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Introduction Proactive deprescribing – identifying and discontinuing medicines where harms outweigh benefits (1) – can minimise problematic polypharmacy, but it has not been routinely implemented into practice and can have risks. There are complex barriers and facilitators to deprescribing, however there is little evidence about how to overcome such barriers or promote facilitators and what resources are needed to safely and routinely implement deprescribing in primary care. Aim To co-design deprescribing resources that aid the implementation of safe and routine deprescribing in primary care. Methods Community-dwelling patients aged ≥65 years taking ≥5 medicines, community pharmacists, primary care pharmacists and GPs were invited to co-design workshops conducted in July 2022. Participants were recruited through social media and research networks. This project did not require formal ethical approval as it was a service improvement initiative. Two online workshops were facilitated using Microsoft Teams and Miro boards and were supported by a Patient and Public Involvement representative. The first workshop comprised a briefing about findings from a scoping review, systematic review and interview study with patients and healthcare professionals about deprescribing implementation, followed by idea generation through group activities. Potential resources identified were collated and, through discussions with the wider research team, two were prioritised to be further developed. The second workshop used storyboards to further understand and add detail to how the resources chosen would aid the implementation of routine and safe deprescribing in primary care. A logic model was then developed for the resource developed in the workshop. Results Five patients, two GPs, one primary care pharmacist and one community pharmacist took part. In the first workshop, participants identified:(a) patients were suitable advocates for their own health and could initiate conversations about medicines necessity but may need prompts or suggested questions to do so; and (b) community pharmacist follow-up with patients post-deprescribing could help ensure safe deprescribing and facilitate appraisal of deprescribing for future learning. In the second workshop, five questions patients could ask healthcare professionals during everyday interactions and two questions patients could ask during a medication review were developed to stimulate conversations on the necessity of medicines. A storyboard about how community pharmacy could act as a safety net post-deprescribing was developed and refined, following the workshop, into a Real World Logic Model (2) to explain how this safety net could work, the safety net context, and the anticipated outcomes. Conclusion Patients may be able to stimulate conversations on medicine necessity leading to routine deprescribing, whilst community pharmacists could potentially help ensure deprescribing safety. Questions were developed to empower patients to raise the issue of medicines necessity, and a logic model demonstrating community pharmacists as a deprescribing safety net were developed to aid safe and routine deprescribing in primary care. The co-participation of patients and healthcare professionals ensured that both groups’ values and priorities informed intervention development. However, the acceptability and usability of the co-designed interventions cannot be known until feasibility testing has been conducted. References 1. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine. 2015;175(5):827-34. 2. Mills, T., Shannon, R., O’Hara, J., Lawton, R., & Sheard, L. (2022). Development of a ‘real-world’ logic model through testing the feasibility of a complex healthcare intervention: the challenge of reconciling scalability and context-sensitivity. Evaluation, 28(1), 113–131.

Introduction Half of older people are prescribed unnecessary or harmful medication that are not routinely deprescribed in hospital. There is a need for trials of deprescribing interventions, and for these to adopt consistent measurement and reporting of outcomes(1). Aim To develop a Core Outcome Set (COS) for use in hospital deprescribing trials for older people under the care of a geriatrician. Methods We developed a list of potentially relevant outcomes from the literature. We sought representation from four stakeholder groups: older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers. A gatekeeper at 15 hospitals in England identified and provided study information to hospital staff by email; and older people taking ≥5 medicines, and their carers received printed study information. Academics were recruited worldwide. The number approached was not captured. Using a two-round Delphi survey of participants from all four stakeholder groups scored , each outcome according to Grading of Recommendations Assessment, Development and Evaluation (GRADE)(2). This was followed by two consensus workshops to finalise the COS by discussing the importance, feasibility and acceptability of outcomes. Results In the Delphi survey, 200 people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in Workshop 1 and 10 people in Workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial and were included in the COS for hospital deprescribing trials with older people under the care of a geriatrician. These outcomes were: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but not currently feasible to collect: number of potentially inappropriate medicines prescribed; burden to the patient from their medication; and medication-related admissions to hospital. Conclusion The COS provides the minimum outcomes that should be collected and reported in all hospital deprescribing trials for older people under the care of a geriatrician. This COS builds on three existing COS for: medication reviews in older people with polypharmacy; addressing polypharmacy in older people in primary care; and optimising prescribing in older people in nursing homes. However, it is important when developing a COS to involve all relevant stakeholders that will be affected by a COS, which in this case was older people under the care of a geriatrician and relevant hospital staff. The six outcomes in the COS were agreed as being the most important to be implemented in all hospital deprescribing trials for older people under the care of a geriatrician. The value of considering the feasibility of outcome data collection is demonstrated by the removal of three outcomes that may have compromised COS uptake. Adoption of the COS by hospital deprescribing trials for older people under the care of a geriatrician will enable results from trials to be compared and also allow future aggregation of trial data. References 1. Lundby C, Pottegård A. Considerations regarding choice of primary outcome in clinical trials in deprescribing. British Journal of Clinical Pharmacology. 2022;88(7):3032–4. 2. Williamson PR, Altman DG, Blazeby JM, Clarke M, Devane D, Gargon E, et al. Developing core outcome sets for clinical trials: issues to consider. Trials. 2012;13(1):1–8.

