A consolidated framework for implementation research (CFIR) informed exploration of a primary care intervention to support deprescribing for problematic polypharmacy in older adults living with frailty (DEPPLOY) in England: a qualitative study

Introduction
The incorporation of deprescribing into structured medication reviews (SMR) is a patient-centred and cost-effective practice in primary care settings. Pharmacists have a key role in deprescribing among older people to improve quality of life and reduce adverse events, but patients and healthcare professionals may be resistant to reducing their medication, and evidence around how deprescribing happens in practice is currently lacking. This study explores the implementation of a co-designed intervention in a single English General Practice (UK).

Aim
To explore key stakeholders’ perceptions of a co-designed primary care intervention to involve patients and their families in deprescribing and its broader intervention context, guided by the Consolidated Framework for Implementation Research (CIFR).

Method
Qualitative semi-structured interview study with a purposive sample of staff, and patients with frailty, to explore perceptions of the deprescribing initiative. Data were analysed using an a priori framework structured by the domains of the CIFR.

Results
Interviews (24 in total) were conducted with 13 staff involved in delivering the intervention and 5 patients living with frailty who completed a structured medication review with recommended medication changes. Key factors (mapped to CFIR domains) included: an imperative for formal training around the intervention delivery (Inner setting), engagement with SMR delivery linked to payment through national agendas (Outer setting); the importance of the fit of the intervention with existing processes around prescribing practice and infrastructure (Inner setting); increased understanding of the aims of deprescribing among patients and recognition of the extended pharmacist role in primary care deprescribing (Individuals); recognition that the successful delivery of the intervention was a team effort (Implementation process).

Conclusion
Structured medication reviews are a suitable mechanism to discuss and make deprescribing decisions as part of a shared consultation. Resources which support the patient through the deprescribing process can engage patients and promote greater satisfaction with service delivery. Operationally, staff can also benefit from tools which facilitate greater understanding of the process and fit within their usual practice plus improving patient care and saving medication costs. Barriers and facilitators to implementation success should be noted and addressed for upscaling and process sustainability.