The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing in the elderly in the ambulatory setting, including significant factors pertaining to Knowledge, Skills, Social/Professional Role and Identity, Social Influences and Environmental Context and Resources. We recognise that the elderly remain a unique population owing to their medical complexity, multimorbidity and frailty, and this can prove challenging for physicians who lack the knowledge and skillsets to effectively manage this group of patients. Patients and their families may exhibit poor healthcare literacy, ‘doctor-hop’, or express unrealistic expectations including the belief that ‘prescribing validates illness’, and may thus be reluctant to discontinue medications. Contextual factors such as socioeconomic status and access to healthcare and resources must also be considered when examining reasons for non-compliance or discrepant beliefs.
Beyond usual evidence-based guidelines which may be more easily applicable in younger patient groups, there is a constant need to weigh the risks and benefits of each recommendation based on individual patient context in the elderly, and thus no ‘one size fits all’ solution. With increased specialisation and fragmentation of care, physicians have also highlighted concerns regarding inter-professional relationships, hesitancy to interfere with recommendations from secondary or tertiary care, and also fears surrounding adverse outcomes or medicolegal consequences. With limited access to prescribing support or pharmacists in the ambulatory setting, it is thus not surprising that this constant need for debate, consultation and individual patient consideration may be time-consuming, resource-intensive, and thus makes it seemingly easier for physicians to skirt around the issue rather than address PIP, and hope that the decision for effective prescribing may be deferred to the next healthcare provider.
Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including patients, physicians, ambulatory clinic systems and healthcare policy makers. At the level of the community, we need to work towards correcting the misconception that ‘more medications constitute better treatment’, that desprescribing does not equate to ‘giving up on the patient’, and gently reinforce the importance of medication review. Healthcare and social policies need to target the issue of healthcare financing, provision of adequate subsidies and ensuring equal access to healthcare. For physicians, more training and education in managing elderly patients may be helpful, but beyond the equipment of knowledge and skills alone there is also the need to develop good clinical reasoning, which may come with increased exposure to geriatric medicine, delivery of holistic, patient-centred care, and with increased experience and clinical wisdom. It is a delicate process that cannot be rushed and needs to be guided by good role models, alongside provision of adequate support including access to members of the multidisciplinary team (e.g. pharmacists for medication reviews, specialty care nurses for counselling on non-pharmacological management e.g. in the management of urinary incontinence), allowing seamless updating and retrieval of diagnoses and medication lists across institutions and healthcare settings, and encouraging open communication among multiple healthcare providers instead of having each one practise in silo.
This scoping review distinguishes itself from existing literature in its focus on elderly patients receiving ambulatory care, which has its own unique set of challenges compared to hospital or residential-based care. It serves as an exploratory piece to better understand the barriers to effective prescribing, and maps out these barriers based on the TDF to provide a comprehensive picture on the ambulatory prescribing climate and allow for more systematic targeting of interventions.
However, because we sought to understand general barriers to prescribing rather than disease-specific or drug-specific considerations, the exclusion of studies that focused on either may have limited the number of studies included in this review. The authors also acknowledge that contextual factors (e.g. access to healthcare) may not be applicable across all healthcare settings, and may need to be interpreted in accordance to each population’s unique needs.
In conclusion, there exist multiple barriers to effective prescribing which will require multipronged interventions targeting patients, physicians and the healthcare system at large in order to reduce PIP and improve care in the elderly. Moving forward, the study team will take findings from this scoping review into a modified Delphi study to explore the significance of the identified TDF domains in Singapore’s context, and ultimately develop a physician-pharmacist collaborative care intervention to guide effective prescribing for the elderly in the ambulatory setting.