Co-design workshops to develop evidence synthesis summary formats for use by clinical guideline development groups.

BACKGROUND: Evidence synthesis is used by decision-makers in various ways, such as developing evidence-based recommendations for clinical guidelines. Clinical guideline development groups (GDGs) typically discuss evidence synthesis findings in a multidisciplinary group, including patients, healthcare providers, policymakers, etc. A recent mixed methods systematic review (MMSR) identified no gold standard format for optimally presenting evidence synthesis findings to these groups. However, it provided 94 recommendations to help produce more effective summary formats for general evidence syntheses (e.g., systematic reviews). To refine the MMSR recommendations to create more actionable guidance for summary producers, we aimed to explore these 94 recommendations with participants involved in evidence synthesis and guideline development. METHODS: We conducted a descriptive qualitative study using online focus group workshops in February and March 2023. These groups used a participatory co-design approach with interactive voting activities to identify preferences for a summary format's essential content and style. We created a topic guide focused on recommendations from the MMSR with mixed methods support, ≥ 3 supporting studies, and those prioritized by an expert advisory group via a pragmatic prioritization exercise using the MoSCoW method (Must, Should, Could, and Will not haves). Eligible participants must be/have been involved in GDGs and/or evidence synthesis. Groups were recorded and transcribed. Two independent researchers analyzed transcripts using directed content analysis with 94 pre-defined codes from the MMSR. RESULTS: Thirty individuals participated in six focus groups. We coded 79 of the 94 pre-defined codes. Participants suggested a "less is more" structured approach that minimizes methodological steps and statistical data, promoting accessibility to all audiences by judicious use of links to further information in the full report. They emphasized concise, consistently presented formats that highlight key messages, flag readers to indicators of trust in the producers (i.e., logos, websites, and conflict of interest statements), and highlight the certainty of evidence (without extenuating details). CONCLUSIONS: This study identified guidance based on the preferences of guideline developers and evidence synthesis producers about the format of evidence synthesis summaries to support decision-making. The next steps involve developing and user-testing prototype formats through one-on-one semi-structured interviews to optimize evidence synthesis summaries and support decision-making.

An international modified Delphi process supported updating the web-based "right review" tool.

OBJECTIVES: The proliferation of evidence synthesis methods makes it challenging for reviewers to select the ''right'' method. This study aimed to update the Right Review tool (a web-based decision support tool that guides users through a series of questions for recommending evidence synthesis methods) and establish a common set of questions for the synthesis of both quantitative and qualitative studies (https://rightreview.knowledgetranslation.net/). STUDY DESIGN AND SETTING: A 2-round modified international electronic modified Delphi was conducted (2022) with researchers, health-care providers, patients, and policy makers. Panel members rated the importance/clarity of the Right Review tool's guiding questions, evidence synthesis type definitions and tool output. High agreement was defined as at least 70% agreement. Any items not reaching high agreement after round 2 were discussed by the international Project Steering Group. RESULTS: Twenty-four experts from 9 countries completed round 1, with 12 completing round 2. Of the 46 items presented in round 1, 21 reached high agreement. Twenty-seven items were presented in round 2, with 8 reaching high agreement. The Project Steering Group discussed items not reaching high agreement, including 8 guiding questions, 9 review definitions (predominantly related to qualitative synthesis), and 2 output items. Three items were removed entirely and the remaining 16 revised and edited and/or combined with existing items. The final tool comprises 42 items; 9 guiding questions, 25 evidence synthesis definitions and approaches, and 8 tool outputs. CONCLUSION: The freely accessible Right Review tool supports choosing an appropriate review method. The design and clarity of this tool was enhanced by harnessing the Delphi technique to shape ongoing development. The updated tool is expected to be available in Quarter 1, 2025.

Primary care micro-teams: an international systematic review of patient and healthcare professional perspectives.

