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\begin{document}

\title{What influences prescribing decisions in a multimorbidity and
polypharmacy context on the acute medical unit? An interprofessional,
qualitative study}



\author[1]{Peter Rivers}%
\author[2]{Nigel Langford}%
\author[3]{Andrew Whitehead}%
\author[1]{Tim Harrison}%
\affil[1]{De Montfort University - City Campus}%
\affil[2]{University Hospitals of Leicester NHS Trust}%
\affil[3]{Buckinghamshire Healthcare NHS Trust}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
ABSTRACT Rationale, aims and objectives The primary aim of the study was
to understand the mindset of doctors and pharmacists, as they embark
upon prescribing in a polypharmacy and multi-morbidity context during
routine practice at a hospital acute admissions unit. The study also
aimed to evaluate to what extent attitudes, embedded within real-life
decision-making scenarios, relate to existing theory and models of
prescribing decisions. Methods Anonymised case studies were identified
from the medical notes of patients aged 65 and over with conditions
likely to be associated with multi-morbidity, medication issues and
polypharmacy: namely: fall, urinary tract infection, confusion or lower
respiratory tract infection. A total of 39 doctors based on the acute
medical admissions unit and 9 pharmacists were recruited to one of three
focus groups. Patient case-studies provided the context for discussion
from which verbatim transcripts were thematically analysed using an
interpretative, qualitative approach. Sub-themes were matched to Murshid
and Mohaidin's proposed model of physician prescribing decisions.
Results Seven principal themes were identified that were associated with
prescribing decisions on the acute medical unit, namely, `patient
characteristics', `drug characteristics', `pharmacist factors',
`trustworthiness', 'reliability of medication history, `competing
pressures and priorities' and `responsibilities of prescribers'.
Conclusion Prescribing decisions on the acute medical admissions unit
were influenced by a variety of factors, some of which have already been
acknowledged within existing theories and models. The findings
provisionally offer new insights, which, subject to confirmation by
further research, bring to light three attitudinal characteristics that
may impact negatively upon the quality of prescribing decisions. These
include, first, how perceived poor reliability of medication history may
result in information gaps that compromise prescribing decisions;
second, how competing pressures and priorities restrict doctors'
aptitude to conduct a review of medication and finally, how doctors may
rationalise the assignment of medication review to the GP.%
\end{abstract}%



\sloppy


\textbf{TITLE PAGE}

\textbf{Title}

What influences prescribing decisions in a multimorbidity and
polypharmacy context on the acute medical unit? An interprofessional,
qualitative study

\textbf{Short running title}

Prescribing decisions on the acute medical unit

\textbf{Author names and affiliations}

Dr Peter H Rivers, Honorary Reader, School of Pharmacy, Hawthorn
Building, De Montfort University, The Gateway, Leicester LE1
9BH\textsuperscript{+}. Tel: 01332 676241. Email:
peterrivers@btinternet.com

Dr Nigel Langford, Email: nigellangford@nhs.net. Honorary Senior
Lecturer, University of Leicester, Consultant Clinical Pharmacologist
and Acute and General Physician

Dr Andrew Whitehead, Specialty Registrar, Intensive Care Medicine and
Anaesthesia, Buckinghamshire Healthcare NHS Trust. Email:
apwhitehead@doctors.org.uk

Mr Tim Harrison, Associate Professor, School of Pharmacy, De Montfort
University Email: tharrison@dmu.ac.uk.

\textsuperscript{+} Corresponding author's present address: 17 Cole
Lane, Ockbrook, Derby DE72 3RD

\textbf{Correspondence to} : Dr Peter Rivers: peterrivers@btinternet.com

\textbf{Running title:} Prescribing decisions on the acute medical unit

\textbf{KEY WORDS}

multimorbidity, polypharmacy, prescribing

\textbf{WORD COUNT:4862 (excluding abstract, key words and references)}



\textbf{ABSTRACT}

\textbf{Rationale, aims and objectives}

The primary aim of the study was to understand the mindset of doctors
and pharmacists, as they embark upon prescribing in a multimorbidity and
polypharmacy context during routine practice at a hospital acute
admissions unit. The study also aimed to evaluate to what extent
attitudes, embedded within real-life decision-making scenarios, relate
to existing theory and models of prescribing decisions.