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 Problematic polypharmacy in older people living with frailty can cause harm due to adverse drug events and deprescribing (withdrawing inappropriate medication to manage polypharmacy and improve outcomes (1)) is one solution to mitigate this. Structured Medication Reviews (SMRs) have been commissioned in England to be conducted by Primary Care Network (PCN) pharmacists for which older people living with frailty are a priority group. SMRs are an ideal opportunity to deprescribe for this high-risk population and a person-centred approach is required to ensure deprescribing is safe, effective and acceptable to patients. However, the optimal deprescribing process has not been developed and tested in this context. Aim To develop a person-centred process for deprescribing for older people living with frailty which could potentially be implemented within SMRs in primary care. Methods We conducted qualitative research with older people living with frailty, carers and primary healthcare professionals to identify barriers and facilitators to deprescribing in this context in the North of England (2). We then used these findings and a “trigger film” of patients’ experiences to conduct Experience-based Co-design (EBCD), a multi-event process where older people living with frailty, informal carers and primary healthcare professionals came together to determine the key features of an ideal deprescribing process and identify priorities for a complex intervention to support the process. Following this, we presented the process model for feedback at the training day of a large multi-site primary care practice based (involving pharmacists, GPs and administrative practice staff) in the North of England and subsequently refined the model to integrate within their evolving SMR programme. Results The co-designed deprescribing process consisted of 3 phases: 1. Prior to the SMR consultation which involved case-finding of high-risk patients, case-note review for deprescribing eligibility and clinician planning for the consultation, inviting and preparing the patient for the consultation with written information (including what to expect during the medication review, and questions for patients about their medicines to reflect upon); 2. The consultation which included shared decision-making, agreement of plans to stop medicines, recording of decisions in the electronic health record, providing written information for patients on how to safely stop their medicines, safety netting and signposting to post-deprescribing support; 3. Post-consultation which involved evaluating patient experiences and organising follow-up and further review as needed. Key elements of the optimal process to ensure it was person-centred, were effective written and verbal communication for patients (during the entire process), shared decision-making and tailored support post-consultation. Conclusion We have developed a person-centred process for deprescribing for older people living with frailty and adapted it for implementation within nationally commissioned SMRs in England. Although the model is grounded in the requirements of multiple stakeholders, the final version requires evaluation. The next steps are to design and develop tools which can support our deprescribing process and to undertake feasibility testing in primary care. References 1. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268. 2. Peat G, Fylan B, Marques I, Raynor DK, Breen L, Olaniyan J, Alldred DP. Barriers and enablers of successful deprescribing as described by older patients with frailty, supporting peers and clinicians: A qualitative interview study. BMJ Open 2022. 12:e054279.

