The identified domains and their associated belief statements are summarized in Figure 1. As illustrated, the four domains may be allocated on a continuum of individual and structural factors influencing joint deprescribing. Beside affecting deprescribing and medication optimization activities in a direct manner, the domains even impact on one another. In the following sections, the domains will be explored in greater detail by means of their corresponding belief statements. Despite this conceptualization, however, even conjunctions between beliefs of the different domains exist.
Professional role and identity of stakeholders
The central themes in all discussions referred to the domain of professional roles and identity as related to deprescribing. Role understandings of each stakeholder group built on beliefs about deprescribing tasks and responsibilities, but also about limitations to such duties. Particularly, the role of GPs in deprescribing was discussed.
GPs are the central medication managers
The role of GPs in deprescribing was unanimously perceived as central agent by participants from all three represented professional groups (Table 1, quotes (Q) 1-5). This role was described as ´central manager` of medication and entailed responsibility for medication reconciliation (Q2,5). Reconciliation in this respect denoted gathering information about all medications actually being prescribed by different providers, as well as about over-the-counter (OTC) medications purchased by the patient herself, and checking them for inconsistencies or incompatibilities. Also, within a broader medication management, GPs were considered responsible for monitoring repeat prescriptions and prioritizing medications according to individual patients’ needs (Q5,6). Notably, all these tasks would entail deprescribing as a potential consequence. The supremacy in the overall medication management decisions was justified by the participating specialists with GPs’ broad knowledge about patients as well as their function as ´interface` between providers (Q3,4).
CSs’ role in deprescribing is well-defined and limited
In contrast to GPs’ overarching medication responsibility, participating specialists portrayed their tasks in medication management and deprescribing as rather clear-cut and confined.
Perceived duties concentrated on monitoring and discontinuation of CSs’ own prescriptions with reference to lacking patient- and medication information necessary for further deprescribing, on which CSs and GPs agreed (Q6,7).
CPs’ should act as supporting second-line force in deprescribing
For pharmacists’ part in medication management and joint deprescribing activities, the identified belief statement included both wide-stretching duties on the one hand, and role limitations explained by lacking authority on the other hand. Hence, while duties encompassed conducting medication reviews on medication interactions and prescription errors, as well as counselling patients on diverse medication-related matters (Q8,9), CPs clearly restrained any direct deprescribing task by appealing to their lack of mandate for this:
CP21M: “We don’t have the expertise. We can’t answer actual medical questions. We must not, too! We can’t. Because we haven’t studied it.” (Q11)
In this sense, CPs portrayed their role limitations in deprescribing not as themselves refusing greater involvement, but rather as external restrictions in terms of skills-based and legal demarcations to their professional terms of reference. This opinion was shared by several GPs who appreciated CPs’ medication reviews as beneficial reminders and, like one GP coined it, could envision a ´first- and second-line task division` in deprescribing (Q12).
Social influences on professional roles and deprescribing collaboration
The second domain that emerged in the discussions designates diverse social influences which impact on the professionals’ role and deprescribing tasks. Here, the beliefs about patients’ trust as supporting GPs’ medication authority, CPs’ potential of undermining this authority, a hierarchy between GPs and CSs and social pressure to continue prescribing manifested.
Patients’ trust supports GPs’ medication authority
GPs’ predominant position in medication management and deprescribing tasks was reported to further receive support by patients’ conferral of trust (Table 2, Q13-14). The status as central person-of-trust for patients was appraised by all stakeholder groups. For long-lasting physician-patient relationships as well as in rural areas, GPs reported even being assigned superiority over CSs (Q18). This superiority would manifest in patients’ requests for guidance on medication prioritization or for reappraisal of CS’s suggestions and prescriptions.
Pharmacists’ involvement may undermine GPs’ authority
CPs’ involvement in medication evaluation was perceived to negatively influence polypharmacy management by threatening GPs’ authority. Especially within the scope of patient counselling, both GPs and CPs themselves expressed concerns about pharmacists providing deprescribing messages or questioning prescriptions. They remarked that this could both endanger patient compliance, undermine the physician’s authority and jeopardize a trustful doctor-patient relationship (Q15,16).
In hierarchy with specialists, GPs come off as inferior
Remarkably, the affirmative connotations that CPs, CSs and supposedly even patients attributed to GPs’ professional role stood in harsh contrast to a belief expressed by participating GPs themselves. At numerous occasions, GPs reported a feeling of inferiority and lack of authority towards specialist providers (Q17):
GP4M: “I, as humble little GP, didn’t just decide: well, cardiology is recommending this, but I say I’ll deprescribe it. I mean, somehow it’s like David versus Goliath. That’s how you feel like, somehow.” (Q17, continued)
Despite some participants challenging this belief (Q19), GPs generally expressed that contact with specialist providers would exert a rather negative impact (Q17-20). The perceived hierarchy was mentioned to acuminate at the hospital setting, as GPs felt that greater importance was routinely assigned by patients to directives of ward specialists (Q18).