\textbf{Methods}

Anonymised case studies were identified from the medical notes of
patients aged 65 and over with conditions likely to be associated with
multimorbidity, medication issues and polypharmacy: namely: fall,
urinary tract infection, confusion or lower respiratory tract infection.
A total of 39 doctors based on the acute medical admissions unit and 9
pharmacists were recruited to one of three focus groups. Patient
case-studies provided the context for discussion from which verbatim
transcripts were thematically analysed using an interpretative,
qualitative approach. Sub-themes were matched to Murshid and Mohaidin's
proposed model of physician prescribing decisions.

\textbf{Results}

Seven principal themes were identified that were associated with
prescribing decisions on the acute medical unit, namely, `patient
characteristics', `drug characteristics', `pharmacist factors',
`trustworthiness', 'reliability of medication history, \emph{`}
competing pressures and priorities' and `responsibilities of
prescribers'.

\textbf{Conclusion}

Prescribing decisions on the acute medical admissions unit were
influenced by a variety of factors, some of which have already been
acknowledged within existing theories and models. The findings
provisionally offer new insights, which, subject to confirmation by
further research, bring to light three attitudinal characteristics that
may impact negatively upon the quality of prescribing decisions. These
include, first, how perceived poor reliability of medication history may
result in information gaps that compromise prescribing decisions;
second, how competing pressures and priorities restrict doctors'
aptitude to conduct a review of medication and finally, how doctors may
rationalise the assignment of medication review to the GP.

\textbf{INTRODUCTION}

It is widely recognised that the more medicines patients take, the
greater the risk of adverse drug reactions and
hospitalisation.\textsuperscript{1} Indeed, prescription medication is
implicated as a causal factor in approximately 7\% of hospital
admissions. \textsuperscript{2} However, when treating patients with
multiple morbidities, deciding which of several medicines are
appropriate (`appropriate polypharmacy') and which are not (`problematic
polypharmacy') \textsuperscript{3} represents a prescribing decision
dilemma, that, to date, remains largely unresolved especially when
multiple prescribers focus upon different disease processes.

A comprehensive review of theories and models of prescribing decisions
by Murshid and Mohsen describes a wide range of variables that relate to
physicians' decisions to prescribe medicines. \textsuperscript{4} The
theories of persuasion, planned behaviour and agency theory have
enhanced our understanding of how prescribing decisions may be
influenced by the characteristics of patients, (e.g. patient
expectations), pharmaceutical marketing\textsuperscript{5 6}, the
characteristics of drugs, the ratio of drug cost to benefit and
physician habit persistence. Social power theory is also important in
terms of understanding how pharmacist -- physician collaboration and the
level of trustworthiness between health care professionals may influence
prescribing decisions. However, in our experience, this knowledge has
not yet been consistently translated into practice to ensure problematic
polypharmacy is avoided.

There is no shortage of professional guidance on how best to encourage
appropriate prescribing in the UK in the face of
polypharmacy.\textsuperscript{3 7 8 9 10 11} Indeed, prescribing
guidance tools such as Beers criteria for the
elderly\textsuperscript{12} and STOPP/START\textsuperscript{13}, are
readily available. However, a recent randomised controlled trial carried
out in six European hospital medical centres reported poor uptake by
clinicians of SENATOR software-generated medication advice based upon
STOPP/START prescribing rules.\textsuperscript{14} A shared aim of all
polypharmacy guidance is to recognise the patient as an individual who
often has multiple problems, rather than as a series of individual
conditions where multiple individual clinical guidelines may be applied.
Thus, some goals may need to be modified to enable the overall health of
an individual to be optimised whilst ultimately ensuring prescribed
medicines are safe.

Owing to the on-going conflict between problematic polypharmacy and
patients' presentation to hospital with multimorbidity, we decided to
find out whether prescribing decisions are influenced by factors other
than those that have already been identified by existing theories and
models of prescribing. We, therefore, decided to evaluate the mindset of
doctors and pharmacists involved in making prescribing decisions in an
acute hospital medical unit (AMU). The term `mindset' reflects the
habitual attitudes and ways of thinking that contribute towards a mental
framework within which prescribing decisions are made. The primary aim
of the study was to gain an understanding of the mindset of prescribers
during routine practice and to evaluate whether this mindset, embedded
within real-life decision-making scenarios, relates to existing theory
and models of prescribing decisions.