BACKGROUND: International trends have shifted to creating large general practices. There is an assumption that interdisciplinary teams will increase patient accessibility and provide more cost-effective, efficient services. Micro-teams have been proposed to mitigate for some potential challenges of practice expansion, including continuity of care. AIM: To review available literature and examine how micro-teams are described, and identify opportunities and limitations for patients and practice staff. DESIGN AND SETTING: This was an international systematic review of studies published in English. METHOD: Databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus) and grey literature were searched. Studies were included if they provided evidence about implementation of primary care micro-teams. Framework analysis was used to synthesise identified literature. The research team included a public contributor co-applicant. The authors conducted stakeholder discussions with those with and without experience of micro-team implementation. RESULTS: Of the 462 studies identified, 24 documents met the inclusion criteria. Most included empirical data from healthcare professionals, describing micro-team implementation. Results included characteristics of the literature; micro-team description; range of ways micro-teams have been implemented; reported outcomes; and experiences of patients and staff. CONCLUSION: The organisation of primary care has potential impact on the nature and quality of patient care, safety, and outcomes. This review contributes to current debate about care delivery and how this can impact on the experiences and outcomes of patients and staff. This analysis identifies several key opportunities and challenges for future research, policy, and practice.

#TreatmentResistantDepression: A qualitative content analysis of Tweets about difficult-to-treat depression.

INTRODUCTION: Treatment-resistant depression (TRD) is depression unresponsive to antidepressants and affects 55% of British primary care users with depression. Current evidence is from secondary care, but long referral times mean general practitioners (GPs) manage TRD. Studies show that people with depression use Twitter to form community and document symptoms. However, Twitter remains a largely unexplored space of documented patient experience. Twitter data could provide valuable insights into learning about primary care experiences of TRD. In this study, we explored Twitter comments and conversations about TRD and produced patient-driven recommendations. METHODS: Tweets from UK-based users were collected manually and using a browser extension in June 2021. Conventional content analysis was used to provide an overview of the Tweets, followed by interpretation to understand why Twitter may be important to people with TRD. RESULTS: A total of 415 Tweets were organised into five clusters: self-diagnosis, symptoms, support, small wins and condition experts. These Tweets were interpreted as showing Twitter as a community for people with TRD. People had a collective sense of illness identity and were united in their experiences of TRD. However, users in the community also highlighted the absence of effective GP care, leading users to position themselves as condition experts. Users shared advice from a place of lived experience with the community but also shared potentially harmful information, including recommendations about nonevidence-based medications. CONCLUSIONS: Findings illuminate the benefits of the TRD Twitter community and also highlight that the perception of a lack of knowledge and support from GPs may lead community members to advise nonevidenced-based medications. PATIENT AND PUBLIC CONTRIBUTION: This study was led by a person with lived experience of TRD and bipolar. Two public contributors with mental health conditions gave feedback on our study protocol and results.

School closures during COVID-19: an overview of systematic reviews.

OBJECTIVES: To assess the benefits and drawbacks of school closures and in-school mitigations during the COVID-19 pandemic. DESIGN: Overview of systematic reviews (SRs). SEARCH METHODS: We searched six databases and additional resources on 29 July 2022: MEDLINE, Embase, Google Scholar, Cochrane Library, COVID-END inventory of evidence synthesis, and Epistemonikos. ELIGIBILITY CRITERIA: We selected SRs written in English that answered at least one of four specific questions concerning the efficacy and drawbacks of school closures. Their primary studies were conducted in primary and secondary schools, including pupils aged 5-18. Interventions included school closures or mitigations (such as mask usage) introduced in schools. DATA COLLECTION AND ANALYSIS: We used AMSTAR 2 to assess confidence in the included SRs, and GRADE was used to assess certainty of evidence. We performed a narrative synthesis of the results, prioritising higher-quality SRs, those which performed GRADE assessments and those with more unique primary studies. We also assessed the overlap between primary studies included in the SRs. MAIN OUTCOME MEASURES: Our framework for summarising outcome data was guided by the following questions: (1) What is the impact of school closures on COVID-19 transmission, morbidity or mortality in the community? (2) What is the impact of COVID-19 school closures on mental health (eg, anxiety), physical health (eg, obesity, domestic violence, sleep) and learning/achievement of primary and secondary pupils? (3) What is the impact of mitigations in schools on COVID-19 transmission, morbidity or mortality in the community? and (4) What is the impact of COVID-19 mitigations in schools on mental health, physical health and learning/achievement of primary and secondary pupils? RESULTS: We identified 578 reports, 26 of which were included. One SR was of high confidence, 0 moderate, 10 low and 15 critically low confidence. We identified 132 unique primary studies on the effects of school closures on transmission/morbidity/mortality, 123 on learning, 164 on mental health, 22 on physical health, 16 on sleep, 7 on domestic violence and 69 on effects of in-school mitigations on transmission/morbidity/mortality.Both school closures and in-school mitigations were associated with reduced COVID-19 transmission, morbidity and mortality in the community. School closures were also associated with reduced learning, increased anxiety and increased obesity in pupils. We found no SRs that assessed potential drawbacks of in-school mitigations on pupils. The certainty of evidence according to GRADE was mostly very low. CONCLUSIONS: School closures during COVID-19 had both positive and negative impacts. We found a large number of SRs and primary studies. However, confidence in the SRs was mostly low to very low, and the certainty of evidence was also mostly very low. We found no SRs assessing the potential drawbacks of in-school mitigations on children, which could be addressed moving forward. This overview provides evidence that could inform policy makers on school closures during future potential waves of COVID-19.

