Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

Abstract

Introduction

The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals’ (HCPs) perspective.

Methods

A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework.

Results

Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process.

Conclusion

Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.

Introduction

The prevalence of polypharmacy, generally considered the use of five or more medications, is rising [1–3]. Globally, polypharmacy increases with age, which is mirrored in Ireland, with 31% of the population over 65 taking five or more medications, rising to 37% in patients over 75 [4,5]. While polypharmacy can be appropriate when all medications are clinically indicated, inappropriate polypharmacy is of concern [6–8]. Age-related physiological changes can cause older adults to be exposed to adverse consequences from medications which were once indicated and appropriate [9–11]. Polypharmacy has been associated with potentially inappropriate medications (PIMs) which are linked with negative outcomes for older adults, such as adverse drug reactions, hospitalisations and mortality, particularly for frail older adults resident in long-term care [12–18].

Internationally, PIM use is highly prevalent among older adults resident in long-term care [19]. A Belgian study identified that 64% of frail long-term care patients had one or more PIM [20]. Similarly, this has been identified as a significant problem in Ireland, with studies documenting that 70% of patients were prescribed at least one PIM [14,21]. Considering the relationship between polypharmacy, PIMs and adverse drug reactions for long-term care patients, efforts are required to improve the appropriateness of prescribing in this setting.

Deprescribing, defined as a patient-centred process of medication withdrawal, is an effective intervention to tackle inappropriate polypharmacy as it aims to improve health outcomes through discontinuing medications that are either potentially harmful or no longer required [22,23]. A systematic review of deprescribing interventions in long-term care found evidence of a 59% reduction in PIMs, improved patient safety and an increase in medication appropriateness [24]. Long-term care-specific deprescribing benefits include improved medication adherence, quality of life and reduced time spent on medication administration [25].

Considering the high incidence of PIMs among frail older adults, deprescribing requires further attention. Despite best-practice guidelines, a US study documented limited PIM discontinuation rates, for older adults with limited life expectancy [26]. Similarly, deprescribing interventions, such as medication reviews, are considered unlikely to be incorporated into daily practice [27]. Researchers have called for an increased focus on implementation science to bridge the “research-to-practice gap”, which may increase deprescribing engagement in clinical practice by, for example, tailoring interventions to the long-term care environment [28,29]. As identified by the Medical Research Council’s framework for developing and evaluating complex interventions, context and stakeholder engagement are core elements to intervention design [30]. To develop a successful deprescribing intervention, a better understanding of HCPs’ deprescribing behaviour and the barriers and enablers which they experience in Irish long-term care settings is required, as these are context-specific [31].

In Ireland, different organisational models for long-term care exist. Long-term care facilities are divided into state-funded (public) and private-owned (private) sites, with 80% of settings owned and operated by private providers [32]. Bolmsjö et al compared studies, investigating the deprescribing opinions of long-term care General Practitioners (GPs), in two different countries; Australia, which has both public and private funding, like the Irish model, and Sweden, where all long-term care is state funded. Results indicated contrasting opinions about interest in long-term care work and the need for financial reimbursement [33]. Understanding the barriers and facilitators in both organisational models is imperative to develop an intervention that fits with and addresses the challenges in a specific healthcare context.

The primary aim of this study is to generate an understanding of barriers and enablers to deprescribing in Irish long-term care facilities, which are perceived to exist by HCPs working in and with that setting. This will provide key considerations when designing an intervention to increase deprescribing. A secondary aim is to compare barriers and enablers experienced by HCPs in public and private settings, due to the key differences in funding and governance between the settings.

Materials and methods

Design

Qualitative description was the chosen methodology for this study [34]. Data was collected using semi-structured interviews. Ethical approval was granted for this study from University College Cork’s Social Research Ethics Committee Log 2021–068.

Study participants

Purposive sampling strategies were used to sample sites for this study. Initially, stratified sampling was used, with the sampling criterion being public/private status. Sites were selected from a stratified list of long-term care facilities in the south/southwest (Cork/Kerry) region of Ireland (n = 98) [35]. From these settings, eligible participants were HCPs involved in the direct care of long-term care residents, including GPs, pharmacists and nurses. Consultants were not invited as GPs are primarily responsible for the medical needs of residents in Irish long-term care facilities [36]. Healthcare assistants were not included as they are not involved in medical decisions [37]. Long-term care facilities were contacted via phone call and/or email to introduce the project, along with a request to advertise the project to their HCPs. Follow up emails were sent within three weeks of initial contact. Management staff at the long-term care facilities referred interested nurses and HCPs working off site (GPs and pharmacists), to the researcher. In addition, to increase the sampling pool, a convenience sample of HCPs working in long-term care, were recruited through postgraduate courses in University College Cork. An email was distributed by university staff to post-graduate students and academics introducing the project, recruiting HCPs who worked in long-term care.

