Discussion This systematic review comprehensively investigates prescriber barriers and enablers to minimising the prevalence of chronically prescribed PIMs in adults. The thematic construct which was developed from
published literature centres on Awareness, Inertia, Self-efficacy and Feasibility. It principally reflects the SAHA HDAC perspectives of primary care physicians managing older, community-based adults. Although the themes and subthemes have been presented separately, the reasons doctors continue to prescribe, or do not cease, PIMs are multifactorial, highly interdependent and impacted by considerable clinical complexity. Many subthemes were common to papers regardless of interstudy differences in the PIMs discussed, patient age and clinical
setting (eg, primary, secondary or residential aged care). Subthemes varied according to whether studies focused on polypharmacy or single PIMs or classes of PIMs, which were also associated with differing levels of prescriber insight and certainty. In the four studies focused on polypharmacy, prescribers were aware of polypharmacy-related harm but could not easily identify which medications were inappropriate, as reflected by the subthemes ‘difficulty/inability to balance benefits and harms of therapy’,30–33 ‘inability to recognise adverse drug effects’,31 32 ‘lack of evidence’30 31 33 and ‘incomplete clinical picture’.30–33 In other studies focusing on specific classes of overprescribed medications, prescribers were aware of this inappropriateness,
but in response voiced various rationalisations for continued prescribing such as ‘drugs work, few adverse effects’,34 35 38 39 41 43–45 47 ‘prescribing is kind and meets needs’,34 37–41 43 44 ‘stopping is difficult, futile, has or will fail’,34 36–38 42 43 47 ‘poor (patient) acceptance of alternatives’,37 38 42–44 and ‘difficult and intractable adverse (patient) circumstance’.34 35 37 39 40 However, in other studies focusing on miscellaneous PIMs, prescribers Batimastat were generally not aware of their inappropriate prescribing until this was revealed to them (eg, through audit and feedback).46 47 49 No definite thematic pattern was observed from the subthemes of six studies which did not specifically focus on the care of older people29 37 39 41 44 45 compared with the remaining 15 which did. Compared with studies in primary care, unique themes emerged from papers set in RACFs and acute care settings. For example, pressure on prescribers to continue prescribing PIMs at the request of RACF nursing staff was unique to this setting.42 43 The one study set in acute care highlighted inexperience and training deficiencies of junior prescribers, as viewed by three geriatricians.