\textbf{METHODS}

Qualitative data were obtained as part of a wider quantitative study
investigating the prescribing history of patients from the time of
hospital admission until the day of discharge. Fieldwork was conducted
by three cohorts of research assistants who were undertaking their final
year of the MPharm pharmacy degree between January and March during
2015, 2016 and 2017. Ethical approval and honorary contracts were
granted by UK University Hospitals of Leicester (UHL) and De Montfort
University (DMU) for each cohort of students: 2015: UHL Reg. No. 7186e,
2016: DMU FREC 1679, 2017: DMU FREC 1866).

Each year, the research assistants selected a sample of clinical notes
of patients who were being treated on the AMU at Leicester Royal
Infirmary. The inclusion criteria for selection were: age 65+ years;
admission during the previous week; having one or more of the following
presentations, all of which are frequently associated with medication
issues and polypharmacy:- fall, urinary tract infection, confusion or
lower respiratory tract infection. From this sample, NL selected 6 case
studies, of contrasting prescribing complexity, that were judged to be
within the experience of participants and who would be expected to
manage within their routine practice. These case studies were
subsequently shown to medical staff and pharmacists during a focus group
in the second phase of the study as a basis for stimulating discussion
about prescribing decisions. The median number of medicines prescribed
at the point of admission to hospital for patients who were included as
case studies was seven (min 2, max 20).

After the quantitative survey had been completed, doctors working within
the AMU were invited (by NL in his role as AMU consultant physician) to
attend a focus group that was held during a normal regular clinical
lunchtime meeting located within the hospital premises. Pharmacists were
similarly invited to a single separate focus group in 2017. It was made
clear that about one hour would be set aside for the focus group and
that attendance was voluntary. Those who took part in the study gave
written consent after having advance opportunity to read a participant
information sheet and a verbal explanation immediately prior to
commencement.

A total of forty-eight participants (39 doctors, nine pharmacists)
attended the focus groups which included a minimum of nine and a maximum
of 19 participants per group. The level of experience of the doctors
ranged from the first foundation year up to consultant level. The names
of the doctors who attended the focus groups were not recorded. Those
who were in their first foundation year attended only one focus group
and doctors in more senior grades attended between one and three groups
according to their availability to attend. Those who attended the
pharmacy focus group were all pharmacists ranging from `band 6' (newly
qualified) to `band 8A' (specialist pharmacists). A semi-structured
topic guide was used by an academic male, non-clinician, facilitator
(PR) in order to encourage open and blame-free discussion relating to
prescribing decisions arising from the case-studies. During the period
of the study PR was employed as pharmacist final project supervisor,
researcher, and evaluator at a local school of pharmacy and not
previously known by the study participants. The facilitator had
extensive previous experience in conducting focus groups in health
contexts using unstructured and semi-structured techniques. His
background as a pharmacist offered a broad understanding of the clinical
use of medicine which facilitated development of rapport with the
participants. However, the facilitator endeavoured to remain neutral
with respect to his views of prescribing decisions while interacting
with the group. Each focus group was also attended by up to three final
year undergraduate pharmacy students primarily as non-participant
observers although assisting the facilitator by intervening occasionally
in order to seek clarification. The number of case studies presented to
participants ranged from three to six per focus group depending upon the
complexity of the cases and consequently the amount time available. The
reason for showing the medical and medication histories was to provide
context and to facilitate opening up discussion on prescribing
decisions.

Upon commencement of the focus group, participants were invited to
reflect upon what they aimed to achieve as prescribers and upon any
difficulties that arise when assessing the medication needs of a newly
admitted patient. The discussion emanating from these opening questions
then provided context for the group to consider prescribing decisions
that were shown within the case studies. The facilitator put each case
study up on screen and paper copies of the case studies were made
available. The facilitator read out, for each case study in turn, the
presenting diagnoses and therapeutic actions including medication that
was stopped, paused, or started during the period of stay. Then the
group was invited to share their thoughts on the case study and to
consider whether they would have acted in the same way with respect to
prescribing decisions. There were no more set questions as such - the
remainder of the focus group was conducted using an unstructured format
where questions arose from the ensuing comments and discussion. The
facilitator encouraged participants to make their own judgements and
comments and, where appropriate, prompted respondents to expand or
explain their thinking.

