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.