TABLE A1.
Consensus Statements with low importance
| TDF | Barrier statements | Minimum | Median | Maximum | IQR |
|---|---|---|---|---|---|
| Physician‐related | |||||
| Knowledge | Lack of awareness of potentially inappropriate medications | Low (5%) | Moderately (35%) | Extremely (10%) | 1 |
| Poor insight into the term and the process of deprescribing | Slightly (10%) | Moderately & Very (30%), (30%) | Extremely (20%) | 1 | |
| Lack of up‐to‐date knowledge | Slightly (15%) | Moderately (40%) | Very (15%) | 1 | |
| Multimorbidity, potential interactions between diseases and medications | Slightly (10%) | Moderately & Very (30%), (35%) | Extremely (15%) | 1 | |
| Polypharmacy, which increases difficulty in rationalizing and deprescribing medications | Slightly (15%) | Moderately & Very (35%), (40%) | Extremely (10%) | 1 | |
| Skills | Lack of confidence and clinical experience in managing elderly patients | Low (5%) | Moderately (55%) | Very (30%) | 1 |
| Physicians are reluctant to talk to patients about their life expectancy because of difficulty in estimating life expectancy and cultural taboo | Neutral (15%) | Moderately (45%) | Very (40%) | 1 | |
| Physicians are reluctant to talk to patients about their life expectancy due to lack of skills to approach the topic or lack of time | Slightly (5%) | Moderately (40%) | Extremely (5%) | 1 | |
| Problems with incorporating patients’ prognoses into decisions about therapy appropriateness | Low (5%) | Moderately & Very (35%), (50%) | Very (50%) | 1 | |
| Difficulty in communicating risk(s) and benefit(s) to patient/family | Slightly (10%) | Moderately (55%) | Very (25%) | 0.5 | |
| *Difficulty in engaging patient/family in a shared decision‐making process | Slightly (11%) | Moderately (63%) | Very (21%) | 0 | |
| Social/professional role and identity | Risk/fear of conflict or damaging the relationship between various healthcare providers | Low (15%) | Moderately (70%) | Moderately (70%) | 1 |
| Respect for hierarchy | Slightly (5%) | Moderately (45%) | Very (40%) | 1 | |
| Beliefs about capability | Influence from prescriber's own beliefs, clinical experience and prescribing habits | Neutral (15%) | Moderately (45%) | Extremely (10%) | 1 |
| Respect prescriber's right to autonomy | Low (10%) | Moderately (50%) | Very (5%) | 1 | |
| Fear of causing potential harm by deprescribing (eg, fear of withdrawal effects) | Low (10%) | Moderately (70%) | Very (15%) | 0 | |
| Fear of damage to reputation, accountability for adverse outcomes, malpractice, or litigation | Low (10%) | Moderately (50%) | Extremely (5%) | 1 | |
| Intentions | Easier to pile on the recommendations of one guideline onto another instead of prioritizing | Low (10%) | Moderately (45%) | Extremely (5%) | 1 |
| Deferring treatment decisions or changes to the next visit | Slightly (15%) | Neutral & Moderately (35%), (45%) | Very (5%) | 1 | |
| Memory, attention, and decision processes | Inability to gauge the efficacy/effectiveness of a drug for individual patients | Slightly (10%) | Moderately (45%) | Extremely (10%) | 1 |
| Managing complex drug regimens and side effects | Slightly (5%) | Moderately & Very (45%), (45%) | Extremely (5%) | 1 | |
| Ethical concerns around denying treatments | Not at all (5%) | Moderately (50%) | Very (10%) | 1 | |
| Limited availability of alternatives to medication | Not at all (5%) | Neutral (50%) | Extremely (5%) | 1 | |
| Environmental context and resources | Failure to meet the challenge of complex decision making | Low (5%) | Moderately (50%) | Extremely (5%) | 1 |
| Overall clinical uncertainty in elderly patients | Slightly (15%) | Moderately (60%) | Very (15%) | 0.5 | |
| Lack of communication between prescribers before adding on new drugs | Slightly (10%) | Moderately & Very (30%), (30%) | Extremely (20%) | 1 | |
| Lack of support from secondary/tertiary care for general practitioners managing complex patients | Slightly (10%) | Moderately (45%) | Extremely (10%) | 1 | |
| Feeling pressured by guidelines to prescribe medications (including preventive drugs) | Low (5%) | Moderately (55%) | Extremely (5%) | 0.5 | |
| Less comfortable in deprescribing guideline‐recommended therapeutic medications (as compared to deprescribing preventive medications) in patients with poor life expectancy | Low (15%) | Moderately (55%) | Extremely (5%) | 0.5 | |
| Pressure to adhere to disease‐specific guidelines | Low (5%) | Moderately (45%) | Very (20%) | 1 | |