\textbf{2.1 Data analysis}

The focus groups were audio-recorded and verbatim transcripts underwent
thematic analysis by the authors based upon a pragmatic process where
components of experiences were pieced together to form a picture of
collective experience of the participants, based upon a method described
by Aronson\textsuperscript{15}. Coding of the transcripts was initially
completed independently and finalised after meetings. The subthemes
derived from analysis were matched, where appropriate, to a proposed new
model of physician prescribing decisions published by Murshid and
Mohaidin\textsuperscript{4}.

The initial coding of transcripts followed by aggregation into thematic
dimensions and subthemes was informed by our philosophical approach. The
study was originally conceived as a descriptive quantitative survey and
the focus groups that followed were intended as a means to critique the
appropriateness of prescribing decisions as audited against quantitative
data derived from the first phase of the study. However, it became
apparent, after transcription of the three focus groups, that there was
greater potential to apply interpretivism in our approach to analysis.
We realised that there were further insights to be gained by
comprehending the thought processes that provide context and foundation
to prescribing decisions. Philosophically, our approach therefore
evolved more into alignment with \emph{verstehen} , a term that was
originally introduced by Max Weber \textsuperscript{16} which
essentially refers to an understanding of the world as others see it. It
is recognised that the term `interpretivism' embraces a variety of
different philosophical approaches.\textsuperscript{17} This study
essentially involves human interpretation and we believe that it may be
more accurately defined as one that is phenomenologically orientated.
Thus, we sought to understand what it is like to be a prescriber and
pharmacist on the AMU (their `lived experience') and to appreciate the
conscientiousness of prescribers and prescribing advisors as they embark
upon making prescribing decisions. It is important to acknowledge that
the medical and pharmacological information that was presented within
the case studies, to provide context for participants, was not relevant
to this phenomenological analysis because there was no intention to pass
judgement over the choice of medicines or to question the
appropriateness of decisions. Thus, we felt that it was important to
disassociate, from the analysis, clinical details relating to care of
patients. For these reasons, the case studies are not included in this
paper.

\textbf{FINDINGS AND DISCUSSION}

The findings highlighted some well-known driving forces that influence
prescribing decisions. These include `patient characteristics', `drug
characteristics', `drug characteristics, `pharmacist factors' and
`trustworthiness'. Interestingly, the influence of `marketing effects'
by the pharmaceutical industry, a variable derived from persuasion
theory \textsuperscript{4} that has been advocated as a main driver for
prescribing decisions in connection with, for example, brands of drug,
was not overtly observed in the present study. The reason for this
finding is unknown but we postulate that, while complacency must be
avoided, there may today be a greater awareness of potential conflict in
interest that can arise between pharmaceutical representatives and
hospital prescribers.\textsuperscript{18} The findings uncovered three
new attitudinal factors that influence prescribing decisions that have
not, to date, been described in the literature:1. Reliability of
medication history, 2. Competing pressures and priorities and 3.
Perceived responsibilities of prescribers. A summary of dimensions and
subthemes identified within the findings and presented in relation to
existing prescribing theory and models is shown in Table 1.

\textbf{3.1 Patient characteristics}

Doctors, in line with the principles of the Hippocratic oath, ``use
treatment to help the sick \ldots{}, but never with a view to injury and
wrong-doing'', aim to ensure that medication is safe and beneficial.
Upon admission to the AMU, the patient's presenting complaint and
clinical picture alongside immediate prescribing for acute treatments
were primary considerations in the prescribing of medicines. Doctors
acknowledged that it was important to ensure that the patient's existing
therapy should not be interrupted so long as it continued to be
beneficial. The characteristics of the patient, such as confusion,
dehydration, or renal function, then modified this decision and acted as
a prompt for further prescribing actions. For example, if kidney
function was poor, this might prompt a decision to stop, or temporarily
withhold, medication, as illustrated by the following quotation: -

\emph{``We have a lot of people with renal failure, pneumonias and
things, so for example, some of the} {[}medicines that are\emph{{]} not
continued, we identified as being nephrotoxic so we would not continue
the medication''.} (Doctor, 2015)

Other patient characteristics included the age of the patient and level
of frailty, particularly in terms of a dose being perceived to be too
high or if a patient would no longer benefit from continuation of
medicines, or any further additions.

