For example, all studies reported the sample size and method and most reported a description

of the sample and interview guide. There was consistency between raw data and interpretive findings in all papers except one in which the interpretation was so brief that its accuracy was considered doubtful.36 For five papers, selleck inhibitor it was unclear whether ethics approval was obtained.29 34 43 44 46 Synthesis of results Thematic synthesis yielded 42 subthemes, 12 unique descriptive themes and 4 analytical themes (figure 2), with multiple interdependencies and relationships. Barrier and enabler descriptive themes and subthemes tended to mirror each other for each analytical theme of Awareness, Inertia, Self-efficacy and Feasibility. The first three themes reflect factors intrinsic to the prescriber and his/her decision-making process while the fourth deals with extrinsic factors. Tables 3 and ​and44

provide illustrative quotations from either primary study participants or study authors relating to barrier and enabler subthemes, respectively. Table 3 Illustrative quotations for barrier themes and subthemes Table 4 Illustrative quotations for enabler themes and subthemes Figure 2 Schematic representation of barriers and enablers associated with each analytical and descriptive theme. Fewer enablers were reported than barriers and there was variation in the relative contribution of each study to each theme. Awareness Awareness refers to the level of insight a prescriber has into the appropriateness of his/her prescribing. This theme was apparent in the three papers which utilised audit or informal third-party

(eg, other health professional) observation and feedback.46 47 49 Poor insight was an observed rather than reported barrier, with interventions to raise prescriber awareness an enabler to minimising the prescription of PIMs. Prescriber beliefs at a population level did not necessarily translate to prescribing practices at an individual level. For example, agreement among prescribers that benzodiazepines should not be used regularly or in the long term did not necessarily preclude such prescribing in individual patients.34 38 41 Inertia Inertia is defined as the failure to act, despite awareness that prescribing is potentially GSK-3 inappropriate, because ceasing PIMs is perceived to be a lower value proposition than continuing PIMs. Fear of unknown/negative consequences of change featured in 15 of 22 papers, and related to consequences for: the prescriber (threatened therapeutic relationship, diminished credibility, increased initial and ongoing workload, potential for litigation, conflict with other prescribers/health professionals)29–31 34–36 38 40 43–47 49; the patient (withdrawal syndrome, symptom relapse or increased risk of the condition/event for which preventive medication was originally prescribed)36 38 40 42–47 and other health professionals (increased workload and safety concerns of staff in RACFs).