Information power was used to determine an appropriate sample size. By applying the five established criteria of information power, an initial sample of between 6–10 participants per HCP group, divided equally between public and private long-term care facilities, was deemed sufficient [38].

Data collection

One-to-one semi-structured interviews were conducted via Microsoft Teams with HCPs. Written, informed consent was obtained from all participants. An interview guide was developed and tailored for each HCP group, guided by the TDF-informed framework of deprescribing barriers and enablers in long-term care facilities [39]. Each domain of the framework informed a question in the topic guide. Additional general questions were included, allowing participants to discuss any factor which they felt was important for deprescribing in long-term care. The guide was reviewed by members of the research team who had experience in qualitative research and refined based on feedback. The interview guide was piloted with a pharmacist, GP, and nurse, all with previous experience of working in long-term care. This confirmed that the guide was clear, understandable and relevant to each HCP group and resulted in no change to the topic guide. As the focus of the study was not related to demographic factors, no demographic details were collected.

All interviews were audio or video-recorded, with the consent of the HCP. Following each interview, recordings were replayed to facilitate familiarisation. All interviews were transcribed verbatim, anonymised and imported into QSR NVivo Version 12® to facilitate analysis.

Data analysis

The analytical strategy involved two processes drawing on the principles of thematic analysis [40]. In the first stage of analysis, interviews were analysed inductively by the primary researcher to develop themes from the data. This stage drew on the principles of Braun and Clarke’s reflexive thematic analysis including familiarisation, generating initial codes, identifying initial themes, reviewing, and developing themes related to deprescribing barriers and enablers [40]. Inductive analysis can support the theory driven deductive approach and offers both a conceptually and contextually rich understanding of the barriers and enablers to deprescribing [41].

This was preferred over direct mapping to the TDF to allow for inclusion of non-TDF related material.

In the second stage, themes were mapped to domains of the deprescribing framework [39]. A second researcher reviewed the inductive themes, with supporting quotes and independently mapped these to the deprescribing framework. Any discrepancies were resolved during regular meetings with the research team, to discuss inductive codes, mapping, and dominant patterns.

Finally, domains of the deprescribing framework were compared according to professional role and type of facility (public/private) to investigate differences. This was conducted independently by two researchers. Meetings were organised to discuss and agree on findings.

To prioritise potential targets for a deprescribing intervention, dominant domains and constructs were identified, based on two criteria (i) frequency with which the barrier/enabler was mentioned and (ii) the importance attached to it by participants.

The consolidated criteria for reporting qualitative research (COREQ-32) statement was used to inform reporting of the findings (Appendix 1). Transcripts were not returned nor was participant checking performed.

Results

A total of 26 interviews of HCPs from 13 long-term care facilities were conducted between July and October 2021, as identified in Table 1. Twenty participants were recruited from long-term care settings and six through academic networks. The interviews had a mean length of 24 mins (range 9 mins-65 mins).

[Figure omitted. See PDF.]

Through inductive analysis, 38 themes related to barriers and enablers to deprescribing were generated. All themes mapped to the deprescribing framework. Dominant barriers and enablers mapped to five domains: ‘knowledge’, ‘social/professional role and identity’, ‘beliefs about capabilities’, ‘environmental context and resources’ and ‘social influence’ as identified in Table 2. Non-dominant barriers and enablers are summarised in Table 3. Constructs representing the major barriers and enablers identified are summarised in (Fig 1). The majority of the dominant domains provide evidence of both barriers and enablers.

[Figure omitted. See PDF.]

(MDT = multidisciplinary team, IT = information technology).

[Figure omitted. See PDF.]

[Figure omitted. See PDF.]

Analysis of domains across HCPs working in public and private settings identified different experiences related to three domains; ‘knowledge’, ‘reinforcement’ and ‘social/professional role and identity’ (Table 4). Commitment, both to the long-term care facility and deprescribing varied among HCPs in public and private settings. Staff from publicly-funded long-term care settings indicated a greater commitment to deprescribing than those working in the private sector. Similarly, HCPs’ opinions on guidelines differed, with HCPs in the private settings reporting limited awareness of deprescribing guidelines. HCPs working in the private sector referenced the need for financial incentives to support their engagement with deprescribing in long-term care to a greater extent than those in public settings.