\textbf{3.2 Drug characteristics}

In general, the underlying mantra of `first do no harm' was seen as an
important aspect of prescribing. For example, both doctors and
pharmacists aimed to avoid harm by identifying side-effects or unwanted
effects and were aware that polypharmacy could be detrimental.

Facilitator: \emph{``What are you seeking to achieve when you assess
medication when you first see a patient?''``Basically - what they are
taking and what they are supposed to be taking?''} (Doctor A,
2017)\emph{``Are any of the medications causing the patient symptoms? Is
there polypharmacy}?'' (Doctor B, 2017)\emph{``Are we worried about any
side-effects?\ldots{}the reason that the patient is here is because of
the medications {[}that{]} can possibly {[}be{]} driving them.''}
(Doctor C, 2017)

Knowledge of national or local guidelines influenced prescribers'
ability to manage this as well as using them as justification for
initiating prescribing. However, guidelines also limited individuals'
prescribing independence with doctors indicating that they were
reluctant to change an existing medicine (i.e. one that the patient had
been taking prior to admission) unless overt clinical harm had occurred,
or prompted by a specific guideline regardless of patient benefit
profile.

These decisions were further modified according to their perceived
knowledge of the pharmacological group of the drug. There was a
reluctance to stop potential `culprit' medicines because of a lack of
knowledge, either of the drug itself, or the original reason for
prescribing it. For example, ``\emph{well generally, how long have they
been on it? \ldots{}Let's be honest, we don't know how they work and
also} {[}I would be concerned about{]} \emph{the side effects of acute
withdrawal\ldots{}''} (Doctor, 2016). ``\emph{Yeah, and the exact
rationale in terms of their use is not necessarily
clear\ldots{}''}(Doctor, 2016). This appeared to apply particularly to
medicines prescribed for psychiatric conditions. By contrast,
participants accepted that they preferred to adjust familiar drugs with
effects they believed were more predictable such as antihypertensive
medications.

\textbf{3.3 Pharmacist factors}

Decisions to prescribe were thought to have been enhanced when
pharmacists were involved. Doctors habitually seek advice from
pharmacists present on the ward to assist in making prescribing
decisions. Surprisingly, the pharmacists themselves appeared to be
unaware of the high esteem within which they were held in terms of their
potential ability to influence prescribing decisions. They tended to
describe their role as being supportive and more as a ``checker'' or
safety-net provider. Moreover, the pharmacists tended to compare
themselves favourably with their medical colleagues with regard to
performing medication reconciliation. The latter is the formal process,
described in a toolkit published by the Royal Pharmaceutical
Society\textsuperscript{19}, that ensures accurate and complete
medication information is obtained at interfaces of care such as when a
patient is admitted to and discharged from hospital.

Facilitator (to pharmacists): \emph{``When assessing medication on
admission, what are you seeking to achieve?''``\ldots{} I would take an
accurate drug history and reconcile that with the meds that have been
prescribed. If there are any discrepancies, highlight them to the
doctors\ldots{} {[}and{]} highlight any incorrect doses as well to the
doctors. Just make sure the basic safety is there and it matches with
the patient that is there''}(Pharmacist ). ..'' \emph{Also check
allergies or anything that the doctors might not pick up such as
eyedrops, creams, ointments, injections.} (Pharmacist ) In response to a
medication history documented in one of the case studies, one of the
pharmacists commented: -\emph{I think \ldots{}the drug history has
probably been done by a doctor}\ldots{}{[}there are{]} \emph{a lot of
things we would have picked up like apixaban, codeine - we wouldn't just
write `15-30mg prn'. We would write `qds prn'. \ldots{}Then stuff like
furosemide -- we wouldn't write `bd'. We would write 8am and 2pm.
\ldots{}Movicol -- we wouldn't write `bd', we would write how many
sachets they are having''}(Pharmacist).

Doctors acknowledged that discharge prescriptions may be prepared based
upon recommendations from pharmacists, as illustrated here: -

``\emph{I think, most of the time, when we are reviewing the medication
at the time of discharge, we do the `lifestyle', and then we go through
the medication they came in with -} {[}and we check to see{]} \emph{if
the pharmacists are concerned about anything} {[}by pharmacist
highlighting in the notes{]}\emph{\ldots{}}(Doctor A, 2016\emph{).``If
you have a really good pharmacist (}Doctor B, 2016).\emph{``Yeah''}
(Doctor C, 2016).\emph{``If the pharmacist hasn't highlighted it, then
actually they go home without those medications} (Doctor D, 2016).