Importantly, dissonances in perceived authority could even manifested in intergroup conflicts. Most often, these centered around the responsibility for specialist-medication (Q20). Hence, while there was mention of CSs’ expectation about GPs to take on their repeat prescriptions (Q6), decision-making power for stopping the medication would not always be transferred. Apart from demarcating their sphere of authority, specialists’ claim for sovereignty over ´their` medications even prompted GPs to ´totally stay out of` specialists’ medication (Q20). Hence, lack of regulations and agreements between GPs and specialists on who should initiate and stop prescriptions evoked uncertainties and an inertia to deprescribe.
Specialists exert pressure to continuing prescribing
Specialists’ claim for sovereignty over medications was mentioned to not only impede GPs’ deprescribing efforts, but also exert social pressure to continue prescribing. As specialists would routinely prioritize their specialist-medication over the remaining (Q21), this would both spur unnecessary polypharmacy and foster a culture of re-prescribing. In light of this, GPs’ professional identity was threatened to get stigmatized of parsimonious medication management. Since deprescribing would save health-care expenditures of unnecessary and expensive medications, GPs worried to get alleged with financial motives for deprescribing and receive a bad image as ´penny pincher` in front of involved providers (Q22). In the same FGD, Q23 reflects a wish of not standing out negatively by ´changing a running system` which once again expresses social influences to continue prescribing. If GPs anyhow decided to follow an assiduous deprescribing agenda, it was deemed necessary for them to develop a firm ´attitude` towards other providers, entailing resistance of getting stigmatized (Q22).
Reinforcements to joint deprescribing action
Among the abundance of deprescribing influences mentioned in the FGDs, two distinct beliefs about reinforcements emerged. While a belief about negative sanctions was attributed to GPs’ interaction with specialists, lacking incentives and reward were discussed for pharmacists’ efforts in medication optimization.
GPs are reprimanded for deprescribing actions
In addition to the above reported role conflicts about authority and hierarchy, tensions between GPs and specialists even reached a level of verbal aggression and reprimand which antagonized further deprescribing attempts:
GP13M: “(…) When I deprescribe a patient’s statin (…), the guy (cardiologist) rips me into shreds, ´this idiot GP who doesn’t know the first thing, deprescribing the statin!` He could die from this AND get a heart attack and so on. Then it’s difficult. And when I know this I won’t deprescribe anything. Because, this scolding -I mean, I can take a lot. But at some point, I need to draw a line.” (Q24)
Facing suchlike conflicts, the same GP pointed out the co-operation with specialists as being the ´biggest problem` when deprescribing (Table 3, Q24). In front of perceived punishments by specialists, GPs expressed feeling discouraged from medication optimization efforts, which, by themselves, were judged time-consuming and sparsely refunded. At a general, there was no mention of positive reinforcements to deprescribing activities among GPs.
CP’s medication optimization efforts are not valued
Lack of positive reinforcements even condensed in a belief about pharmacists’ efforts in medication optimization. Apart from the above-mentioned reservation about CPs’ patient counselling, CPs consistently experienced that even their performance of medication reviews would receive none, or negative feedback from GPs. One CP expressed:
CP19F: “(…) I had it only once in my career I heard a doctor saying ´I appreciate your call.` (…) Once! In 20 years!” (Q25)
Although GPs’ accounts on this topic were heterogeneous with some participants expressing appreciation of medication reviews, others indeed criticized them as all-knowing and challenging GPs’ competencies (Q26,27). Hence, there was indication of some GPs’ exasperation with this service due to perceptions of offense or insult to their professional skills. As one GP put it:
GP17M: “How do we manage all this without offending anybody? The pharmacist’s got the expertise, but the physician doesn’t want anybody to interfere.” (Q28)
Beyond the issue of professional expertise, however, some participating GPs indicated reluctance towards collaboration with CPs even at a general level. This distancing was explained with pharmacists’ dependency on financial revenues, which triggered an overall distrust about conflict of interests (Q29). While the participating pharmacists confirmed the condition of economic dependency on a sales-per-unit reimbursement, they rated it genuinely unwanted and problematic. Being dependent on sales was perceived as both burden and scorn to CPs’ moral efforts of medication optimization. Hence, as CPs felt ´doing the right thing, and getting less for it` when engaging in deprescribing collaboration, they just expressed another negative sanction (Q30).
Environmental context and resources
The theme of reimbursement structures already alludes the fourth identified domain environmental context and resources as a deprescribing influence. Further beliefs within this domain concerned the lack of managerial resources, fragmentation of care, but also potential assets not fully utilized yet.