[Figure omitted. See PDF.]

Analysis of barriers and enablers specific to professional role, identified two findings specific to a healthcare profession; commitment and organisational leadership. Organisational commitment was a barrier attributed only to GPs. Nurses were identified as the organisational leaders of deprescribing by all HCPs based on their knowledge of residents and their role in communication with the GP which leads to medication review.

Discussion

This qualitative study examined the perceived barriers and enablers to deprescribing among HCPs working in Irish long-term care facilities. To the best of our knowledge, this is the first study to utilise the TDF to analyse in-depth the factors which influence deprescribing behaviour in Irish long-term care facilities. Additionally, this study examines how these factors contrast across publicly-funded and privately-run long-term care settings. The major barriers to deprescribing included insufficient resources, lack of co-ordination between healthcare settings, negative social influences among colleagues and patient representatives’ understanding of deprescribing as a removal of care. The main enablers of deprescribing in long-term care were interprofessional support and patient involvement in deprescribing decision making. Potential enablers of deprescribing suggested by HCPs included deprescribing education, role expansion for pharmacists and tailored guidelines. These findings are important as they identify potential targets and important obstacles to consider, when designing a deprescribing intervention in long-term care.

Education was identified by all HCPs as a strong potential deprescribing enabler, similar to other deprescribing studies in this setting [24,42]. Educational opportunities include continuing professional development courses and on-site training, both of which have shown to effectively reduce PIM use in older adults [43]. HCPs proposed that a structured procedure, utilising a multidisciplinary team (MDT) and evidence-based tailored guidelines, would encourage deprescribing engagement. Wouters et al similarly suggest refining the STOPP/START guidelines for implementation in long-term care, to facilitate deprescribing decision making [44]. Considering the awareness among participants of STOPP/START, a future option could be the implementation of STOPPFrail, guidelines tailored for the frail older adult, often the population seen in long-term care [45].

Resources such as time, staff and documentation were described as insufficient in Irish long-term care facilities and a lack of communication and co-ordination between healthcare settings was believed to be responsible for the fragmented care for long-term care patients. These environmental barriers echo challenges identified in Irish primary care settings [46,47] and in international long-term care settings. [48–53]. Investment in resources, such as electronic health records could help to address these obstacles, supporting communication and co-ordination of patient care. Benefits of electronic health records in long-term care include improved access to patient information, increased documentation accuracy and better evidence-based practice implementation [54]. Furthermore, benefits of sharing health records between healthcare systems included improved communication and care planning, which could improve the time, administrative burdens and communication barriers which exist in long-term care [55].

Similarly, HCPs in this study reported insufficient financial resources to engage in deprescribing, which is a widely documented barrier in all healthcare settings [51,56–58]. Where financial incentives exist, HCPs are more positive toward deprescribing [33]. Currently in Ireland, HCPs are not reimbursed to provide deprescribing services in long-term care facilities. Furthermore, community pharmacists are reimbursed per item dispensed and thus, deprescribing could be perceived as a potential financial disincentive. A similar challenge exists in Germany, with pharmacists explaining that by deprescribing PIMs, they are “doing the right thing, and getting less for it” [59]. This remains a barrier which requires change in the reimbursement structure and potential governmental incentivisation to overcome. Despite lack of resources and communication channels, the long-term care environment was regarded by participants as an ideal setting for deprescribing. This is due to the increased patient observations compared to the community setting, perceived quality of nursing care and a controlled environment.

Deprescribing in long-term care is negatively impacted by the widespread perception of an ‘established hierarchy’, where GPs are regarded as having seniority above pharmacists and nurses [57,60]. Interestingly, in this study, GPs did not feel pressure to conform to the prescribing practices of consultants, as they perceive themselves to be the HCP responsible for patient care. This contrasts with the international opinion where consultants occupy the apex of the hierarchy, despite little difference in consultant roles between jurisdictions [48,50,51,61]. Future deprescribing interventions could benefit from incorporating the entire MDT to mitigate fears of perceived hierarchy. Reinforcing this, HCPs called for an expansion of integrated pharmacist services in long-term care. Pharmacists are identified as deprescribing facilitators, offering knowledge, support and confidence in decision making. Similar campaigns exist internationally promoting the integration of pharmacists into long-term care, to provide clinical services, participate in discussions and educate staff [62]. A systematic review by Sadowski et al concluded that there is evidence to support the integration of a pharmacist into long-term care, particularly to provide medication reviews to increase medication appropriateness, supporting the response from study participants [63].

