Table 4.

The domain of environmental context and resources

Environmental context and resources to deprescribing and medication optimization
Belief (as expressed by professional group)	Quote No.	Quote and speaker (indicating professional group, participant ID and sex e.g. GP1M = General practitioner 1, male)
Reimbursement systems impede deprescribing activities (CP, CS, GP)	31	CP12F: We have an obligation to give counsel and we must check interactions. We have already received this mandate and we are penalized if we don’t comply with it. But unfortunately, it is an additional expense and really takes time, but we are not being refunded for this. That’s the great problem.
	32	CP12F: We just needed the possibility to provide consulting hours in which patients can come and ask questions about things that we have noticed. But we would also need some kind of monetary compensation for this consultation. And principally this could also reduce the doctor’s burden.
	33	CP12F: Paid work is transformed into goodwill. (…) That is the core problem. CS14M: I believe this, too. (…) The pharmacist, just like the physician, invests his time and work (in medication optimization) without getting any compensation for it. (…) Of course there is a problem at that point.
Lack of managerial resources impedes collaboration (CS, GP)	34	CS32M: In these times when we’re all very busy, (…) nobody really has time to pick up the phone and call a colleague. We really should communicate more closely and continuously with the GPs, because I think they should be in charge of defining which medication is most important for the patient whom they know from a holistic view (…) But we don’t have enough time for all this (…) And that makes it really difficult.
	35	CS33M: We not only work together with three GPs, but probably there are rather more than a hundred who we cooperate with and everyone is of a particular kind. One doctor makes a fuss if we discontinue a medication, the other one does if we don’t. One doesn’t want us to prescribe a certain medication, he wants to do it himself, the other is upset if we haven’t prescribed it. And to know all these attitudes of the respective GPs, that’s quite difficult.
Fragmentation of care impairs medication optimization (CS, GP, CP)	36	GP1M: Today a patient’s wife gave me a box full of mediations. I had tried to withdraw zolpidem from her husband (…) and there were 50, 60 medications in there, most of which I never had prescribed. That was stuff from colleagues, right? I had never received any letter about these medications! Which means, I wasn’t the only one who had prescribed zolpidem! He also had visited two psychiatrists.
	37	CS14M (on double-prescriptions): The reason is that we often don’t receive information on the medication! So I would say, 4/5 of my patients either don’t bring their medication plan or don’t know what they’re taking at all! In this case we just call the GP, ask: ´what does this patient take, anyway?` (…) The people themselves don’t know!
	38	CP21M: If someone comes in and buys an OTC medication which doesn’t match with his medication -especially if he’s taking 5–7 different meds- you would have the chance to check that. But (…) it’s difficult for us because we don’t know what else he is taking.
	39	CP11F: … if we in the pharmacy would receive a signal so we could all pull together. Because of course we have no idea what you (GPs) are thinking. And us telling the patient the opposite of what you’ve said, that’s the worst that can happen (…) If we counteract each other, we’ll get it all wrong. But if we knew: okay, you are having the same problem, that pantoprazole is a requested medication, or whatever, then- [cooperation would work]
Existing resources are not fully utilized (CP, GP, CS)	40	CP19F (on who is the patient’s central contact-point): I think, in regard to application and effect, the pharmacy is, just because there is more time for this. And it’s for free. We may always answer all questions, the pharmacy is open
	41	CP21M (on non-compliance): I think we recognize such things even better than the doctor, because the patient is too shy to tell the doctor. CP19F: I think the psychological barrier is easier to overcome in our case. At our place, one rather talks about that.
	42	GP13M: Surprisingly they [the patients] all come to you! They rarely call on us. If I say: ´Please bring all your medications`, the next time they have already forgotten to bring them. So there seems to be a higher affinity towards talking to the pharmacist than to me as a physician.
	43	GP8M (on CP-medication reviews): I really appreciate this, because often I don’t know what kind of antidepressants and stuff everybody has [prescribed].
	44	GP18M: Well what I think works well with the pharmacy: they just have a different software for medication interactions (…) GP20F: Actually I always thought this was quite helpful.
	45	CP12F: It would be awesome if there was a compatible software in the doctor’s office as well as in the pharmacy, for passing information back and forth, making it possible to read the medication plan, check it and have feedback on it.
	46	CS14M (on exchange of medication- and patient information): Actually that’s the good thing about a proper referral. And that’s why I’m actually sad that we don’t have the so-called practice fee anymore. Because in these days the patients at least came after a referral. Now there are 90% without a referral.
	47	CP21M: I really think that the GP is the best interface. And the most important link in this position. And I actually think that everyone should be obliged to visit their GP before they see a specialist!

Legend: GP General practitioner, CP Community pharmacist, CS Community specialist