Barriers to Effective Prescribing in Older Adults: Applying the Theoretical Domains Framework in the Ambulatory Setting – A Scoping Review

Abstract

Background: As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. Methods: A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results: A total of 5,731 articles were screened. 29 studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour. Conclusion: The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Barriers to appropriate prescribing in older adults with multimorbidity: A modified Delphi study

“…Although the remaining barriers from the physicians' perspective cluster were mapped onto different domains, namely in environmental context and resources, intentions, and professional/social role and identity , 6 they shared similar sentiments in reflecting uncertainty and aloneness in the prescribing decision‐making process. This leads to reluctance in making changes to medications that have been prescribed for long periods or by other physicians.…”

“…For our secondary aim, the 11 barrier statements identified as highly important were linked to the intervention functions in the BCW, 9 via their mapped TDF domains 6 . Table 2 shows results of the linkage.…”

“…Due to the large number of barriers identified from the scoping review, 6 an arbitrary cutoff point was determined in the current study, as it would be impossible to address all identified barriers with one intervention. It is also unlikely that an intervention could directly address some of the pervasive healthcare system–related problems that require broader system or policy changes.…”

“…This study consisted of two rounds of questionnaires. Statements presented were formulated based on findings from a previous scoping review 6 . The barriers identified in that study were mapped onto 10 of the 14 domains in the Theoretical Domains Framework: knowledge; skills; social/professional roles and identity; beliefs about capability; beliefs about consequences; intentions; memory, attention and decision process; environmental contexts and resources; social influences; emotions 6 .…”

“…Statements presented were formulated based on findings from a previous scoping review 6 . The barriers identified in that study were mapped onto 10 of the 14 domains in the Theoretical Domains Framework: knowledge; skills; social/professional roles and identity; beliefs about capability; beliefs about consequences; intentions; memory, attention and decision process; environmental contexts and resources; social influences; emotions 6 . The barriers were further divided based on stakeholders influencing the prescribing process, either directly or indirectly: physician, patient, or healthcare system at large 6 .…”