Comparing the opinions of HCPs from public and private settings, HCPs working in privately-funded long-term care facilities had a limited awareness of deprescribing guidelines and increasingly called for financial incentives compared to their counterparts in publicly-funded settings. GPs and pharmacists from both settings are remunerated for care provided to patients; however, HCPs felt that the current format and extent of reimbursement for private long-term care work isn’t sufficient to warrant the time required to engage with deprescribing. This is an important consideration, if developing a deprescribing intervention for long-term care. Similarly, commitment levels to long-term care work varied among HCPs. GPs and pharmacists in public settings are “contractually required” to attend the long-term care setting. Contrastingly, in the private sector, GPs explained that often it is their registrar who attends the long-term care facility, as they themselves do not have sufficient time. This perceived lack of interest and commitment appears to be an ongoing problem within Irish healthcare, as it was highlighted in 2015 by Nursing Homes Ireland as an issue of concern [64]. Bolmsjö et al similarly identified contrasting interest in long-term care work among HCPs from two jurisdictions with different organisational structures [33]. A UK study which switched the frequency of long-term care visits from ad hoc to weekly, resulted in reduced hospital admissions and care home visits. The routine structure allowed ‘ward round style’ care, similar to public long-term care facilities, supporting HCP education and decision making [65]. Incorporating routine visits into the Irish private long-term care sector could support deprescribing engagement; however, reimbursement may be required to incentivise GPs to dedicate time to such work. Alternatively, an organisational switch toward a medical officer model could be considered, creating a defined, reimbursed role.

The foundation to support deprescribing exists in long-term care. The medication review is identified, both from this study and the wider literature, as an ideal opportunity to engage with successful deprescribing [24,66,67]. However, in the Irish context this needs reform, switching from a “tick-box” exercise to a meaningful intervention, facilitating deprescribing. Suggested changes include creating a structured procedure, incorporating the MDT, shared decision-making and tailored guidelines, to increase uniformity, acceptability, and engagement.

Strengths/Limitations

Strengths of this study include the chosen methodology and sampling strategy. Qualitative description allowed for a rich description of experiences, from the perspective of participants [68]. Purposively sampling HCPs from both private and public long-term care settings, in addition to triangulation of opinions from multiple HCPs involved in the immediate care of long-term care residents, offers an in-depth understanding of the barriers and enablers present in different types of long-term care settings operating in Ireland. The results will inform the development of an intervention that can be tailored to each setting, but also providing contextual information to support transferability of the findings. This study mapped barriers and enablers to a TDF-informed deprescribing framework, increasing the utility of the study to inform intervention development [69]. Using a deprescribing framework, created to identify barriers and enablers in long-term care, allows incorporation of contextual influences which can moderate behaviour. Such motives may not be captured in a purely TDF-focused deductive analysis [70].

Some limitations of this study exist. The interviewer is a pharmacist. This was known to the participants at the time of the interview and may have affected responses; participants tailoring their opinions to meet anticipated expectations. However, conversations were meaningful and engaging. This also could have introduced professional bias during analysis, as the majority of the research team were pharmacists. Long-term care facilities were asked to introduce the project to their staff, therefore the risk of selection bias cannot be ruled out. Due to COVID-19 restrictions, interviews were conducted via Microsoft Teams ©. The use of technology may have deterred potential participants from engaging in the research, possibly due to technical issues, planning, privacy and rapport [71].

Conclusion

HCPs working in Irish long-term care understand deprescribing; however, it is not routine practice. Deprescribing interventions can build on existing structures, such as the quarterly medication review by incorporating a MDT approach, drawing on the knowledge and experiences of all HCP in a structured, routine manner. A deprescribing algorithm, supported with tailored guidelines and education could support engagement from all HCPs, both during formal medication reviews and for any change in a patient’s clinical condition, requiring deprescribing. Furthering knowledge and encouraging engagement for all HCPs can offer the confidence required to make evidence-based deprescribing decisions in long-term care. It is suggested that the environment of the long-term care facility is an ideal setting for deprescribing, however limited resources in addition to the poor co-ordination with other healthcare settings, confines HCPs from successfully deprescribing. Expanding pharmacists’ role to include deprescribing responsibilities may help to overcome time constraints for other HCPs. Patient engagement in the form of shared decision making is an option to overcome the anticipated negative response from patients and representatives toward deprescribing. HCPs consider it feasible to implement deprescribing in long-term care, however an intervention must be designed to account for the nuanced barriers which exist in both settings.