Reimbursement systems impede deprescribing activities
For CPs, not only the sales-per-unit revenues in themselves constituted a barrier to medication optimization, but rather the lack of other reimbursement for activities such as patient counselling and performance of medication reviews. They stressed the drawback of being obliged to both give medication counselling and perform medication reviews as professional assignments while not getting compensated for it (Table 4, Q31, 32). Thus, CPs felt that the health-system environment did not provide the preconditions necessary for either medication optimization nor cooperation activities. This circumstance was even affirmed by several GPs and CSs, who in their turn appealed for better remuneration of time-consuming but hitherto uncompensated polypharmacy management such as routine medication evaluation (Q33).
Lack of managerial resources impedes collaboration
Adjacent to lacking reimbursement structures, CSs and GPs even judged managerial resources to be deficient. Thus, CSs raised arguments about a lack of time resources, on which GPs agreed, as well as organizational capacity for closer communication and cooperation between providers (Q34,35). As to CS33M, both scarcity of time and organizational demands for successful cooperation with GPs acuminated in urban settings:
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 (…)” (Q35)
Hence, specialists explained limited deprescribing collaboration by rather pragmatic and context-related causes. Nevertheless, the resulting communication deficiencies between CSs and GPs emerged as a recurrent theme in the FGDs, and both GPs and CPs highlighted the severity of its consequences in terms of medication errors like double-prescriptions or prescribing cascades (Q8,36).
Fragmentation of care impairs medication optimization
The strain of dealing with prescription errors resulting from deficient knowledge exchange between providers was a theme pertinent throughout the discussions and across professional groups. However, the participants expressed a belief that these information shortages were not only product of deficient communication, but exacerbated by a system-wide fragmentation of care. Information flow between care levels, they argued, was frequently disrupted or lacking, which entailed severe impediment to polypharmacy management (Q8,36). In this sense, CSs who earlier had been alleged with skewed prioritization of their specialist-medications explained their narrow prescription focus and by lack of information about overall prescriptions:
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!” (Q37, continued)
Prudent prescribing routines, hence, were deemed impossible without synthesis of prescription information across providers. To date, however, the latter completely relies on patients’ diligence to bring along their medication plan as no further cross-level medication transparency is given in Germany. Unfortunately, the cited participant’s strategy to gather missing medication information by giving a telephone call to the respective GP just conflated with earlier-mentioned time constraints.
Yet, not only CSs requested transparency about prescription (as well as OTC-) medicines. Likewise, GPs criticized lacking information on specialists’ prescriptions (Q36) while CPs demanded more detailed and routine medication information including prescription rationale to optimize counselling (Q38). Importantly, better medication transparency was highlighted to not only benefit prescription optimization, but also help attaining synchronization of medication messages towards patients, and hence preserving colleagues’ authority. If this was achieved, participants could envision CPs and GPs to ´pull together` in persuading patients for medication optimization (Q39).
Existing resources are not fully utilized
In contrast to the above deficits in the structural environment, the discussions also contained accounts of resources to deprescribing collaboration not yet fully utilized. In terms of information resources, the pharmacy was depicted as a place of knowledge accumulation. As many patients would stick to their local pharmacy, not only different physicians’ prescriptions were stated to run together at the CPs’, but even knowledge about OTC-medication use and patient-related information such as medication application problems, non-adherence or side-effects (Q40-42). Hence, CPs described themselves as central contact point for patients concerning medication issues, and for patient-relevant medication matters, CPs presumed being even more knowledgeable than GPs (Q41):
CP21M: “…we recognize such things [non-compliance] even better than the doctor, because the patient is too shy to tell the doctor.” (Q41, continued)
This rich-in-information position was explained by the low-threshold and free-of-charge character of community pharmacy-services in Germany (Q40). In line with this, even pharmacist-led medication reviews were appraised as underutilized assets. Although several GPs felt offended by this service, there was, when speaking generally, anyhow appreciating of medication reviews checks as an otherwise ´missing link` of information which could bridge information gaps across providers (Q43). If not for the personal feedback in medication reviews, physicians did value CPs’ software system for interaction checks and promoted increased utilization of it (Q44). Even CPs approved this, but emphasized the urge to configurate software systems uniform or compatible to permit quick data exchange between physicians and pharmacists (Q45). Given such preconditions, CPs’ judged their involvement as capable of reducing GPs’ workload (Q32).
Finally, participants even highlighted the potential of GPs as gatekeepers to specialist services as an underutilized resource (Q46, 47). As mandatory GP consultations for specialist-referrals would optimize medication transparency and avoid multiple-prescriptions or prescribing cascades, a strengthening of this role position was requested. The fact that specifically CSs and CPs advocated this strengthening of GPs’ role positioning during the focus groups may serve as promising to future joint approaches.