The pharmacists did not always appreciate the clinical reasoning that
underpinned prescribing decisions when an alternative action would be
more obvious to them:-

Pharmacist 1: ``\emph{Why are they on digoxin? Maybe they have developed
AF {[}atrial fibrillation{]}?''} Pharmacist 2: ``\emph{Yeah''},
Pharmacist 3: \emph{``They are on bisoprolol 2.5mg, why don't they just
optimise that {[}bisoprolol{]} first before starting
digoxin?''}Pharmacist 2: \emph{``They've got the patient on senna
{[}which{]} can actually cause hypokalaemia which can cause digoxin
toxicity''.}Pharmacist 1: \emph{``You would want to know if they are
having palpitations''.}

The full potential of pharmacists with therapeutic knowledge was not
evident within the doctors' focus group transcripts, a finding that has
also been reported by Anderson et al.\textsuperscript{20} The skills of
pharmacists appeared to be under-utilised with regard to new product
prescribing, as has been reported by Tan et al.\textsuperscript{21} and
in community pharmacy practice \textsuperscript{22}, as well as a lack
of formal partnership between the two groups resulting in the actions of
pharmacists' being curtailed. Recent research in the UK demonstrates,
however, that community pharmacists can conduct medication reviews and
work effectively within a multidisciplinary team to tackle polypharmacy
resulting in reduced re-admission rates after discharge from
hospital.\textsuperscript{23 24}

\textbf{3.4 Trustworthiness}The concept of trustworthiness was relevant
in terms of the veracity of medication records and, on a human level,
between doctors themselves and their colleagues. Prescribing decisions
reflected decision-making by doctors independently and in collaboration
with pharmacists.

The way trustworthiness informed prescribing decisions was evident
within the discourse of both doctors and pharmacists. On a `systems'
level, trustworthiness was apparent in terms of a perceived lack of
reliability of the medication history and its currency in relation to
the patient's presenting condition. Drug histories were viewed with a
healthy degree of scepticism even when taken directly from
patients\textbf{.} For example\emph{-- ``I ask them: `Are you taking
your medication'?''} (Doctor 2, 2017)\emph{\ldots{}``and they all say
``yes''!'} (Doctor 5, 2017)\emph{.} This was modified by the extent to
which they thought patients were adhering to prescribed regimens. On a
human level, there was evidence that some of the more experienced
doctors did not always trust junior colleagues as active decision-makers
- ``\emph{It is usually the junior doctors who access the system and
make the changes on senior instructions - so on the system it may look
like the juniors are making decisions but they are just acting on
instructions''} (Doctor, 2015). Pharmacists, regardless of their level,
were trusted by doctors to be more accurate regarding the recording of
drug histories. This perception was reinforced by some pharmacists, who
also believed there was degree of reliance upon them to pick up
problems.

\textbf{3.5 Reliability of medication history}

Both doctors and pharmacists were cognisant of the information vacuum
within which they were working at the AMU. The initial clerking of a
patient focused upon obtaining up-to-date knowledge of the medication
history and this was often thwarted because of incompleteness or
datedness of records or lack of confidence in the patient's story. This
was recognised particularly as a problem of prescribing within the unit
as prescribers were working within an imperfect communications
environment, piecing together a jigsaw, and filling in gaps using
collateral sources. The following quotation is illustrative of
frustration that several doctors expressed: -

\emph{``The whole med rec {[}reconciliation{]} part of it is a nightmare
in terms of \ldots{} getting access to what they are on reliably, and
you can say -- ``yes'' {[}``it is correct''{]}-- not on a scrap bit of
paper that they have written their drug doses down on 10 years
before\ldots{}.} (Doctor 2016)

Owing to difficulties when working within an uncertain medication
history, problems persist as prescribers' intentions remain insecure.
For example,

\emph{``There {[}is{]} some medication} {[}that is{]} \emph{specifically
very distinctly difficult such as warfarin\ldots{} you never know what
the dose is and if the patient doesn't know then it's very difficult to
prescribe appropriately. And also, insulin and pain relief -- if it's
`prn'} {[}when required{]} \emph{you may prescribe the lowest dose prn
but they might be on the maximum dose which makes it very
difficult}(Doctor, 2015). ``\emph{Sometimes\ldots{}the medical notes
don't match up to the EPMA {[}Electronic Prescribing and Medicines
Administration{]} system\ldots{} certain medicines have been missed off,
so we're not too sure whether they have actually been stopped or just
accidentally missed off}'' (Doctor, 2016).