Supporting information

S1 File.

https://doi.org/10.1371/journal.pone.0274552.s001

(DOCX)

Acknowledgments

C.H.H would like to acknowledge Mr. Eoin Hurley for his assistance in the reviewing the mapping process involved in the research. C.H.H. would also like to acknowledge Prof. Eileen Savage, School of Nursing and Midwifery, University College Cork, Ireland, who teaches PG6024, a postgraduate module in qualitative research.

Citation: Heinrich CH, McHugh S, McCarthy S, Donovan MD (2022) Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland. PLoS ONE 17(12): e0274552. https://doi.org/10.1371/journal.pone.0274552

About the Authors:

Clara H. Heinrich

Contributed equally to this work with: Clara H. Heinrich, Sheena McHugh, Suzanne McCarthy, Maria D. Donovan

Roles: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft

E-mail: [email protected]

Affiliation: School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland

ORICD: https://orcid.org/0000-0002-8296-4393

Sheena McHugh

Contributed equally to this work with: Clara H. Heinrich, Sheena McHugh, Suzanne McCarthy, Maria D. Donovan

Roles: Conceptualization, Supervision, Writing – review & editing

Affiliation: School of Public Health, University College Cork, Cork City, Co. Cork, Ireland

Suzanne McCarthy

Contributed equally to this work with: Clara H. Heinrich, Sheena McHugh, Suzanne McCarthy, Maria D. Donovan

Roles: Conceptualization, Supervision, Writing – review & editing

Affiliation: School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland

Maria D. Donovan

Contributed equally to this work with: Clara H. Heinrich, Sheena McHugh, Suzanne McCarthy, Maria D. Donovan

Roles: Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Affiliation: School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland

References

1. World Health Organization. (2019). Medication safety in polypharmacy: technical report. World Health Organization. https://apps.who.int/iris/handle/10665/325454. License: CC BY-NC-SA 3.0 IGO.

2. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatrics. 2017 Oct 10;17(1):230. pmid:29017448

3. Payne RA, Avery AJ. Polypharmacy: one of the greatest prescribing challenges in general practice. Br J Gen Pract. 2011 Feb 1;61(583):83–4. pmid:21276330

4. Richardson K, Moore P, Peklar J, Galvin R, Bennett K, Kenny RA. Polypharmacy in adults over 50 in Ireland: Opportunities for cost saving and improved healthcare [Internet]. The Irish Longitudinal Study on Ageing; 2012 Dec [cited 2021 May 4]. Available from: https://tilda.tcd.ie/publications/reports/Polypharmacy/.

5. Wang R, Chen L, Fan L, Gao D, Liang Z, He J, et al. Incidence and Effects of Polypharmacy on Clinical Outcome among Patients Aged 80+: A Five-Year Follow-Up Study. PLOS ONE. 2015 Nov 10;10(11):e0142123. pmid:26554710

6. Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3 rd Edition, 2018. Scottish Government [Internet]. [cited 2021 May 6]. Available from: https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf.

7. Cadogan CA, Ryan C, Hughes CM. Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many. Drug Saf. 2016;39:109–16. pmid:26692396

8. Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol. 2014 Jun;77(6):1073–82. pmid:24428591

9. Dagli RJ, Sharma A. Polypharmacy: A Global Risk Factor for Elderly People. J Int Oral Health. 2014;6(6):i–ii. pmid:25628499

10. Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list—appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician. 2012 Dec;41(12):924–8. pmid:23210113

11. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? The Lancet. 2007 Jul 14;370(9582):173–84. pmid:17630041

12. Abdulah R, Insani WN, Destiani DP, Rohmaniasari N, Mohenathas ND, Barliana MI. Polypharmacy leads to increased prevalence of potentially inappropriate medication in the Indonesian geriatric population visiting primary care facilities. Ther Clin Risk Manag. 2018 Sep 4;14:1591–7. pmid:30233194

13. Jankyova S, Rubintova D, Foltanova T. The analysis of the use of potentially inappropriate medications in elderly in the Slovak Republic. Int J Clin Pharm. 2020 Feb 1;42(1):100–9. pmid:31820202

