | Benzos (1), Misc PIMs (1), Polypharm (1); Older (1) and all ages (2); Primary care (3) | “He’s fairly amenable to tinkering with his pills, so we'll look at that”46 |
| Poor prognosis49 | Misc PIMs (1); Older age (1); Secondary care (1) | “Sometimes people have taken 10 medicines while they were in curative care, and gradually they move on to palliative care. Then we must reconsider all the prescriptions, drug by drug, saying: OK, what's the goal? To improve your comfort? Well, this medicine will make you feel more comfortable; we can stop this other one”49 | |
| Resources | Adequate reimbursement 38 | Benzos (1); Older age (1); Primary care (1) | “Reimbursement is very low…I think if it was something that we did get reimbursed on I think you would see physicians’ attitudes a lot different. You'd be more willing to spend time”38 |
| Access to support services31 37 41 46 | Benzos (2), Polypharm (1), Misc PIMs (1); Older (1) and all ages (3); Primary care (4) | ‘Most GPs work closely with a local pharmacist [when undertaking medication review to stop medicines]: the task perception of such pharmacists was an important factor when a GP was looking for decision support in medication review’31 | |
| Work practice | Stimulus to review29 31 40 44 48 49 | Antidepressants (1), Misc PIMs (3); Polypharm (1), PPIs (1); Older (4) and all ages (2); Primary (5) and secondary (1) care | ‘A new patient entering the practice list is welcomed as an opportunity to review their medication’31 |
| Regulatory | Raise the prescribing threshold 44 45 | PPIs (2); All ages (2); Primary care (2) | “I think we are all sitting here and debating about this mainly because of the pressure on us by our pharmaceutical advisors not to prescribe PPIs because of cost implications to the NHS; I bet that this will not be an important topic in 2 years when Losec goes generic”44 |
| Monitoring by authorities 34 | Benzos and minor opiates (1); All ages (1); Primary care (1) | ‘The continuous monitoring of prescriptions by health authorities also put stress on the doctors’34 | |
*Age focus refers to the indicative age group of patients who were the focus of participant discussions, as suggested by the terms used in each article, which did not specify the exact age ranges.
Benzos, benzodiazepines; Misc, miscellaneous; PIMs, potentially inappropriate medications; Polypharm, polypharmacy; PPIs, proton pump inhibitors.