| Lack of time to perform medication reviews during the clinic consultation visit | Slightly (10%) | Moderately (50%) | Extremely (10%) | 1 | |
| Competing demands of practice (ie, prioritizing other aspects of care rather than deprescribing) | Neutral (5%) | Moderately (50%) | Extremely (5%) | 1 | |
| Limited prescribing support (formularies and computer decision support have limited adaptability and flexibility with multiple conditions) | Low (15%) | Moderately (50%) | Extremely (5%) | 1 | |
| Lack of resources to assist family caregivers with challenging symptoms (eg, incontinence) | Low (10%) | Moderately (65%) | Extremely (10%) | 0 | |
| Lack of evidence for the use of or discontinuation of specific drugs for older patients (mainly due to exclusion of multimorbid older patients in clinical trials) | Slightly (5%) | Moderately (45%) | Extremely (10%) | 1 | |
| Emotion | Feeling a sense of fear towards older patients in general owing to their frailty and comorbidities | Not at all (5%) | Moderately (55%) | Very (10%) | 1 |
| Patient‐related | |||||
| Environmental context and resources | Patients do not inform GPs about their medication intake or side effects | Slightly (5%) | Moderately (55%) | Extremely (10%) | 1 |
| Lack of adherence to medications, or self‐titration of medications | Slightly (20%) | Moderately (45%) | Extremely (10%) | 1 | |
| Usage of over‐the‐counter and traditional medications (often without informing the primary coordinating physician) | Slightly (5%) | Moderately (55%) | Very (25%) | 0.5 | |
| Nonadherence to visits | Low (5%) | Moderately (60%) | Very (20%) | 0 | |
| Choosing to “doctor or pharmacy hop” | Slightly (10%) | Moderately (70%) | Extremely (10%) | 0 | |
| Patients are reluctant or disinclined to stop medications that they have used for a long time, resistant to change, poor acceptance of alternatives | Low (5%) | Moderately (40%) | Extremely (10%) | 1 | |
| Unrealistic expectations/demands of patients and families | Low (5%) | Moderately (55%) | Extremely (5%) | 0.5 | |
| Personal beliefs, demands, and expectations of patient and family about their care and medications | Slightly (10%) | Moderately (45%) | Very (35%) | 1 | |
| Discrepancies between the patients’ preferences and best practice recommendations | Slightly (20%) | Moderately (50%) | Very (15%) | 1 | |
| Demanding specific medications and when refused, obtaining them from different physicians | Neutral (15%) | Moderately (65%) | Very (20%) | 0 | |
| Social influences | Patients’ social context and access to healthcare and resources | Low (5%) | Moderately (65%) | Extremely (5%) | 0 |
| Patients who change living or care arrangements may be accompanied by different caregivers to visits, which may result in inconsistent reports from the family and/or lack of continuity of care | Slightly (5%) | Moderately & Very (35%), (40%) | Extremely (10%) | 1 | |
| Patients’ socioeconomic status | Low (15%) | Moderately (65%) | Very (5%) | 1 | |
| Healthcare system–related | |||||
| Environmental context and resources | Specialists’ lack of a holistic or geriatric view on elderly patients | Slightly (5%) | Moderately & Very (40%), (45%) | Extremely (5%) | 1 |
| Inadequate documentation | Neutral (10%) | Moderately (45%) | Extremely (15%) | 1 | |
| Poor acquisition and documentation of patients’ medication lists | Slightly (10%) | Moderately (50%) | Extremely (15%) | 1 | |
| Difficulty in obtaining colleagues’ reasons for prescription | Slightly (5%) | Moderately (55%) | Extremely (5%) | 1 | |
| Difficulty in achieving clear overview of the patient's medical treatment | Low (5%) | Moderately (55%) | Extremely (10%) | 0.5 | |
| Quality measure‐driven care | Not at all (5%) | Neutral (50%) | Moderately (20%) | 1 | |
| Most guidelines suggest adding medications instead of removing them (ie, EBM guidelines contribute to polypharmacy | Low (10%) | Moderately (65%) | Very (15%) | 0 | |
| Challenges in implementing guidelines to elderly patients with multimorbidity | Slightly (5%) | Moderately & Very (40%), (40%) | Extremely (10%) | 1 | |
| Widespread marketing of medications in mainstream media | Not at all (5%) | Neutral (40%) | Very (5%) | 1 | |
| Lack of access to patients’ clinical data (eg, current medication) from other healthcare settings | Slightly (15%) | Moderately (45%) | Extremely (15%) | 1 | |
| Lack of access to expert advice and user‐friendly decision support (eg, computer prompts or alerts to notify prescribers of PIMs) | Low (15%) | Moderately (55%) | Moderately (55%) | 1 | |
*
Only 19 responses for this statement due to missing data.