Strong recommendations from low certainty evidence: a cross-sectional analysis of a suite of national guidelines.

BACKGROUND: Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and assign a strength to recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance warns against making strong recommendations when the certainty of the evidence is low or very low, but has identified five paradigmatic situations (e.g. life-threatening situations) where this may be justified. AIMS AND OBJECTIVES: We aimed to characterize the strength of recommendations and certainty of the evidence in Irish National Clinical Guidelines using the GRADE approach. METHODS: All National Clinical Guidelines from the National Clinical Effectiveness Committee (NCEC) website using the GRADE approach (fully or partially) were included. All recommendations and their corresponding certainty of the evidence, strength of recommendations and justifications were extracted. Authors classified instances of strong recommendations with low certainty evidence (referred to as discordant recommendations) into one of the five paradigmatic situations. Descriptive statistics were calculated. RESULTS: From the 29 NCEC Clinical Guidelines available at the time of analysis, we identified 8 guidelines using GRADE with a total of 240 recommendations; 38 recommendations did not use the GRADE approach and were excluded. Half of the included guidelines focused on emergency situations. In the final dataset of 202 recommendations, 151 (74.7%) were classified as strong and 51 (25.3%) as conditional. Of the 151 strong recommendations, 55 (36.4%) were supported by high or moderate certainty evidence and 96 (63.6%) by low or very low certainty evidence and were considered discordant. Of these 96 discordant recommendations, 55 (73.7%) were consistent with one of the five paradigmatic situations. However, none were specifically described as such within the guidelines. CONCLUSIONS: The proportion of discordant recommendations identified in this analysis was higher than some previous international studies (range of all strong recommendations being discordant 30-50%), but similar to other guidelines focused on emergency situations. The majority of discordant recommendations could be mapped to one of the five situations, but no National Clinical Guideline explicitly referenced this. Guideline developers require further guidance to enable greater transparency in the reporting of the reasons for discordant recommendations.

Understanding and Improving Older People's Well-Being through Social Prescribing Involving the Cultural Sector: Interviews from a Realist Evaluation.

Social prescribing is a non-clinical approach to addressing social, environmental, and economic factors affecting how people feel physical and/or emotionally. It involves connecting people to "community assets" (e.g., local groups, organizations, and charities) that can contribute to positive well-being. We sought to explain in what ways, for whom, and why the cultural sector can support social prescribing with older people. We conducted semi-structured interviews with 28 older people (aged 60+) and 25 cultural sector staff. The following nine concepts, developed from interview data, progressed the understanding of tailoring cultural offers, which came from our previous realist review-immersion, buddying, café culture, capacity, emotional involvement, perseverance, autonomy, elitism, and virtual cultural offers. Through tailoring, we propose that older people might experience one or more of the following benefits from engaging with a cultural offer as part of social prescribing-being immersed, psychological holding, connecting, and transforming through self-growth.

Investigating how the GRADE Evidence to Decision (EtD) framework is used in Clinical Guidelines: a scoping review protocol.

