PONE-D-24-26224Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing settingPLOS ONE

Dear Dr. Yusuff,

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We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

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KBY

Undergraduate Research Experience Program (UREP) award [UREP29-092-3-029] from the Qatar National Research Fund (a member of The Qatar Foundation). The contents are solely the responsibility of the authors.

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript as presented could benefit from additional information, rationale to support decision-making and clarity. These follow in summary and more detail in peer review report.

1. Amend title to include Qatar

2. Offer definition of deprescribing for this study Lines 57-59. Deprescribing is identified as “… an important clinical tool…” but for clarity, it would be helpful to offer a definition or detailed description of deprescribing as used in this study.

3.Lines 85-88 would benefit from each key assertion being individually referenced

4. Lines 102-104 It can be helpful to identify the search criteria utilised

5. Lines 112-117 It could assist readers to identify additional information such as the fourteen domains and those especially relevant to this study, for example

6.Lines 140-144 ? Please explain the research team’s decision-making on this point. Please describe the fourteen domains and the theoretical background as it informs this study.

7. Lines 170-173 This section could be enhanced by some details about the research assistants since they seem to be the “face” of this study to pharmacist participants.

8. Analysis section - In a manuscript, it is beneficial to identify those functions within SPSS that were used to analyse the data, similarly any recoding of values such as for negatively phrased items. More detailed information is needed to understand the results obtained and the conclusions drawn.

9.study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest =5, high = 4, moderate = 3, low = 2, Lowest = 1). However, in Results section Table 2, the columns are labelled,

Low

n (%) Moderate

n (%) High

n (%) Median (IQR)

If additional analyses or re-coding were undertaken to result in these three categories, that needs to be clearly detailed.

10. Apparent repetition Lines 173-176 AND Lines 165-167 - Both state “The respondents who agreed to participate in the study signed the written informed consent form before the start of data collection, and they were all informed of their right to decline participation at any point in the study.”

11. Results Additional detail would be helpful to understand the results of the study and its outcomes.

12. Additional guidance is available in this article, “A Consensus-Based Checklist for Reporting of Survey Studies (CROSS)” in which the reporting guidelines are found in the supplementary material – supplement 3

13.The discussion benefits from being better contextualised by discussing recent publications centred on Qatar

14. Limitations - it was not evident in the manuscript which locations were sampling towns or regions as differences in perceptions, experiences and resources might be anticipated in various locations

15. The the link between methodology (survey) and favourable responses is not clearly explained but benefits from being so.

16.This reference (number 36) appears to be inconsistent with Vancouver referencing:

Gerlach N, Michiels-Corsten M, Viniol A, et al. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing—a qualitative study. BMC Fam Pract. 2020/09/06 ed. 2020 Sep 4; 21(1):183.

17. Please review all references for consistency with Vancouver format.

Reviewer #2: The manuscript is good but I think the following points should be addressed:

1- rewrite the title as the title is not clear such using facilitators instead of enablers

2- I prefer to attach the developed questionnaire in the appendix or supplement file

3- I think also mention how did you summarize answers from five choices to three choice (table 2) in the methodology section after line 161-162

4- I think mention the current practice in Qatar, it is manly traditional practice or there is/are some advance practice such as reviewing medication, providing vaccination, prescribing authorizes, etc... will be beneficial and strengthen the study

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Reviewer #1: No

Reviewer #2: Yes: Mohammed Abdullah Kubas

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Attachments

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Submitted filename: PLOS ONE ReviewFINAL Author Editor.pdf

PONE-D-24-26224R1Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in QatarPLOS ONE

Dear Dr. Yusuff,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

 Thank you for your responses and revisions. The original reviewers have evaluated your responses and have asked for some further minor revisions to improve clarity of your work.

Please submit your revised manuscript by Jan 05 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for submitting your revised manuscript. To my perception the changes made have enhanced the clarity and communication of the manuscript. There are also opportunities for additional clarity and enhanced communication of your research, the decision-making inherent to the research and the outcomes. In particular, it is important to meet the journal's expectations for key sections such as the introduction which provides sufficient context and background for readers unfamiliar with the study site to understand the setting, professional practice in that setting, and, issues that may benefit from exploration and dissemination. Then the next key component - the methodology which benefits from sufficient information and justification for decisions made such as the choice of function within a data analysis program to inform the reader why and for which purpose that analysis plan has been effected. Lastly, the discussion provides some context within which the results of the study can be situated and considered - so it may be what is specific about pharmacy and pharmacy practice in Qatar.

