Table 3.

Exemplary quotes from clinicians and patients by themes

Theme 1: System-level barriers to deprescribing
Limited electronic medical record interoperability Clinician quotes only
1a: “I think some of the external barriers is the electronic medical record. For us, it would be amazing if we had access, but even our clinic to dialysis to hospital, none of them… talk to each other.” (Dialysis clinician focus group)  1b: “…it's very challenging comanaging dialysis patients because we don't share any of the records even when you have like nephrologists [with access to the same EMR], who are, you know, their dialysis physician you know, so it's a lot of barriers to like direct communication.” (PCP focus group)  1c: “I mean I think that the most important thing from my perspective on [deprescribing] is just the importance of an accurate medication list and I think one of the biggest challenges in a dialysis unit is that a lot of our EMRs…don't cross, so…unfortunately they rely on faxed records...” (Pharmacist)
Time constraints and competing priorities Clinician quotes only
1d: “I don't think [nephrologists] have the – even if they do have the willingness, they just don't have the time to do it… their days so packed in, they have to drive from hospital to hospital or practice to practice that they just don't have time to talk and explain to the patient.” (Dialysis clinician focus group)  1e: “The visits are 20 minutes, it can take 10 minutes, 15 minutes to even room the patient and then when you go in the room, you have 5 minutes left, 10 minutes left and they have all these other things that are going on and it's not just possible.” (PCP focus group)  1f: “Bringing up [deprescribing decision making] can be a very involved process and you know, sometimes … you ideally would want to get a patient back…you may be really limited in that …adherence to follow up and close follow up and there's transportation issues that the patients then face.” (PCP focus group)  1g: “… there's so many other competing responsibilities or competing problems that probably, [deprescribing is] probably the last one that, you know, the providers are [concerned about].” (Dialysis clinician)  1h: “Deprescribing is best done when you don't have an acute issue or don't have an active issue and you want to take a step back and step through all the problems and all the medications and that takes, that itself takes a lot of time so if you're competing with another issue that you're trying to address, that becomes very challenging.” (PCP focus group)  1i: “The med rec process in our outpatient unit is kind of the nurses going through you know, presumably every thirty days, going through that checklist, but…there's not a formalized process of [calling pharmacies] to make sure that we have everything accurate…the nurses are great and everything, but they've got a million other things on their plate.” (Pharmacist focus group)
Theme 2: Undefined comanagement among clinicians
Unclear roles delineation
Clinician quotes	Patient quotes
2c: “…accountability…is unclear. Is the nephrologist worried about diabetes? Some of them do and some of them don't …sometimes we end up repeating each other's work. I don't think the patients know either….if they come and their blood pressure is really high and I say well is your nephrologist adjusting your medicine and they don't know.” (PCP focus group)  2d: “I have some patients that will come to me and say my primary care wants to do this, are you okay with it? And then I have the flip side where I ask, talk to a patient and say, I think we should do this, but oh, I need to talk to my primary care about it.” (Dialysis clinician focus group)  2e: “So, I really think, as with everything in medicine, it truly is like person, patient, dependent on the conversation, for anything including deprescribing and who that particular patient feels is their main you know, trust in what they should do and I think for many patients, that is their dialysis physician, but sometimes it is still that primary care. So, especially in the older patients, if they're in a community or setting where they've been seeing them for you know, 40 plus years, they still just want that approval.” (Dialysis clinician focus group)	2f: “I would always get a second opinion [about deprescribing from either primary care or dialysis doctor], regardless.” (61-year-old woman)  2g: “I be asking [my PCP] what is [the medication] for and do I really need to take it.” (57-year-old woman)  2h: “I don't discuss any medications [with my dialysis doctor], not unless there's a change or I feel like something is going wrong.” (57-year-old woman)
Clinician caution about prescriber boundaries Clinician quotes only
2i: “If I didn't start it, I would think long and hard before I stop it because my presumption is somebody that did start it had a good reason to do so.” (Dialysis clinician)  2j: “You know, what I think a lot of times what we encounter is that people are hesitant to discontinue in situations where they feel that they're stepping on somebody else's toes and so… ideally we would have everybody onboard before we made that decision to deprescribe.” (Pharmacist)  2k: “A lot of patients are okay with deprescribing as long as their doctor agrees with it, so they also want to have their you know, doctor buy in to the whole plan.” (Pharmacist)
Theme 3: Stakeholders' limited knowledge about deprescribing potentially inappropriate medications
Knowledge limitations among clinicians Clinician quotes	Knowledge limitations among patients Patient quotes
3a: “The other barrier is educational as well. So, let's say someone is on oxycodone and I want to give them NSAIDS. Now I have a question in my mind, how much can I give somebody safely on hemodialysis? I don't have that answer clear in my mind.” (PCP focus group)  3b: “Once we define a few things, we speak with the nephrologist attending or the physician on board and we give them the plan because most of the time…they are not aware of the alternatives.” (Pharmacist)	3c: In response to “tell me why you don't ask any questions [about your medications]”: “Because he should know what he's doing …I don't have anybody else to trust about this stuff.” (61-year-old woman)  3d: “How will it [affect] me, positively or negatively. Will it have side effects to it? Is it gonna make a difference with … my quality of life?” (82-year-old man)  3e: “I want to know why they want to cut back or do away with this medication. Now, that's the first thing I want to know and then if somebody tell me, I can do some research or something like that to find out why all this going on.” (67-year-old man)
Theme 4: Patients prioritize symptom control over potential harm
Clinicians expect resistance to deprescribing Clinician quotes
4a: “Most dialysis patients will tell you, they've had all the other alternatives and whatever they're on now is what they're comfortable with and what works and they don't want any more change.” (Dialysis clinician focus group)  4b: “They'd rather take the consequences of … the side effects of the medications than get rid of them.” (PCP focus group)  4c: “Yes, they are probably psychologically dependent upon it and they're convinced that they cannot go without them…that's the hardest, probably the greatest barrier to deprescribing some of these agents.” (Pharmacist)  4d: “If you tell them you're gonna [deprescribe and] counsel on good sleep hygiene… but …patients just want the pill to take at night to help them sleep.” (Pharmacist focus group)  4e: “Sometimes the patients just do not want to be involved. They sort of disassociate with their care and you have no choice but to talk to the [caregiver].” (Dialysis clinician)  4f: “[Family is] comfortable with mom being comfortable sitting in a recliner and sleeping after dialysis, rather than having to take her to rehab….We have seen some of those barriers with family member being busy also and having family member caregiver fatigue.” (Dialysis clinician focus group)
Patients weigh risks and benefits Patient quotes
4g: “Well, if you advised me not to take it, I have pain, what are you gonna give me in place of it?” (76-year-old woman)  4h: “Yeah, that would be okay, as long as it was just as affective [for pain].” (Response to replacing pain pill with one with fewer side effects) (66-year-old woman)  4i: “That's a hard question cause it's a yes and no. If I need it, well am I benefitting from it or am I not benefitting from it? ....That's something I really have to ponder on. I can't give you no definite answers to that.” (Response to question: What would you think if you knew that a medication that you are taking has side effects that can make you rely more on others for your daily activities?) (76-year-old woman)

EMR, electronic medical record; PCP, primary care provider; NSAIDs, nonsteroidal anti-inflammatory drugs.