Introduction: The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework provides a structured and transparent approach for clinical guideline developers to use when formulating recommendations. Understanding how stakeholders use the EtD framework will inform how best to provide future training and support. This scoping review objective is to identify the key characteristics of how the GRADE EtD framework is used and identify studies on perception of use by those involved in developing clinical guidelines. Methods: JBI methodology for scoping reviews will be followed. This scoping review will consider both peer review published literature and grey literature. This will include empirical studies on the use of EtDs (including both quantitative, qualitative, and mixed methods primary research articles) and discussion papers/ commentaries on the experience of using the EtD. It will also include a random sample of publicly available populated EtDs identified from databases and repositories of GRADE guidelines. The search strategy will aim to locate both published and unpublished documents. First, we will conduct an exploratory search of MEDLINE and Embase (Elsevier), supplemented with citation analysis of included articles. Populated EtDs will be identified through searches of databases and repositories of GRADE guidelines. Two researchers will independently screen, select, and extract identified documents. Data will be presented in tables and summarized descriptively. Conclusion: This scoping review will identify the key characteristics of how the GRADE EtD framework is currently being used in clinical guidelines. Review findings can be used to inform future guidance and requirements for using GRADE EtD, as well as training on how to consider the criteria in developing recommendations. Results will be disseminated through publications in peer - reviewed journals and conference presentations. We will present our findings to relevant stakeholders via the networks of the co-author team at a one-day workshop.

Community pharmacy and general practice collaborative and integrated working: a realist review protocol.

INTRODUCTION: Increasing collaborative and integrated working between General practice (GP) and Community pharmacy (CP) is a key priority of the UK National Health Service and has been proposed as a solution to reducing health system fragmentation, improving synergies and coordination of care. However, there is limited understanding regarding how and under which circumstances collaborative and integrated working between GP and CP can be achieved in practice and how regulatory, organisational and systemic barriers can be overcome. METHODS AND ANALYSIS: The aim of our review is to understand how, when and why working arrangements between GP and CP can provide the conditions necessary for optimal communication, decision-making, and collaborative and integrated working. A realist review approach will be used to synthesise the evidence to make sense of the complexities inherent in the working relationships between GP and CP. Our review will follow Pawson's five iterative stages: (1) finding existing theories; (2) searching for evidence (our main searches were conducted in April 2022); (3) article selection; (4) data extraction and (5) synthesising evidence and drawing conclusions. We will synthesise evidence from grey literature, qualitative, quantitative and mixed-methods research. The research team will work closely with key stakeholders and include patient and public involvement and engagement throughout the review process to refine the focus of the review and the programme theory. Collectively, our refined programme theory will explain how collaborative and integrated working between GP and CP works (or not), for whom, how and under which circumstances. ETHICS AND DISSEMINATION: Formal ethical approval is not required for this review as it draws on secondary data from published articles and grey literature. Findings will be widely disseminated through: publication in peer-reviewed journals, seminars, international conference presentations, patients' association channels, social media, symposia and user-friendly summaries. PROSPERO REGISTRATION NUMBER: CRD42022314280.

Understanding the roles and work of paramedics in primary care: a national cross-sectional survey.

OBJECTIVES: This research aimed to fill a current knowledge gap, namely the current scope of clinical role of paramedics in primary care, in relation to specific constructs such a level of education and clinical experience. SETTING: The survey was distributed to paramedics in primary care across the UK through the College of Paramedics. PARTICIPANTS: A total of 341 surveys were returned (male=215). 90% of responses were from paramedics in England, 1.7% from paramedics in Northern Ireland, 4.6% from paramedics in Scotland and 2.9% from paramedics in Wales. This represents approximately 33% of the primary care paramedic workforce in England and Wales. Estimates for percentages in Northern Ireland and Scotland are unavailable due to the lack of workforce datasets capturing paramedics in primary care. RESULTS: Considerable variation was found in job titles, level of education and provision of clinical supervision of paramedics in primary care. Differing levels of practice were noted, despite guidance documents that attempt to standardise the role. Statistical analysis of quantitative data highlighted that relationships exist between paramedic clinical exposure in primary care, level of education, and ability of independently prescribe medicines and the extent to which clinical presentations are seen and examinations performed. However, free-text responses indicated that challenges in relation to access to further education and clinical supervision to support clinical development resulted in frustration for paramedics who work in this setting. CONCLUSIONS: As well as offering an insight into the demographics of the primary care paramedic work force, there is indication of the clinical scope of role undertaken in this setting. Based on our findings, we recommend changes to education and support, governance and legislation to ensure paramedics employed in primary care can work to achieve the full extent of their professional capability.

The effectiveness and acceptability of evidence synthesis summary formats for clinical guideline development groups: a mixed-methods systematic review.