Under such circumstances, it is clear that some prescribing decisions
were left unmade with prescribers hoping that the issue will be picked
up at a later point when more information or advice was available.

\textbf{3.6 Competing pressures and priorities}

The narrative of doctors illustrated that prescribing behaviour is
contextualised by the environment within which they work. For example,
owing to the limited number of doctors and reduced availability of
pharmacists when working out of hours, a process of prioritisation arose
by necessity.

\emph{``If it's 2'oclock in the morning\ldots{}if you have other things
going on, then you would prescribe the stuff that needs to be done and
then highlight {[}}other prescribing\emph{{]} to the day team''.
(Doctor, 2016)}Sometimes, high workload levels mitigate against doctors
responding to system alerts designed to flag up medication warnings
which may be over-ridden during busy times. ``\ldots{} \emph{because
you're doing a busy ward round {[}}and a pop-up message arrives{]}
\emph{you just press okay, okay. It's the automatic alerts that come
up\ldots{}. For pretty much everything and sometimes you say `okay,
carry on'} {[}and{]} \emph{every click takes just 10 seconds''} (Doctor,
2016).

One doctor recalled that he had been requested to expedite preparation
of a `take home' prescription for a patient -- ``\ldots{} \emph{the
review of the medications as a whole comes when the patient is in the
discharge lounge and the nurses are on your neck -- `Do the TTO! Do the
TTO! Do the TTO! So, you don't actually have time to review} '' (Doctor
2017).

\textbf{3.7 Responsibilities of prescribers}

There was evidence that prescribers develop demarcation lines whereby
they identify where their responsibilities should be prioritised and,
conversely, where tasks can be entrusted to others. This was apparent in
the context of considering the extent to which the GP was responsible
for the review of medication initiated pre-admission -- ``\emph{the GP
is better placed at optimising those kind of doses unless we} {[}believe
we should{]} \emph{outright stop it. For optimisation we have to have
good reason as to why we have chosen to optimise it. We only see the
patient acutely''} (Doctor, 2017).

The sentiments described in this theme overlap with the theme of
competing priorities.



\textbf{3.8 Strengths and Limitations}

The strength of this study resides within the premise that it seeks to
understand the mindset, in the real world, of both doctors and
pharmacists, with varying levels of experience, associated with
prescribing decisions on the AMU. The choice of an acute medical unit as
the prescribing forum was advantageous because an admission to hospital
presents an opportunity to review medication with potential to influence
future prescribing decisions by the GP in the community. However, the
study has a number of limitations including the fact that it was carried
out at a single site, with a series of common presentations which may
not, therefore, be representative of all prescribing situations, or of
all AMUs throughout the UK. The focus group was conducted
retrospectively, at least one day after the actual decisions had been
made and therefore did not represent `real-time' thought processes at
the moment of prescribing or the thoughts of the actual prescriber.

Further research is needed that would ideally reflect the individual
thought processes of prescribers and advisors prospectively at the time
decisions are made and in samples of patients with a wider variety of
diagnoses and in different acute hospital settings.

\textbf{3.9 Implications for practice}

An important factor identified in the present research was the perceived
dearth of trusted medication history resulting in doctors understandably
lacking confidence in making prescribing decisions based upon absent or
inaccurate data. An inadequate medication history represents a
significant shortcoming in the context of encouraging safe prescribing.
Electronic patient medication records (ePMR) with alert systems are now
routinely used in pharmacies and act as a safety-net prior to dispensing
in pharmacies. Although ePMR are effective in alerting users of
potential clinical hazards and errors, problems of false alerts and
inconsistencies in alert management still
persist.\textsuperscript{25}There remains, therefore, an on-going need
to sit with the patient and take a traditional drug history to ensure
not only prescribed medicines are included but also that alternative
therapies, treatments or lifestyle medicines that have been purchased
from pharmacies, or bought over the internet, are also included. The
perceived value of pharmacists, as experts in taking a medication
history, lends support to an argument for pharmacists to be present on
the AMU out of hours in order to provide support for medical staff in
the medicines reconciliation process.