14. O’Sullivan DP, O’Mahony D, Parsons C, Hughes C, Murphy K, Patterson S, et al. A prevalence study of potentially inappropriate prescribing in Irish long-term care residents. Drugs Aging. 2013 Jan;30(1):39–49. pmid:23229766

15. Fried TR, O’Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health Outcomes Associated with Polypharmacy in Community-Dwelling Older Adults: A Systematic Review. Journal of the American Geriatrics Society. 2014;62(12):2261–72. pmid:25516023

16. Hedna K, Hakkarainen KM, Gyllensten H, Jönsson AK, Petzold M, Hägg S. Potentially inappropriate prescribing and adverse drug reactions in the elderly: a population-based study. Eur J Clin Pharmacol. 2015 Dec 1;71(12):1525–33. pmid:26407684

17. Herr M, Grondin H, Sanchez S, Armaingaud D, Blochet C, Vial A, et al. Polypharmacy and potentially inappropriate medications: a cross-sectional analysis among 451 nursing homes in France. European Journal of Clinical Pharmacology. 2017;73(5):601–8. pmid:28093640

18. Bjerre LM, Ramsay T, Cahir C, Ryan C, Halil R, Farrell B, et al. Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario’s older population: a population-based cohort study applying subsets of the STOPP/START and Beers’ criteria in large health administrative databases. BMJ open. 2015/11/27 ed. 2015 Nov 25;5(11):e010146. pmid:26608642

19. Storms H, Marquet K, Aertgeerts B, Claes N. Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review. Eur J Gen Pract. 2017 Mar 8;23(1):69–77. pmid:28271916

20. Fournier A, Anrys P, Beuscart JB, Dalleur O, Henrard S, Foulon V, et al. Use and Deprescribing of Potentially Inappropriate Medications in Frail Nursing Home Residents. Drugs Aging. 2020 Oct 13. pmid:33047252

21. Ryan C, O’Mahony D, Kennedy J, Weedle P, Cottrell E, Heffernan M, et al. Potentially inappropriate prescribing in older residents in Irish nursing homes. Age Ageing. 2013 Jan;42(1):116–20. pmid:22832380

22. Page A, Clifford R, Potter K, Etherton-Beer C. A concept analysis of deprescribing medications in older people. Journal of Pharmacy Practice and Research. 2018;48(2):132–48.

23. Mangin D, Bahat G, Golomb BA, Mallery LH, Moorhouse P, Onder G, et al. International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action. Drugs Aging. 2018 Jul;35(7):575–87.

24. Kua CH, Mak VSL, Huey Lee SW. Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2018/12/26 ed. 2019 Mar;20(3):362-372.e11. pmid:30581126

25. Ailabouni N, Tordoff J, Mangin D, Nishtala PS. Do Residents Need All Their Medications? A Cross-Sectional Survey of RNs’ Views on Deprescribing and the Role of Clinical Pharmacists. J Gerontol Nurs. 2017/09/26 ed. 2017 Oct 1;43(10):13–20. pmid:28945268

26. Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, et al. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. Journal of the American Geriatrics Society. 2020;68(11):2609–19. pmid:32786004

27. Dalin DA, Vermehren C, Jensen AK, Unkerskov J, Andersen JT. Systematic Medication Review in General Practice by an Interdisciplinary Team: A thorough but Laborious Method to Address Polypharmacy among Elderly Patients. Pharmacy. 2020 Jun;8(2):57. pmid:32244439

28. Ailabouni NJ, Reeve E, Helfrich CD, Hilmer SN, Wagenaar BH. Leveraging implementation science to increase the translation of deprescribing evidence into practice. Res Social Adm Pharm. 2021 Jun 6;S1551-7411(21)00184-4. pmid:34147372

29. Thompson W, Reeve E, Moriarty F, Maclure M, Turner J, Steinman MA, et al. Deprescribing: Future directions for research. Res Social Adm Pharm. 2018/09/23 ed. 2019 Jun;15(6):801–5. pmid:30241876

30. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021 Sep 30;374:n2061. pmid:34593508

31. Scott S, Twigg MJ, Clark A, Farrow C, May H, Patel M, et al. Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists. Age Ageing. 2019/11/12 ed. 2019 Dec 1;49(1):102–10. pmid:31711097

32. Health Information and Quality Authority Annual Report 2020 [Internet]. [cited 2021 Oct 20]. Available from: https://www.hiqa.ie/sites/default/files/2021-08/HIQA-Annual-Report-2020_0.pdf.