PLOS ONE Review 2

TITLE: Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar.

RELEVANCE OR SIGNIFICANCE: Currently those in Qatar older than sixty years of age constitute 3.6% of the population though that is predicted to increase to approximately 20.3% by 2050, which is in 26 year’s time, so lacking apparent immediate urgency. So,please seek to firmly and clearly identify the significance or implications of undertaking this study now in 2024 - Why is it needed? Why now? What has to change and what else has to happen for the activity on which this research is focussed to come into effect. In my experience, often authors may be well aware of what is happening in their setting, what could be desirable and will of the pharmacist population to provide a proposed service or modify a standard procedure, for example. However, readers from outside the setting are often quite unfamiliar with a study's setting, and in lieu of more information may wonder if it is much the same as in t he reader's setting. In my experience providing context, information, including some statistics will assist the reader the view the study within the actual study setting.

INTRODUCTION: PLOS ONE expectations for introductory material is for: provision of sufficient background and context of the manuscript such that readers are able to understand the purpose and significance of the study; clarity in identifying the issue addressed and why it is problematic or necessary; concluding with a brief description of the overall aim and whether/how that was/was not achieved. Comments on this section of this manuscript follow.

Some were requested previously but not clarified or reviewed to reflect the information/request:

Issue Lines 57-59. Deprescribing is identified as “… an important clinical tool…” but for clarity, it would be helpful to offer a definition or detailed description of deprescribing as used in this study.

Authors response:

Response-6: Heartfelt thanks to the reviewer for this valuable comment. We agree that a definition of deprescribing will further enhance clarity. In fact, we respectfully submit that we have already done this in the last sentence of the first paragraph of the Introduction section. However, this sentence has been revised to enhance its clarity as recommended by the reviewer. In addition, we have also added one of the references kindly suggested by the reviewer because we think its definition of deprescribing seems to have been captured in line 61-65 [Pg 3-4]

The lines referred to have content as follows:

provides an opportunity for a dispassionate review of the relevance and utility of the medications prescribed to older adults with a view to identify the medications that are no longer required or harmful, and should be discontinued or replaced with safer and more effective alternatives.

Issue - A little more clarity would beneficial - what is a dispassionate review? What benefit arises from a dispassionate view? Why not a standard protocol? Why not take into consideration the patient’s perceptions of their medications or issues they may be having? Further, the key is to identify medications that are no longer required - for which reasons? duplication of therapy? continuation of medication to manage an acute condition? removal of a medication that manages an adverse effect of another medication taken by the patient?

Issue- benefit of additional clarity as to why deprescribing needs to be added, legally, to community pharmacists scope, and why the timing since hospital pharmacists have and are trialling a deprescribing initiative- how is it that deprescribing is within scope for hospital pharmacists in Qatar but not community pharmacists?

Response-2: We thank the reviewer for the important observation and we see the points raised. However, we are of the opinion that the potential clinical and financial burden associated with the harms inherent in the use of inappropriate medications in elderly population is better avoided by provision of a clinical service such as easily accessible. In addition, 3.6% of the current population translates to about120,000 elderly patients in Qatar (Estimated pop is about 3million). Hence, there is a lot of potential inherent benefits associated with the deployment of a care-enhancing clinical service such as deprescribing of inappropriate medications in one of the most vulnerable patient group such as the elderly. In addition, it is generally well established that early deployment of interventions focused improving patient outcomes and strengthening the health system often result lasting positive impact on public health.

This sort of explanation benefits from being included in the manuscript. Further, currently it would appear to be illegal for community pharmacists to do unless and until legislative change is effected, so how quickly can community deprescribing be instituted legally and effectively?. Further, in the 3.6% of the population, how many may be managed by hospital pharmacists who are trialling deprescribing already?

Lines 63-65 assert that the greatest risk to the elderly from medication lies in the number of medicines, and certainly, the more medicines taken, the more there can be a risk of drug-drug, drug-herb, drug-disease state interactions, but there are also some medicines that have an inherent risk of adverse effects in the elderly, even with a lesser number of medications taken. These include NSAIDS, medicines with an anticholinergic effect, some diuretics, antihypertensives and others (https://www.msdmanuals.com/en-au/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults).

