It demonstrates the importance of awareness-raising strategies for prescribers. Inertia, as in failure to deprescribe when appropriate, sits at odds with the more traditional use of the word as symbolising failure to intensify therapy when indicated.50 Inertia has been linked to selleck compound ‘omission bias’ where individuals deem harm resulting from an act of commission to be worse than that resulting from an act of omission.51 52 In the case of deprescribing as an act of commission, it becomes more a matter of reconciling a level of expected utility (accrual of benefits) with a level of acceptable regret (potential

to cause some harm).53 Fear of negative consequences resulting from deprescribing contributes to inertia and is not easily allayed by the current limited evidence base regarding the safety and efficacy of deprescribing.54 In the same papers in which prescribers rationalised continuation of therapy with the belief that drugs work and have few adverse effects,34 35 38 39 41 43–45 47 prescribers also identified different thresholds for initiating versus continuing the same therapy. This anomaly suggests a lack of prescriber insight, clear differences in prescribers’ attitudes towards initiation versus continuation, or a social response bias towards a false belief induced by the methodology used by interviewers.

Relevance to previous literature One meta-synthesis of seven papers has recently been published online exploring prescribers’ perspectives of why PIP occurs in older people.55 Compared with our review, this study had a generic focus on PIP, including underprescribing, and its search strategy retrieved fewer articles (n=7). Scanning their reference list did not reveal any additional papers which would have met our selection criteria and their results yielded no additional themes. Our findings are consistent with those in the literature (largely focused on initiation of therapy),

suggesting that pharmacological considerations are not the only factors impacting doctors’ prescribing decisions.56 Interacting clinical, Cilengitide social and cultural factors relating to both the patient and prescriber influence prescribing decisions.56–58 Reeve et al20 recently published a review of patient barriers and enablers to deprescribing and have emphasised the importance of a patient-centred deprescribing process.59 When comparing their results with ours, we find that prescribers’ barriers are concordant with those of patients with respect to resistance to change, poor acceptance of non-drug alternatives, and fear of negative consequences of discontinuation. However, prescribers also underestimate enabling factors including patients’ experiences/concerns of adverse effects, dislike of multiple medicines, and being assured that a ceased medication can be recommenced if necessary.