36 37 48 The barrier belief that drugs appear to work with few adverse effects was apparent in nine papers34 35 38 39 41 43–45 47 of which two studied ‘high-rate’ and ‘low-rate’ benzodiazepine www.selleckchem.com/products/mek162.html prescribers. ‘High-rate’ prescribers consistently downplayed risks of harm, whereas ‘low/ medium-rate’ prescribers were more conscious of such risks.34 41 The futility

and potential harm of cessation in patients of advanced age was a subtheme predominantly present in papers considering psychoactive agents.34 35 38 43 46 47 Another barrier was the devolvement of responsibility to another party for the decision to continue or cease a medication (eg, another prescriber, health professional, society or the patient). One example was continuation of PIMs in patients that prescribers had inherited from colleagues where the former failed to question the rationale used by the latter in prescribing such drugs.29 34 41 49 Another example was the provision of PIMs on the

request of RACF nursing staff42 or patients34 40 43 without a critical prescriber review. Finally, inappropriate prescribing of psychotropics, while viewed as a public health concern, was considered beyond the scope of individual prescribers.35 Self-efficacy This analytical theme refers to factors that influence a prescriber’s belief and confidence in his or her ability to address PIM use. It involves subthemes relating to knowledge, skill, attitudes, influences, information and decision support. Knowledge or skill deficits,30–35 40 45 49 including difficulty in balancing the benefits and harms of therapy,30–33 recognising adverse drug effects31 32 and establishing clear-cut diagnoses/indications

for medicines,34 35 40 were challenges prescribers faced in identifying and managing PIMs. Balancing the benefits and harms was perceived to be especially difficult when reviewing preventive medications in multimorbid older people with polypharmacy where shorter life expectancy, uncertain future benefits and higher susceptibility to more immediate adverse drug effects must all be considered.30–33 On the other hand, better Cilengitide quantification of the benefits and harms of therapy,30–32 48 confidence to deviate from guidelines and stop medications if thought necessary,33 45 greater experience,30 45 and targeted training, especially in prescribing for older people,49 were seen as enabling factors. Compounding generic knowledge and skill gaps were information deficits specific to individual prescribing decisions, resulting from poor communication with multiple prescribers and specialists involved in patient care, inadequate transfer of information at care interfaces, fragmented and difficult-to-access patient medical records, and failure of patients to know/disclose their full medical history/medication lists to prescribers.