This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid-tapering interventions and services from a 2018 international systematic review and a 2019 England-wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid-tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive-based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.
IntroductionOver 50% of older adults are prescribed a medicine where the risk of harm outweighs the chances of benefit. During a hospital admission, older adults and carers expect medicines to be reviewed for appropriateness and any inappropriate medicines proactively deprescribed. While the principle of proactive deprescribing is an expectation of good prescribing practice, it is yet to become routine. The CompreHensive geriAtRician-led MEdication Review (CHARMER) study aims to develop and test a five-component behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. This study aims to test the feasibility and acceptability of study processes and CHARMER implementation.Methods and analysisA two-arm purposive allocation feasibility study is being undertaken at four acute hospitals in England, UK (three intervention and one control). The target sample is 400 patients across all hospitals. Primary outcome measures are: (1) participant recruitment rate and (2) participant attrition rate. Secondary outcome measures are: (1) hospital readmission rate; (2) mortality rate and (3) quality of life. Quantitative data will be checked for completeness and quality, and practitioner and patient demographics descriptively analysed. We will undertake a rapid qualitative analysis on observations, interviews and study meeting minutes data. A subsequent thematic analysis will be undertaken with codes mapped to the Theoretical Domains Framework and Normalisation Process Theory. Triangulation of qualitative and quantitative data will be undertaken.Ethics and disseminationEthics approval was obtained from Wales Research Ethics Committee 1 (IRAS ID 312494) and study approval from the Health Research Authority (22/WA/0087). Informed consent will be sought from all hospital staff involved in data collection activities and for patients involved in enhanced data collection activities. The findings of this study will be disseminated in peer-reviewed journals and conference presentations.Trial registrationISRCTN11899506.
Introduction 50% of older adults are prescribed a medicine that is unnecessary or harmful that should be deprescribed (1). CompreHensive geriAtRician-led MEdication Review (CHARMER) is a behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe. Five determinants of deprescribing have been prioritised and the following six Behaviour Change Techniques (BCTs) selected that now require designing (2): 1&2. Pros and cons and salience of consequences to address misconceptions that deprescribing is risky, 3. Restructuring pharmacists working to facilitate contribution to deprescribing 4. Social comparison to address misconceptions that patients/carers are resistant to deprescribing 5. Action planning to prioritise deprescribing and 6. Incentivising deprescribing. Aim We aimed to co-design the content, mode of delivery and intensity of BCTs to develop a hospital deprescribing behaviour change intervention. Methods We maximum variation sampled three hospitals to represent contextual factors likely to influence CHARMER implementation: diversity of patient population, geography, IT infrastructure maturity and include a combination of larger teaching and smaller district general hospitals. We recruited geriatricians, pharmacists and staff likely to be involved in implementation to join one co-design panel per hospital. We convened two rounds of workshops with each hospital to design BCT prototypes following the five iterative steps of design thinking: empathise, define, ideate, prototype and test. We introduced geriatrician and pharmacist personas in round 1 and panels discussed how barriers and enabler influence practice through a journey mapping exercise, followed by brainstorming ideas for how BCT(s) to address them could be operationalised. Round 2 aimed to reach consensus about which of the Round 1 BCT operationalisation ideas were most promising, and then refine their content, mode of delivery and duration/intensity. Behavioural scientist and practitioner members of the research team prepared prototypes for feedback at a final workshop attended by the three hospital panels. Results The six BCTs were operationalised into an intervention comprising: (1 & 2) 2-hour workshop with pros and cons activities and videos of salient patient cases (3) Weekly short face-to-face pharmacist:geriatrician deprescribing discussions (4) 5-minute videos of geriatricians navigating challenging deprescribing consultations (5) Hospital deprescribing action plan template (6)Dashboard updated weekly to benchmark deprescribing activity with other hospitals Automated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs. These were later excluded as they address ‘memory, attention and decision processes’ and a ‘primary care social influence’ respectively which does not align with the determinants of deprescribing (1). Conclusion This study illustrates the integration of theory and co-design methodology for a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach. Maximum variation sampling for hospital permitted representation of the ‘extremes’ of contextual factors but may result in an intervention that is not optimised for the majority. The intervention is undergoing feasibility testing across four English hospitals and will proceed to a definitive trial across 42 hospitals in Spring 2023 to determine effectiveness and cost effectiveness. References 1. Gallagher P, Lang PO, Cherubini A, Topinková E, Cruz-Jentoft A, Montero Errasquín B, et al. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. European journal of clinical pharmacology. 2011;67(11):1175–88. 2. Scott S, May H, Patel M, Wright DJ, Bhattacharya D. A practitioner behaviour change intervention for deprescribing in the hospital setting. Age and ageing. 2021;50(2):581–6.
