Physicians Report Numerous Barriers to Deprescribing Patients' Medications

Deprescribing ongoing medications has been identified as a way to prevent adverse drug events and avoid unnecessary medication utilization, but a recent study finds that physicians report a number of obstacles making it difficult for them to deprescribe in their practice.

In the study, published in Annals of Family Medicine, researchers conducted interviews with 24 primary care physicians to elicit their thoughts on deprescribing, or tapering and withdrawing medicines if they determine the risks outweigh the benefits. The strategy has been identified as a key component of best prescribing practices, but most research to date has focused on patients’ reactions to deprescribing or how to deprescribe in long-term care settings, rather than physicians’ opinions and experiences.

The interview subjects generally felt that deprescribing was an important part of ensuring patient safety, but reported a number of obstacles that made it difficult for them to do in practice. Essentially, declaring that they will stop prescribing an ongoing regimen feels like “swimming against the tide,” one physician said, in part due to patients’ expectations and the complex medical culture surrounding prescribing practices.

Physicians reported feeling like patients expect to receive a prescription for every complaint and are unaccustomed to having these prescriptions terminated after ongoing use. Although the interviews were conducted in New Zealand, physicians’ perceptions of patient expectations would likely be similar in countries like the United States that also allow pharmaceuticals to be marketed directly to consumers.

Another theme, particularly among younger and less experienced interviewees, was that physicians were hesitant to discontinue a medication that another doctor or a specialist had prescribed, citing a “professional etiquette” that discouraged this practice. Some also reported concerns that patients and families might internalize deprescribing as a sign that the physician had given up on them or was just trying to save money.

There were also organizational obstacles to deprescribing, such as the use of phone calls for medication refills, that makes represcribing much simpler than deprescribing. The physicians also noted that fragmented sources of care without a streamlined flow of medical history further complicated the decision to deprescribe. Furthermore, prescribing guidelines generally did not encourage deprescribing, and non-drug options like therapy were more difficult to obtain than writing a prescription.

“This study suggests that the barriers to deprescribing are formidable, ranging as they do from patient expectations and the medical culture of prescribing through fear of bad outcomes and myriad organizational factors,” the authors summarized.

The physicians did indicate that they would be incentivized to deprescribe if they felt it was in the patient’s best interest, and listed some reforms that would make this easier. For instance, electronic health records could improve information sharing among prescribers, and improved patient education might help them to communicate the risks of overprescribing along with the message that more is not always better.

“Given that the only incentive to deprescribing that physicians identified was the duty to do what was right for the patient, it would be logical to design regulations and policies that support physicians in practicing according to their professional ethical values—taking on the risks inherent in deprescribing and doing what was right for the patient, regardless,” the study concluded.