Discussion
To the best of our knowledge, there appear no studies done to investigate HCPs’ insight on deprescribing in Africa, and this study assessed HCPs’ perceptions and experiences with medication discontinuation decisions in Ethiopia. Polypharmacy increases the chance of interactions and inappropriate medications (5, 6, 8) leading to adverse drug reactions and hospital admission (15, 16). As a result, polypharmacy makes prescribing medication be more difficult and complicated (1). Till date, all other studies (17-24) employed qualitative methods to explore HCPs’ perceived barriers to deprescribing practice. To our knowledge, this is the first quantitative study to evaluate factors influencing HCPs’ deprescribing decisions in resource-limited settings like Ethiopia.
Overall, consideration of medication discontinuation is less influenced by the overall five domains in most of the participants for 73 (89%) having a mean influence level of less than 1.5. This may be due to the fact that participants’ deprescribing practice may be suffering from other challenges unaddressed in this quantitative study. In other studies (18, 25), barriers affecting deprescribing practice have been broadly classified into intrinsic factors to the HCPs (beliefs, attitudes, knowledge, skills, and behaviour) and extrinsic factors to the HCPs such as patient, work setting, health care system and culture (18, 25).
In the current study, the occurrence of significant physical health conditions profoundly influenced HCPs to discontinue patients’ medication. They also feel confident to make a deprescribing decision with the patient’s clinical endpoints such as blood pressure. However, HCPs’ level of comfort to decide medication discontinuation is least influenced by the strong relationship they have with their patients. A systematic review by Anderson K. et al. identified intrinsic problems, prescribing inertia (failure to deprescribe inappropriate medication despite the awareness of its presence), and low self-efficacy. The busy workflow and feasibility aspects were also acknowledged as external barriers in routine clinical practice (25).
Similarly, a qualitative study done in Australia and Sweden demonstrated that environmental factors, skills and abilities, and intentions could influence HCPs’ behaviour to deprescribe. The study explained that intentions to deprescribe could also be affected by the HCP’s attitude, norms, and self-efficacy (18). Patients centred decision-making process should be a part of deprescription practice. Involving patients in deprescription necessitates their readiness to discontinue their medications. A study done in Ethiopia showed that older patients were willing to discontinue their medication as long as their doctor believed it was possible (10). This could enable HCPs to cooperate with their patients in deprescription decisions effectively.
Formal education and on-the-job experience were frequently reported to be more important for HCPs to consider medication discontinuation in our study. In Bolmsjö BB et al. study has also explored that skills and knowledge are mostly lacking (18), and suggested a need for more education for evidence-based deprescribing (26).
The current study showed that clinical pharmacists had good perception level towards medication discontinuation as compared to physicians. Physicians may not be well acquainted with the deprescribing process and its benefit due partly to the lack of adequate evidence to change the usual clinical practise (18). Physicians’ decisions for deprescribing could be supported by other HCPs recommendations like pharmacists (27). Thus, inter-professional communication could improve decision making and facilitate successful deprescribing practise since different HCPs may have different barriers and priorities for deprescribing interventions (24, 28).
A study by Forsetlund et al. have shown that interventions, including education and pharmacist-led medication review could lessen harmful medications under certain circumstances (29). A recent study conducted in Canada suggested that pharmacist-led deprescribing focused medication review minimised unnecessary and potentially harmful medications (30). There have been several tools to support HCPs to assuredly deprescribe harmful or unwanted medications (31). However, it is unknown as to which tools are more important to effectively deprescribing and improving patient outcomes particular to the Ethiopian context. As an initial step, developing therapy-specific algorithm could assist HCPs with deprescribing decisions.