Pressure from patients, relatives or carers may result in uncomfortable
prescribing decisions by hospital prescribers, \textsuperscript{26} but
stress within the work environment has not yet been acknowledged in
relation to prescribing decisions. The finding that there are competing
priorities encountered by doctors on the AMU implies that it is
unrealistic to assume an effective medication review can be completed
immediately prior to a patient being discharged. A suggested way forward
would be to allocate staff with protected time to overcome these
challenges. Alternatively, proven schemes could be expanded, such as
those in Scotland \textsuperscript{23} and Cornwall\textsuperscript{24},
where the value of community pharmacists reviewing medicines of patients
who have recently been discharged from hospital has been demonstrated.
The AMU is recognised as being a high-pressure working environment owing
to the clinical urgency of patients' admissions as well as the need to
maintain patient flow through the hospital. If doctors feel under
pressure, they may focus principally on the primary diagnosis,
prescribing medicines that are efficacious in relation to symptoms
associated with the cause of admission rather than to plan the discharge
prescription in the context of avoiding longer-term inappropriate
polypharmacy. Such an approach may ultimately increase the likelihood of
patients experiencing an adverse drug event in primary care as outlined
by Slight et al.\textsuperscript{27}Moreover, perceived workplace
pressure may legitimise hospital prescribers, underpinned by recent UK
guidance to assign accountability to the GP for the continuation or
modification of medicines that were not initiated in hospital.
\textsuperscript{28}

Prescribing tools such as Beers and STOPP/START criteria have been
available for over a decade and have been integrated into computerised
clinical decision support systems (CDSS). Prescribing tools have been
successfully deployed to quantify the incidence of inappropriate
prescribing but several studies over recent years, in a variety of
clinical settings, have demonstrated that there is insufficient evidence
of their clinical or economic
impact.\textsuperscript{14,29,30,31,32,33}The failure of prescribing
tools such as STOPP/START to reduce the incidence of inappropriate
prescribing suggests that an alternative approach may be worthy of
consideration. Hence, we propose that a greater understanding of factors
that directly influence doctors during routine practice at the point of
prescribing may help point the way towards providing better support for
prescribers, including CDSS support, to ensure prescribing guidance
translates into patient benefit.



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\textbf{ACKNOWLEDGEMENTS}

The authors gratefully acknowledge the contribution of the following
who, as students, were involved in this research when undertaking their
final year MPharm projects: Iman Ahmed, Mobeen Aziz, Kaash Chandarana,
Jignasa Chawda, Navpreet Gill, Kiran Hothi, Mohsin Patel, Ramanpreet
Rai.

\textbf{CONFLICT OF INTEREST}

The authors declare no potential conflicts of interest with respect to
the research, authorship, and / or publication of this article.

Table 1: Subthemes relating to prescribing decisions identified from
data analysis\textsuperscript{1} and existing prescribing decision
theory\textsuperscript{2}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
DIMENSION\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
SUBTHEME\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Patient characteristics \textsuperscript{1,2}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Presenting complaint or pathology\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Age of patient\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Wishes of family\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Adherence\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Drug characteristics \textsuperscript{1,2}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Clinical picture informing prescribing decisions\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Avoiding harm\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Polypharmacy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Drawing upon guidelines as resource (e.g. NICE)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Iatrogenesis\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Review / lack of review of medication\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pharmacist factors \textsuperscript{1,2}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pharmacist as checker and optimiser, not clinical decision maker\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Expertise\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Trustworthiness \textsuperscript{1,2}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Distrust of information source until proved correct / reconciled\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Doctors compared with pharmacists and vice-versa\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Perception that junior doctors may not have enough experience to review
drugs\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Marketing effects \textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Not overtly observed in verbatim transcripts\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Reliability of medication history (written and verbal)
\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Confidence in obtaining accurate history Filling in knowledge gaps from
collateral sources Availability \& functionality of Electronic
Prescribing \& Administration System / use of decision support tools
Language ambiguity\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
External pressures \& priorities\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Time-consuming aspects of job\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pressure to expedite `take home' prescription on discharge\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Coping strategies in response to demands on workload\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Responsibilities of prescribers\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Reluctance to change medicines perceived not to be associated with cause
of admission\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Passing the buck. Perception that GP (not self) is responsible for
prescribing drugs that were originated in primary care setting\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
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