INTRODUCTION: Clinical guideline development often involves a rigorous synthesis of evidence involving multidisciplinary stakeholders with different priorities and knowledge of evidence synthesis; this makes communicating findings complex. Summary formats are typically used to communicate the results of evidence syntheses; however, there is little consensus on which formats are most effective and acceptable for different stakeholders. METHODS: This mixed-methods systematic review (MMSR) aimed to evaluate the effectiveness and acceptability (e.g. preferences and attitudes and preferences towards) of evidence synthesis summary formats for GDG members. We followed the PRISMA 2020 guideline and Joanna Briggs Institute Manual for Evidence Synthesis for MMSRs. We searched six databases (inception to April 20, 2021) for randomised controlled trials (RCTs), RCTs with a qualitative component, and qualitative studies. Screening, data extraction, and quality appraisal were performed in duplicate. Qualitative findings were synthesised using meta-aggregation, and quantitative findings are described narratively. RESULTS: We identified 17,240 citations and screened 54 full-text articles, resulting in 22 eligible articles (20 unique studies): 4 articles reported the results of 5 RCTs, one of which also had a qualitative component. The other 18 articles discussed the results of 16 qualitative studies. Therefore, we had 5 trials and 17 qualitative studies to extract data from. Studies were geographically heterogeneous and included a variety of stakeholders and summary formats. All 5 RCTs assessed knowledge or understanding with 3 reporting improvement with newer formats. The qualitative analysis identified 6 categories of recommendations: 'presenting information', 'tailoring information' for end users, 'trust in producers and summary', 'knowledge required' to understand findings, 'quality of evidence', and properly 'contextualising information'. Across these categories, the synthesis resulted in 126 recommendations for practice. Nine recommendations were supported by both quantitative and qualitative evidence and 116 by only qualitative. A majority focused on how to present information (n = 64) and tailor content for different end users (n = 24). CONCLUSIONS: This MMSR provides guidance on how to improve evidence summary structure and layout. This can be used by synthesis producers to better communicate to GDGs. Study findings will inform the co-creation of evidence summary format prototypes based on GDG member's needs. Trial registration The protocol for this project was previously published, and the project was preregistered on Open Science Framework (Clyne and Sharp, Evidence synthesis and translation of findings for national clinical guideline development: addressing the needs and preferences of guideline development groups, 2021; Sharp and Clyne, Evidence synthesis summary formats for decision-makers and Clinical Guideline Development Groups: A mixed-methods systematic review protocol, 2021).

Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review.

BACKGROUND: Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. METHODS: The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. RESULTS: We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. CONCLUSION: Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.

Tailoring cultural offers to meet the needs of older people during uncertain times: a rapid realist review.

BACKGROUND: Non-medical issues (e.g. loneliness, financial concerns, housing problems) can shape how people feel physically and psychologically. This has been emphasised during the Covid-19 pandemic, especially for older people. Social prescribing is proposed as a means of addressing non-medical issues, which can include drawing on support offered by the cultural sector. METHOD: A rapid realist review was conducted to explore how the cultural sector (in particular public/curated gardens, libraries and museums), as part of social prescribing, can support the holistic well-being of older people under conditions imposed by the pandemic. An initial programme theory was developed from our existing knowledge and discussions with cultural sector staff. It informed searches on databases and within the grey literature for relevant documents, which were screened against the review's inclusion criteria. Data were extracted from these documents to develop context-mechanism-outcome configurations (CMOCs). We used the CMOCs to refine our initial programme theory. RESULTS: Data were extracted from 42 documents. CMOCs developed from these documents highlighted the importance of tailoring-shaping support available through the cultural sector to the needs and expectations of older people-through messaging, matching, monitoring and partnerships. Tailoring can help to secure benefits that older people may derive from engaging with a cultural offer-being distracted (absorbed in an activity) or psychologically held, making connections or transforming through self-growth. We explored the idea of tailoring in more detail by considering it in relation to Social Exchange Theory. CONCLUSIONS: Tailoring cultural offers to the variety of conditions and circumstances encountered in later life, and to changes in social circumstances (e.g. a global pandemic), is central to social prescribing for older people involving the cultural sector. Adaptations should be directed towards achieving key benefits for older people who have reported feeling lonely, anxious and unwell during the pandemic and recovery from it.

Experiences of treatment-resistant mental health conditions in primary care: a systematic review and thematic synthesis.

