Barriers to and facilitators of deprescribing for older people in secondary care in Saudi Arabia: a qualitative study using a theory-based approach
Authors: Alenzy T M , Barry H E , Alkahtani S A , Parsons C 
Published: April 2024

Abstract

Introduction
In Saudi Arabia, more than 55% of older patients are subjected to potentially inappropriate prescribing.[1] Despite this, deprescribing by healthcare professionals (HCPs; e.g. physicians and pharmacists) is limited. Therefore, identifying barriers to and facilitators of deprescribing from HCPs’ perspective is crucial to establish the evidence base to inform future development of a deprescribing intervention in the hospital setting in Saudi Arabia.

Aim
To explore HCPs’ experiences and perspectives of deprescribing in older patients in order to identify barriers to and facilitators of deprescribing, using a theory-based approach.

Methods
A qualitative study using semi-structured interviews conducted with physicians and pharmacists who worked in hospitals in a southern region of Saudi Arabia. A purposive sampling approach was employed to recruit participants from various hospitals with different levels of experience. Physicians who worked with older inpatients and pharmacists with a ward-based role who had input into prescribing decisions were eligible to be included. Theoretical Domains Framework (TDF2)-based interviews were conducted with participants until theoretical data saturation was achieved.[2] Interviews were audio recorded, transcribed verbatim and data analysed inductively using reflexive thematic analysis. Themes were mapped to the TDF2, enabling prioritisation of domains and identification of behaviour change techniques (BCTs) for inclusion in future intervention development.

Results
Forty HCPs were interviewed (20 physicians and 20 pharmacists). Four themes associated with facilitators and barriers to deprescribing were identified: (i) perceptions and consequences of deprescribing; (ii) roles of HCPs and communication; (iii) factors influencing deprescribing decisions and (iv) culture, environment, and resources. All determinants from these themes were mapped to TDF domains. Six TDF domains were prioritised to represent key barriers and facilitators. These were: the limited role of pharmacists in deprescribing (‘Social/professional role and identity’); lack of formal documentation of deprescribing outcomes (‘Behavioural regulation’); perceived risks versus benefits of deprescribing (‘Beliefs about consequences’); lack of tailored guidelines for deprescribing (‘Knowledge’); lack of a connected system between different hospital settings (‘Environmental context/resources’) and the importance of inter-professional social support and collaboration between HCPs (‘Social influences’). These domains were mapped to 40 BCTs for consideration for inclusion in a deprescribing intervention.

Conclusion
This study served as a starting point for the design of a theory-based intervention in Saudi Arabia to implement deprescribing in hospital settings. The findings have revealed influences on deprescribing that have not previously been described in this context. These encompassed the need to enhance the interface between primary and secondary care and the potential impact of improving health and social care systems in Saudi Arabia to enable deprescribing. Participants were sampled across a southern region of Saudi Arabia, which enhanced the transferability of the findings to other similar hospital settings. However, only physicians and pharmacists were recruited, which may limit the international transferability of the findings to countries where other professionals have a role in deprescribing. Future work will determine the prioritised BCTs to be operationalised in the intervention using the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria.

References
1. Alsuwaidan A, Almedlej N, Alsabti S et al. A Comprehensive Overview of Polypharmacy in Elderly Patients in Saudi Arabia. Geriatrics. 2019; 4(2):36.
2. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):1–17.