Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study

Abstract

ObjectivesGeriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers.DesignWe used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group.SettingInterviews took place in a tertiary, 886-bed hospital located in Los Angeles, California.ParticipantsInterview participants included physicians, pharmacists, pharmacist technicians, and nurses.ResultsWe interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge.ConclusionsWhile we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.

Older Adult and Primary Care Practitioner Perspectives on Using, Prescribing, and Deprescribing Opioids for Chronic Pain

“…Reported barriers to deprescribing were synthesized using the COM-B (capability, opportunity, motivation, and behavior) model of behavior change, as the act of deprescribing requires new behaviors by both clinicians and patients . The COM-B framework has been applied to identify barriers to deprescribing other medications . Direct quotes were used to illustrate themes.…”

“…14,21,22 The COM-B framework has been applied to identify barriers to deprescribing other medications. 23,24 Direct quotes were used to illustrate themes.…”

Deprescribing medications among patients with multiple prescribers: A socioecological model

“…28 For example, inpatient clinicians may be hesitant to stop medications initiated or managed by outpatient prescribers. 29 When medications have been used for many years, there may be diffusion or loss of responsibility to evaluate their continued benefit and deprescribe as indicated. 30 The involvement of a patient's care partners, while typically beneficial, can increase interpersonal complexity.…”

“…For example, barriers such as limited communication across health facilities or pessimism about patients' attitudes about stopping medications can be used to design and test evaluations that improve communication between prescribers and reduce pessimism about deprescribing. 29 At the organizational level, research into how health systems are structured and organized can help identify the extent of collaboration that prescribers have with each otherand how these structural factors may hinder or help deprescribing efforts. Additionally, understanding these structural factors can inform how and whether deprescribing interventions can be widely disseminated and adapted to improve reach and feasibility.…”

“…Some prescribers may be hesitant to deprescribe when they are unfamiliar with other members of their patient's care team or have limited involvement with a patient's treatment regimen 28 . For example, inpatient clinicians may be hesitant to stop medications initiated or managed by outpatient prescribers 29 . When medications have been used for many years, there may be diffusion or loss of responsibility to evaluate their continued benefit and deprescribe as indicated 30 …”