Deprescribing falls risk increasing drugs (FRIDs) in older people who have had a fall: a qualitative interview-based study of pharmacist-reported barriers and facilitators

Abstract Introduction World guidelines for falls prevention and management for older adults recommend the modification/withdrawal of falls risk increasing drugs (FRIDs) in older people who have had a fall.1 There is a lack of research examining barriers to and facilitators of deprescribing FRIDs, despite the known association of these medicines with falls, morbidity and mortality. Aim To investigate barriers to and facilitators of deprescribing FRIDs in older people who have fallen, from the perspective of pharmacist prescribers within a large NHS Healthcare Trust in Northern Ireland and identify relevant theoretical domains for behaviour change to inform development of future interventions to facilitate deprescribing. Methods One-to-one semi-structured qualitative interviews were conducted via Microsoft Teams® or in person using an interview topic guide developed and piloted with pharmacists representative of the target population. The topic guide was based on the Theoretical Domains Framework (TDF), a theoretical framework for understanding behaviour (namely, deprescribing of FRIDs) and informing intervention development.2 Participants were recruited using a purposive sampling approach. Additional inclusion criteria were prescribing responsibilities and recent clinical experience (defined as ‘within the previous 12 months’) of medicines management in older people who have fallen. Interviews were recorded and transcribed verbatim. Data were analysed by two researchers independently using an inductive reflexive thematic approach. Each broad theme was explored to identify subthemes, which were then mapped deductively to TDF domains. Results Iterative data analysis revealed information power was achieved after 12 interviews. Participants’ experience practising as a pharmacist ranged from 8 to 29 years, across hospital clinical pharmacy, care homes and palliative care facilities. Seven broad themes relating to barriers to and facilitators of deprescribing FRIDs were identified. Pharmacists described ‘Emotional challenges around deprescribing’ which was a key theme including barriers and facilitators mapped to the TDF domain ‘Emotion.’ They described ruminating on deprescribing decisions and fear of confrontation with patients and healthcare professionals. Lack of connectivity of information systems between primary and secondary care was reported as a barrier within the themes ‘Support systems’ and ‘Communication’ and mapped to the TDF domain ‘Environmental context and resources.’ ‘Outcomes and impact of deprescribing FRIDs was another theme with barriers and facilitators, mapped to the TDF domain “Beliefs about consequences” where pharmacists outlined the challenge of risk–benefit considerations when deprescribing FRIDs. “Pharmacists” confidence in deprescribing role’, ‘Clinical setting’ and ‘Knowledge and training/experience’ were further themes that emerged, mapped to the TDF domains ‘Social influences,’ ‘Knowledge,’ ‘Skills’ and ‘Social and professional role and identity.’ Conclusion Barriers and facilitators to deprescribing FRIDs were reported including emotional challenges and lack of connectivity of information systems, as well as the need for risk evaluation. Participants were from various roles and locations in the hospital setting and across the interface between primary and secondary care, ensuring a broad range of opinions was gathered. However, confining the study to this setting in one UK region may limit transferability of findings. Barriers, facilitators and TDF domains identified will be presented to Trust policymakers to inform interventions to support deprescribing FRIDs in this patient group.