33. Bolmsjö B, Palagyi A, Keay L, Potter J, Lindley R. Factors influencing deprescribing for residents in Advanced Care Facilities: insights from General Practitioners in Australia and Sweden. BMC Family Practice. 2016 Nov 5;17.

34. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000 Aug;23(4):334–40. pmid:10940958

35. Health Service Executive. Nursing Homes in Ireland—HSE Open Data [Internet]. 2017 [cited 2021 Dec 14]. Available from: https://data.ehealthireland.ie/dataset/list-of-nursing-homes-in-ireland/resource/489aad00-cad1-41d7-92bf-8b5cdd9d61ea.

36. Corroon-Sweeney E, Murphy C, Collins DR. Caring for nursing home patients—a primary care perspective. Ir Med J. 2009 Nov 1;102(10):317–20. pmid:20108798

37. Conyard KF, Codd M, Metcalfe A, Corish S, Flannery J, Hannon P, et al. Healthcare Assistants and Qualified Carers, A Trained, but Untapped Underutilised Resource: A population-based study in Ireland of skillset, career satisfaction, wellbeing and change across all sectors and care settings [Internet]. UCD CSTAR & HCA & Carers Ireland; 2020 Mar [cited 2021 Dec 15]. Available from: https://researchrepository.ucd.ie/handle/10197/11457.

38. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016 Nov;26(13):1753–60. pmid:26613970

39. Heinrich CH, Hurley E, McCarthy S, McHugh S, Donovan MD. Barriers and enablers to deprescribing in long-term care facilities: a ‘best-fit’ framework synthesis of the qualitative evidence. Age and Ageing. 2022 Jan 1;51(1):afab250. pmid:35077555

40. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006 Jan 1;3(2):77–101.

41. McGowan LJ, Powell R, French DP. How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. British Journal of Health Psychology. 2020;25(3):677–94. pmid:32558289

42. Lo SY, Reeve E, Page AT, Zaidi STR, Hilmer SN, Etherton-Beer C, et al. Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff. Drugs Aging [Internet]. 2021 Jun 25 [cited 2021 Jul 12]; Available from: https://link.springer.com/10.1007/s40266-021-00874-2.

43. Rognstad S, Brekke M, Fetveit A, Dalen I, Straand J. Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial. Br J Gen Pract. 2013 Aug 1;63(613):e554–62. pmid:23972196

44. Wouters H, Foster JM, Ensink A, O’Donnell LK, Zuidema SU, Boersma F, et al. Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study. Front Pharmacol [Internet]. 2019 [cited 2020 Nov 11];10. Available from: https://www.frontiersin.org/articles/10.3389/fphar.2019.01026/full.

45. Liu W, Puts M, Jiang F, Zhou C, Tang S, Chen S. Physical frailty and its associated factors among elderly nursing home residents in China. BMC Geriatr. 2020 Aug 17;20:294. pmid:32807098

46. Kelly D, Graffi J, Noonan M, Green P, McFarland J, Hayes P, et al. Exploration of GP perspectives on deprescribing antidepressants: a qualitative study. BMJ Open. 2021 Apr 1;11(4):e046054. pmid:33820792

47. Heinrich CH, Donovan MD. Assessing community pharmacists’ attitudes towards identifying opportunities for deprescribing in clinical practice in Ireland. International Journal of Pharmacy Practice. 2022 Jan 1;30(1):28–35. pmid:34998277

48. Foley RA, Hurard LL, Cateau D, Koutaissoff D, Bugnon O, Niquille A. Physicians’, Nurses’ and Pharmacists’ Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study. Pharmacy. 2020 Mar;8(1):17. pmid:32046022

49. Simmons SF, Bonnett KR, Hollingsworth E, Kim J, Powers J, Habermann R, et al. Reducing Antipsychotic Medication Use in Nursing Homes: A Qualitative Study of Nursing Staff Perceptions. The Gerontologist. 2018;58(4):e239–50. pmid:28575301

50. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM (2016) Challenges and Enablers of Deprescribing: A General Practitioner Perspective. PLoS ONE 11(4): e0151066. pmid:27093289

51. Kua CH, Mak VS, Lee SWH. Perspectives of health professionals towards deprescribing practice in Asian nursing homes: a qualitative interview study. BMJ Open. 2019 Oct 1;9(10):e030106. pmid:31604786

52. Ellis ML, Molinari V, Dobbs D, Smith K, Hyer K. Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes. Aging & Mental Health. 2015 Jun;19(6):507–16.

