Background: over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. Methods: fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. Results: geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. Conclusion: the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

Deprescribing is a partnership between practitioners, patients and caregivers. External characteristics including age, comorbidities and polypharmacy are poor predictors of attitude towards deprescribing. This hospital-based study aimed to describe the desire of patients and caregivers to be involved in medicine decision-making, and identify attitudinal predictors of desire to try stopping a medicine. Patients and caregivers recruited from seven Older People’s Medicine wards across two UK hospitals completed the revised Patients’Attitudes Towards Deprescribing (rPATD) questionnaire. Patients prescribed polypharmacy and caregivers involved in medication decision-making of such patients were eligible. A target of 150 patients and caregivers provided a 95% confidence interval of ±11.0% or smaller around rPATD item agreement. Descriptive statistics characterised participants and rPATD responses. Responses to items regarding desire to be involved in medication decision-making and desire to try stopping a medicine were used to address the aims. Binary logistic regression provided the adjusted odds ratios (OR) for predictors of desire to try stopping a medicine. Patient participants (N = 75) were a median (IQ) 87.0 (83.0, 90.0) years old and the median (IQ) number of pre-admission medication was 8.0 (6.0, 10.0). Caregiver participants (N = 76) were a median (IQ) 70.0 (57.0, 83.0) years old and the majority were a spouse (63.2%). For patients and caregivers respectively, the following were reported: 58.7 and 65.8% wanted to be involved in medication decision-making; 29.3 and 43.5% reported a desire to try stopping a medicine. Attitudinal predictors of low desire to try stopping a medicine for patients and caregivers are a perception that there are no unnecessary prescribed medicines [OR = 0.179 (patients) and 0.044 (caregivers)] and no desire for dose reduction [OR = 0.199 (patients) and 0.024 (caregivers)]. A perception of not being prescribed too many medicines also predicted low patient desire to try stopping a medicine [OR = 0.195]. A substantial proportion of patients and caregivers did not want to be involved medication decision-making, however this should not result in practitioners dismissing deprescribing opportunities. The three diagnostic indicators for establishing desire to try stopping a medicine are perceived necessity of the medicine, appropriateness of the number prescribed medications and a desire for dose reduction.

Background: hospital deprescribing trials have demonstrated marginal increases in deprescribing activity that are not sustained beyond the trial period. The hospital deprescribing implementation framework (hDIF) links barriers and enablers of deprescribing in hospital with 44 potential intervention components. This study aimed to support geriatricians and pharmacists to select and characterise hDIF components according to affordability, practicability, effectiveness, acceptability, safety and equity (APEASE) to design a deprescribing intervention in the English hospital setting. Methods: we convened a modified Nominal Group Technique with a panel of nine geriatricians and pharmacists representing five English hospitals. Panel members selected and characterised intervention components from the hDIF based on the APEASE criteria. We set a consensus threshold of 80% agreement per APEASE criterion in order for the intervention component to be included. Results: the panel selected five intervention components supporting engagement with deprescribing: an organisational action plan to prioritise deprescribing, two training activities to address pharmacists’ beliefs about negative deprescribing consequences, restructuring pharmacists’ working patterns to facilitate their contribution to deprescribing decisions, and sharing experiences of successfully engaging patients/family in deprescribing conversations to support others to do the same. A sixth component was selected to sustain engagement with deprescribing through measuring and sharing deprescribing activity achieved between teams. Conclusions: deprescribing interventions targeting geriatricians’ and pharmacists’ behaviour in the English hospital context should include the six characterised components. A component to sustain deprescribing activity is a notable omission from previously reported deprescribing interventions and may explain their failure to maintain efficacy beyond the short-term trial period.

Deprescribing is the term used to describe the discontinuation of medicines. It can be either ‘reactive’, for example in response to an adverse event or therapeutic failure, or ‘proactive’, when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

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