Further high-quality prospective clinical trials are urgently needed in demonstrating the safety, benefits

and optimal modes of deprescribing, especially in relation to multimorbid older people.61 64 The fog of polypharmacy else clouds a prescriber’s capacity and confidence to identify PIMs which, to be overcome, requires complete and accurate clinical information and decision support. Professional organisations and colleges have an important role in encouraging the necessary cultural and attitudinal shifts towards ‘less can be more’ in appropriate patients. The push for guideline adherence and intensification of therapy needs to be counterbalanced by the view that judicious reduction, discontinuation or non-initiation of medication, in the context of shared decision-making and agreed care goals, is an affirmation of highest quality, individualised care.65 This view needs to be embraced in the education and training of all health professionals, not just doctors, who influence the prescribing process. Prescribers are making decisions in the face of immense clinical and health system complexity. Appropriate deprescribing needs to be regarded as equally important and achievable as appropriate initiation of new medications. Understanding how

prescribers perceive and react to prescribing and deprescribing contexts is the first step to designing policy initiatives and health system reforms that will minimise inappropriate overprescribing. Supplementary Material Author’s manuscript: Click here to view.(2.4M, pdf) Reviewer comments: Click here to view.(147K, pdf) Acknowledgments The authors thank the University of Queensland librarians Mr Lars Eriksson and Ms Jill McTaggart for their assistance in developing the search strategy

and Ms Debra Rowett for her invaluable insights when scoping the search and developing the manuscript. Footnotes Contributors: IS conceived the paper, the scope of which was refined by all authors. KA searched the literature, led AV-951 the data analysis and drafted the manuscript. IS and DS read articles and assessed the data analysis for comprehensiveness and reliability. IS, DS and CF provided critical comments and contributed to the interpretation of the analysed results and framework development. All authors read, revised and accepted the final draft. Funding: KA and IS are funded through a National Health and Medical Research Council grant under the Centre of Research Excellence Quality & Safety in Integrated Primary/Secondary Care (Grant ID, GNT1001157). Competing interests: KA received a speaker honorarium for an Australian Association of Consultant Pharmacy presentation. DS reports personal fees from the National Prescribing Service, outside the submitted work.