BACKGROUND: Most adults fail to achieve remission from common mental health conditions based on pharmacological treatment in primary care alone. There is no data synthesising the reasons. This review addresses this gap through a systematic review and thematic synthesis to understand adults' experiences using primary care for treatment-resistant mental health conditions (TRMHCs). We use the results to produce patient-driven recommendations for better support in primary care. METHODS: Eight databases were searched from inception to December 2020 for qualitative studies reporting research on people's experience with TRMHCs in primary care. We included the following common mental health conditions defined by NICE: anxiety, depression, panic disorder, post-traumatic stress, and obsessive-compulsive disorder. Two reviewers independently screened studies. Eligible studies were analysed using an aggregative thematic synthesis. RESULTS: Eleven studies of 4456 were eligible. From these eleven studies, 4 descriptive themes were developed to describe a cycle of care that people with TRMHCs experienced in primary care. In the first stage, people preferred to self-manage their mental health and reported barriers that prevented them from seeing a GP (e.g., stigma). People felt it necessary to see their GP only when reaching a crisis point. In the second stage, people were usually prescribed antidepressants, but were sceptical about any benefits they had to their mental health. In the third stage, people self-managed their mental health (e.g., by adjusting antidepressant dosage). The fourth stage described the reoccurrence of mental health and need to see a GP again. The high-order theme, 'breaking the cycle,' described how this cycle could be broken (e.g., continuity of care). CONCLUSIONS: People with TRMHCs and GPs could break the cycle of care by having a conversation about what to do when antidepressants fail to work. This conversation could include replacing antidepressants with psychological interventions like talking therapy or mindfulness.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis.

BACKGROUND: Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES: We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES: Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS: The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS: Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS: Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS: Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK: The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION: This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Many patients take multiple medicines, every day, on a long-term basis. Some feel overloaded by their medicines. However, both doctors and patients have told us that they feel anxious about knowing when and how to safely stop medicines. TAILOR aimed to help by providing the information that doctors and patients need to make individual (tailored) decisions about whether or not to stop (deprescribe) medicines. We had two research questions and so used a different research method to answer each. Both methods involved us first finding all the published research looking at deprescribing for older people living with long-term conditions and using five or more medicines a day. Our first (scoping) review produced a map of what we know about deprescribing: how it is done and if it is safe. We found evidence that structured deprescribing can be safe and acceptable to clinicians, but specific effects were very varied and patient views were often not reported. Our team's patient partners continuously reminded us that medicines mean more to individuals than just a medical effect (e.g. a 'tablet for my blood pressure'), meaning that our research needed to describe good person-centred deprescribing. Our second (realist) review focused on this by looking at if and how tailored deprescribing decisions happen. Our results showed that health-care services need to give clinicians the permission and resources they need to work with patients to develop a joint understanding of the value of medicines, to guide decisions about using/changing medicines, and so to build and maintain trust. Our findings remind us that decisions about medicines are personal. We need to remember that any changes in medicines affect not just an individual's disease, but also their understanding of their health and health care. Our work makes recommendations on how future practice and research can be more person centred. We are now working with patients and health-care professionals to share our findings with a wide audience.

Social prescribing for older people and the role of the cultural sector during the COVID-19 pandemic: What are link workers' views and experiences?

Older people's well-being can be bolstered by engaging with cultural activities and venues. They may be encouraged to try cultural offers by a link worker as part of social prescribing. However, the cultural sector, like all parts of life, was affected by the COVID-19 pandemic; this has had implications for cultural offers available to link workers. A study was conducted to explore the views and experiences of link workers in using the cultural sector within social prescribing, particularly for older people (aged 60+) during the pandemic. An online questionnaire was distributed to and completed by link workers in the UK. Data were analysed mainly using descriptive statistics. Open text responses were clustered into similar ideas to create key concepts. Useable responses were received from 148 link workers. They highlighted a general lack of interaction between link workers and the cultural sector about how the latter could support social prescribing. Results suggested that personal familiarity with cultural offers might prompt link workers to refer to them. Some respondents proposed that cultural offers were regarded as elitist, which deterred them from referring there. However, there was a general acknowledgement that the cultural sector could contribute to social prescribing. Link workers need to regard the cultural sector as accessible, appropriate, adequate, affordable and available before referring older people to cultural offers as part of social prescribing. Link workers may benefit from becoming more familiar with cultural sector staff and offers, including online resources, so they can then propose them to patients with confidence.