Introduction Swallowing tablets/capsules can become difficult and dangerous for People with Parkinson’s (PwP) who develop oropharyngeal dysphagia(1). Switching to a liquid delays the need for progressing to last line patches/injections. However, liquids are rarely used therefore a change in prescribing practice is warranted but, as with any change in behaviour, may be met with resistance. Aim To characterise PwPs and carers’ barriers and enablers (determinants) of switching from solid to liquid Parkinson’s medication formulations. Methods Underpinned by the Theoretical Domains Framework, focus groups with PwPs and carers from across the UK were convened to identify determinants of switching. Carers were included in focus group discussions as they are often involved in supporting administration of medication(1). A semi-structured topic guide was developed and piloted which asked open questions on participants’ thoughts and feelings about switching to liquid medicines. Focus group discussions were analysed and data inductively coded as barriers and enablers to switching from solid to liquid medication. Guided by the TDF domain definitions, the inductive codes were then mapped to the relevant TDF domain(s). An online questionnaire was developed to measure the importance and generalisability of the identified barriers and enablers to switching. The questionnaire was developed based on the barriers and enablers to switching identified in the focus groups. Questionnaire item(s) were generated for each identified barrier and enabler within the relevant TDF domain to measure the extent to which they influenced the decision to switch. Patient and Public Involvement members piloted the questionnaire to identify any difficulties interpreting items and formulating responses. Determinants were prioritised if ≥50% of respondents agreed/strongly agreed that they were important to their decision to switch to a liquid formulation. Percentage precisions were reported as 95% confidence intervals. Results From the three focus groups six themes were generated: (1) the process of change; (2) impact on lifestyle; (3) margin for error; (4) reflections on ability to administer; (5) position in treatment pathway and (6) curiosities. 131 questionnaire responses from PwPs and carers prioritised nine determinants. Three enablers had almost unanimous agreement: liquids’ flexibility for incremental dosing (72% ±8); decline in Parkinson’s control (72% ±8); prescriber’s endorsement to switch (70% ±8). Two of the barriers: perception that tablets/capsules are easier to dose than liquids (72% ±8); and prescriber’s opposition to switching (70% ±8), attracted similarly high agreement. Conclusion There is a desire to switch to liquids when Parkinson’s progresses and for their use beyond this to offer flexibility in dosing, a previously unrecognised indication for switching. The only notable resistance to switching may be addressed by innovations from the pharmaceutical industry to make liquids easier to measure. The influencers of switching to a liquid version of a Parkinson’s medication that require addressing are mapped to 40 Behaviour Change Techniques. This provides an evidence and theory-based framework from which strategies may be selected to support a safe and acceptable switch(2). References 1. Kwon M, Lee JH. Oro-Pharyngeal Dysphagia in Parkinson’s Disease and Related Movement Disorders. JMD. 2019 Sep 30;12(3):152–60. 2. Atkins B, Bhattacharya D, Smith C, Scott S. Barriers and enablers to switching from a solid to a liquid formulation of Parkinson’s medication: a theory-based mixed methods investigation. Int J Clin Pharm. 2022 Aug;44(4):1046–56.
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