So some additional clarity in the definition about how medicines may be harmful as medicines have many different perceptions to lay people, to various health professionals such as doctors, specialist doctors, nurses, pharmacists.

Lines 102-104. The manuscript states, “Indeed, only one such study focused on the assessment of community pharmacists’ knowledge of deprescribing and their self-perceived enablers and barriers to providing the service in the United Arab Emirates was identified.”

It can be helpful to identify the search criteria utilised as the databases, the search terms (e.g. whether words were used or truncation was included) and the timeframe as search engines often give different outcomes at different times, so when the search occurred also matters.

METHODS: The requested information in PLOS ONE is detailed and clear – the journal requires sufficient detail to allow suitably skilled researchers to fully replicate this study. When the methods are well established, authors may cite articles where those are described in detail, but even so THIS manuscript should include sufficient information to be understood independent of those references.

Please provide a copy of the survey in an appendix so format, item wording, response sets, item order can be considered.

ANALYSIS: The manuscript identifies that IBM SPSS (Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) software was used for data analysis. Descriptive statistics such as median (IQR) was used for continuous data with non-normal distribution while frequency (%) was used for categorical data, with significance set at p ≤ 0.05.

Additional clarity sought: In a manuscript, it is beneficial to identify those functions within SPSS that were used to analyse the data. In survey research, it usually matters both what you ask and how you ask it. So, for example, the manuscript data was stated to have been analysed to yield descriptive statistics such as median (IQR) for continuous, non-normal data and frequency for categorical data.

The SPSS Descriptive function data analysis can yield mean, sum, standard deviation, variance, minimum, maximum, range, skewness, kurtosis and standard error of the mean.

The SPSS Frequencies function yields mean, standard deviation, variance, minimum, maximum, range, skewness, kurtosis, valid & missing responses, median, mode quartiles, percentiles.

It is beneficial to identify the SPSS function actually used as that assists a reader to see whether that data analysis could yield the results of the study or whether a different analysis may have yielded more relevant or more useful result.

Words discussing the analysis can also assist readers as can the actual wording of items, order of items, response set and format of the survey, the study instrument.

The manuscript identified that it elicited responses on a Likert-like response set. Most commonly Likert scales have two extreme responses, two moderate responses and a neutral response per item (strongly disagree, disagree, neutral, agree, strongly agree or reverse order).

Subsequently, the responses were described as ranked, “Further, study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest =5, high = 4, moderate= 3, low = 2, Lowest = 1)”. The difference between rating and ranking lies in the information elicited. Rating scale questions such as Likert scales seek to elicit respondents’ attitude(s) towards something ( how much do you agree with this statement, for example). A ranking question seeks a respondent’s preference order.

More detailed information is needed to properly understand the results obtained and the conclusions drawn, so please provide additional information, and in particular, more detail.

RESULTS: PLOS ONE accepts single categories across Results/Discussion/Conclusions or merged categories such as Results/Discussion or Discussion/ Conclusions. This manuscript presents all three sections separately. Only Results will be addressed for review in this section.

The Results section starts with a presentation of the characteristics of the respondents noting for example, that “… [they] consisted mainly of 5 nationalities (91.0%; 182/200) including Indian (40.5%), Egyptian (22.5%), Jordanian (22%) and Sudanese (6%). Since only 182/200 may have responded to this item the absence of Qatari respondents was of interest as in 2024 it might be expected that there could be perhaps some 12 cohorts of graduating students from Qatar University since the course is listed as commencing in 2007 with full accreditation in 2011 (https://www.qu.edu.qa/static_file/qu/colleges/pharmacy/documents/Pharmacy%20A4%20Magazine-compressed%2019AY.pdf).

Additional detail and context would be helpful to fully understand the results of the study and its outcomes. It would be beneficial to understand where Qatari educated pharmacists work – data were elicited from chain pharmacies and none were identified as Qatari, so perhaps Independent pharmacies? Industrial pharmacy? Hospital pharmacy? Further, in a 2021 study which included independent and chain pharmacies differences were noted such as a preponderance of males rather than the females majority identified in the current study.

Response-22: We respectfully submit that the results obtained are as presented in the manuscript and the observed trend is consistent with published reports from several studies from Qatar. The community pharmacy sector in Qatar is dominated mainly by foreigners.