53. Robbins I, Gordon A, Dyas J, Logan P, Gladman J. Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study. BMJ Open. 2013 Jul;3(7):e003178. pmid:23872297

54. Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: early adopters in long-term care facilities. Health Care Manage Rev. 2011 Sep;36(3):265–74. pmid:21646885

55. Powell KR, Deroche CB, Alexander GL. Health Data Sharing in US Nursing Homes: A Mixed Methods Study. Journal of the American Medical Directors Association. 2021 May 1;22(5):1052–9. pmid:32224261

56. Conklin J, Farrell B, Suleman S. Implementing deprescribing guidelines into frontline practice: Barriers and facilitators. Res Social Adm Pharm. 2018/09/23 ed. 2019 Jun;15(6):796–800. pmid:30241874

57. Disalvo D, Luckett T, Bennett A, Davidson P, Agar M. Pharmacists’ perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study. Int J Clin Phar,. 2019 Aug;41(4):950–62. pmid:31123899

58. Doherty AJ, Boland P, Reed J, Clegg AJ, Stephani AM, Williams NH, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open. 2020 Aug 1;4(3):bjgpopen20X101096. pmid:32723784

59. Gerlach N, Michiels-Corsten M, Viniol A, Schleef T, Junius-Walker U, Krause O, et al. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing—a qualitative study. BMC Fam Pract. 2020/09/06 ed. 2020 Sep 4;21(1):183. pmid:32887551

60. Palagyi A, Keay L, Harper J, Potter J, Lindley RI. Barricades and brickwalls—a qualitative study exploring perceptions of medication use and deprescribing in long-term care. BMC Geriatr. 2016 Jan 15;16:15. pmid:26767619

61. Turner JP, Edwards S, Stanners M, Shakib S, Bell JS. What factors are important for deprescribing in Australian long-term care facilities? Perspectives of residents and health professionals. BMJ Open. 2016/03/12 ed. 2016 Mar 10;6(3):e009781. pmid:26966056

62. Harrison SL, Sluggett JK. Impact of interdisciplinary approaches to deprescribing psychotropics on clinical outcomes in older residents of long-term care facilities. Int Psychogeriatr. 2021 Jun;33(6):543–6. pmid:34078496

63. Sadowski CA, Charrois TL, Sehn E, Chatterley T, Kim S. The role and impact of the pharmacist in long-term care settings: A systematic review. J Am Pharm Assoc (2003). 2020 Jun;60(3):516-524.e2. pmid:31987811

64. Equal Care Equal Rights. Nursing Home Ireland 2015 [Internet]. [cited 2021 Oct 14]. Available from: https://nhi.ie/wp-content/uploads/2019/05/Nov_2015_Equal_Care_Equal_Rights_NHI_Submission_re_GP_Contract.pdf.

65. Roche E. Time to change care home resident management: reflections on a GP-led service. Br J Gen Pract. 2014 Nov 1;64(628):591–2. pmid:25348989

66. Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017/01/09 ed. 2017 Mar;38:3–11. pmid:28063660

67. Tangiisuran B, Rajendran V, Sha’aban A, Daud NAA, Nawi SNM. Physicians’ perceived barriers and enablers for deprescribing among older patients at public primary care clinics: a qualitative study. Int J Clin Pharm [Internet]. 2021 Oct 12 [cited 2021 Oct 21]; Available from: pmid:34642869

68. Sullivan-Bolyai S, Bova C, Harper D. Developing and refining interventions in persons with health disparities: the use of qualitative description. Nurs Outlook. 2005 Jun;53(3):127–33. pmid:15988449

69. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017/06/24 ed. 2017 Jun 21;12(1):77. pmid:28637486

70. McGowan . How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review—McGowan—2020—British Journal of Health Psychology—Wiley Online Library [Internet]. 2020 [cited 2021 Jul 5]. Available from: https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/bjhp.12437.

71. Boland J, Banks S, Krabbe R, Lawrence S, Murray T, Henning T, et al. A COVID-19-era rapid review: using Zoom and Skype for qualitative group research. Public Health Res Pract [Internet]. 2021 [cited 2021 Dec 9]; Available from: https://www.phrp.com.au/?p=40557.