Introduction Stopping medicines where harms outweigh benefits (deprescribing) (1) can reduce adverse events from inappropriate polypharmacy. Deprescribing should be undertaken in a patient-centred way with shared decision-making. However, there is a lack of evidence about the patient perspective on how deprescribing should be safely and routinely implemented in UK primary care. Such evidence is needed to enhance the implementation of deprescribing in primary care. Aim • To identify optimal methods of introducing and actioning deprescribing from the patient’s perspective • To understand the nature of support patients require during deprescribing • To identify patient views on the involvement of different healthcare professionals in deprescribing. Methods UK patients aged ≥65 years taking ≥5 medicines and living in their own homes were recruited through social media, service user groups and NIHR People in Research. An interview guide was developed using deprescribing literature, patient and public involvement input, and informed by the theoretical implementation framework Normalisation Process Theory (2). Interviews were conducted online (Microsoft Teams®) or via telephone, audio recorded and transcribed verbatim. Data were analysed using the Framework method. Results Twenty patients, diverse in age and gender, were recruited and three main themes developed: 1. ‘Why deprescribe now?’ focused on the importance of communicating the deprescribing rationale; 2. ‘Monitoring and follow-up’ in which safety netting around deprescribing and patients’ motivations to self-monitor after deprescribing interventions were highlighted; 3. ‘Roles and relationships’ focused on patient views of different healthcare professionals involved in deprescribing and the interpersonal skills needed to develop therapeutic relationships. Conclusion Optimal methods of introducing deprescribing from the patient’s perspective included communication of a convincing and well-communicated rationale for stopping medicines. Patients required support from a range of healthcare professionals with whom they had an existing therapeutic relationship. Whilst patients were motivated to self-monitor any unwanted/unexpected effects post-deprescribing, this was under the condition that timely support would be available when needed. These findings provide a deeper understanding of patients’ needs for the implementation of safe and routine deprescribing in primary care, and these should be considered when designing medication review and deprescribing services. A strength of this study was the overall diversity in age and gender of the patients interviewed. However, although multiple recruitment pathways were utilised, due to the COVID-19 pandemic, recruitment was mainly online which will have excluded patients who did not have access to the internet. References 1. Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D., Gnjidic, D., Del Mar, C. B., Roughead, E. E., Page, A., Jansen, J. & Martin, J. H. 2015. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine 175, 827-834. 2. Murray, E., Treweek, S., Pope, C., Macfarlane, A., Ballini, L., Dowrick, C., Finch, T., Kennedy, A., Mair, F., O'donnell, C., Ong, B. N., Rapley, T., Rogers, A. & May, C. 2010. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Medicine 8, 63.

Introduction Polypharmacy, the use of ≥5 medicines, continues to increase worldwide and can become problematic potentially leading to adverse drug reactions (ADRs) and poor patient outcomes. Deprescribing - discontinuing medicines where harms outweigh benefits (1) - can help minimise problematic polypharmacy. Although deprescribing is effective in stopping medicines it has not been routinely incorporated into practice, with a lack of evidence on how deprescribing can be implemented in primary care. The support and education patients require and the training that clinicians need, must be established to effectively implement routine safe deprescribing in primary care. This scoping review was conducted to identify research gaps and determine the value of undertaking a systematic review on the barriers and facilitators of implementing deprescribing in primary care. Aim Methods The Arksey and O’Malley framework for scoping reviews was used (2). The Cochrane Library, PubMed, Embase, MEDLINE, Web of Science and International Pharmaceutical Abstracts were searched from 1996 – February 2020. Additional references were identified from reference lists of included articles. Abstracts and titles were screened and potentially relevant articles received full text screening. Inclusion criteria were quantitative, qualitative and mixed-methods literature on deprescribing in primary care. The exclusion criteria were conference papers, non-English language papers and literature on palliative care/life-limiting illness, patient self-discontinuation, withdrawal of medicine due to ADR, substance misuse, and long-term care facilities. For intervention studies; country, study design, aims, population, intervention, education used, follow-up used and findings were collected. For non-interventional studies; study design, aims, population and themes identified were collected. For the deprescribing trials, barriers and facilitators to implementing the intervention were identified. Results 4612 articles were identified and 72 articles included (32 intervention studies; 40 non-intervention). The majority of articles were from the Netherlands (15), Canada (13), USA (10), and UK (seven). Study designs included 12 RCTs, 11 quasi-experimental studies, six follow-up papers, three protocols, 19 surveys studies, eight interview studies, two observational studies, a meta-ethnography, a Q-methodology study, a process evaluation and eight narrative reviews. Five studies documented providing patient support post-deprescribing with little description of what this consisted of. The provision of patient education or clinician training was used in 14 studies. Six of seven studies incorporating patient education into their intervention were able to safely deprescribe for a significant proportion of patients. Research on the barriers and facilitators to implementing deprescribing into primary care was not routinely reported with a greater focus on the process of deprescribing, rather than implementation. Conclusion There is a paucity of research on the fundamental characteristics required for deprescribing to be routinely and safely implemented in primary care. There is a lack of description on what type of education and support patients need, and training that clinicians require, for routine safe deprescribing. Future research is needed to identify and address these factors for the benefits of deprescribing to be realised. References (1) Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine. 2015;175(5):827-34. (2) Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32.