Firstly, then please provide the context using the published reports from several studies in Qatar cited in your reply as response 22. Irrespective, pharmacists working in Qatar would seem to be bound by the Law irrespective of nation of initial education and registration/authorisation to practice. Further, it is of interest to pharmacists/researchers globally where Qatari educated pharmacists work and WHY community pharmacy is run by foreigners, which may often be considered an issue in some nations. PLOS is an international journal and while pharmacy has a role in most if not all nations, in my experience, the roles, ownership, ability to practice as an out-of-nation educated pharmacist vary, sometimes greatly.

DISCUSSION: The discussion identified that the community pharmacist respondents would find continuing professional development, the availability of a shared electronic patient record and an improved remuneration package to be key enabling factors in deprescribing in older adults in Qatar who currently reported to be 3.6% of the population. However, there are already reports of an initiative in outpatient pharmacies at Rumailah Hospital, Qatar (Alyazeedi, A., Sherbash, M., Algendy, A. F., Stewart, C., Soiza, R. L., Alhail, M., Aldarwish, A., Stewart, D., Awaisu, A., Ryan, C., & Myint, P. K. (2024). Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults. Healthcare (Basel, Switzerland), 12(12), 1186. https://doi.org/10.3390/healthcare12121186). If hospital outpatient pharmacies in 2022-23 are using, and others perhaps intending to use Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults i.e. community dwelling, what is the rationale for community pharmacists to also undertake deprescribing? This considers the significance of the outcomes of the manuscript study compared to an existing tool and implementation in outpatient pharmacies.

Please discuss and contextualise.For example, how many elderly people see only community pharmacists, how many or what proportion see both a hospital pharmacist and a community pharmacist and how many or what proportion see only a hospital pharmacist? Some of the reasons that detail and information is important to understanding is what others say about pharmacy practice in Qatar. For example, Nadir Kheir in a book chapter in December 2016 entitled "Pharmacy Practice in Qatar" identified that pharmacy services in Qatar are rapidly developing and pharmacists are rapidly changing, committing to lifelong learning, self leadership and self development. Further, within that chapter it was observed that one of the strongest drivers of the change and development in pharmacy practice is Qatar's National Health Strategy which a further on community pharmacy. It was envisioned that community pharmacy could contribute to a primary health care model of practice and care. So, from 2016 to 2024, what has happened?

LIMITATIONS: Limitations section identifies those characteristics of the study methodology or design that impact the research outcomes or interpretations. As such the limitations are addressed in the section from lines 294 to 301. The limitations identified were firstly, non-probability sampling as participants were drawn predominantly from chain or banner group pharmacies which represent 75% approximately of the community pharmacies in Qatar.

So, this is a valid issue and benefits from discussion as to any ameliorating factors or processes that the research team may have applied. It was also not known how community pharmacies are owned as the owners’ views and actions may also influence employed pharmacists’ perceptions. Context is important as there is not one single vision and practice of pharmacy, or even community pharmacy, world-wide. How different might community pharmacy be in New Zealand, in Thailand, in Japan, in Spain, in Sweden, in Brazil, for example? In some countries, pharmacies may only be owned by registered pharmacists, sometimes with limits imposed on the number of pharmacies owned by a registered pharmacist, in some countries companies can own pharmacies and employ pharmacists to provide services, so context benefits from greater clarity about the situation in Qatar.

The second limitation noted was that a quantitative survey design may have triggered social desirability bias or social acquiescence though the link between methodology (survey) and favourable responses is not clearly explained but benefits from being so.

To my perception, this is a well published area - there are a number of approaches such as published articles that consider this and also social desirability scales which could be included in the study instrument, and other options that can be explored such as Lechner and colleagues 2019; Bergen and Labonte 2020; Larson 2019; Primi and colleagues 2019; Kreitchmann and colleagues 2019; Tan and colleagues 2022 . Which approaches did the researchers use? If none of the approaches were used what was the rationale for not doing so?

So please, provide the critical analyses, the detail, the context that enhance understanding of your study, its results and proposed outcomes.

Reviewer #2: The manuscript looks good and I agree with proceeding for publication, but small comment; the sentence in the line 99-101, I did not any references of the studies that were mentioned

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Reviewer #1: No

Reviewer #2: Yes: MOHAMMED ABDULLAH KUBAS

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Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar

PONE-D-24-26224R2

Dear Dr. Yusuff,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

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