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Table 3 CMOCs developed

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

Influence of organisational/system-level factors
CMOC1: In the absence of applicable deprescribing guidelines and evidence (C), healthcare providers may feel like they cannot make justifiable decisions regarding medication changes (O) because they don’t feel like these decisions are supported by the system (M).
CMOC2: When healthcare providers feel like they cannot make justifiable decisions that are supported by guidelines (C) they may be reluctant to make changes to medications (O) because they are afraid of negative consequences (M).
CMOC3: When healthcare practitioners are not supported by incentive and policy structures (C) they may not be able to take the time necessary for complex medication management processes (O) and be reluctant to make changes (O) because they don’t feel supported to do so (M).
CMOC4: When healthcare professionals cannot access information about a patient’s medication regimen (C) they do not have an accurate understanding of the medication regimen (O) because they don’t understand the patient’s history (M).
CMOC5: When healthcare professionals are unsure about whose responsibility medication management is (C) they may struggle to engage in making medication changes (O) because they don’t feel they have ownership over the process (M).
Influence of healthcare professional-level factors
CMOC6: When a healthcare professional has previous experience deprescribing medication (C) they are more likely to feel able to deprescribe (O) because they know what to do and expect (M).
CMOC7: When healthcare professionals feel they don’t have the necessary skills and knowledge to manage medicines in older adults (C) they are less likely to make changes to patients’ medicine regimes (O) because they are not confident in their ability to make good decisions (M).
CMOC8: When medicines have been prescribed by a specialist (C) other healthcare providers from other specialities may be reluctant to make changes to patients’ medicine regimens (O) because they do not feel they have the knowledge to make a safe decision (M).
CMOC9: When medicines have been prescribed by another healthcare professional (C), healthcare providers may be reluctant to make changes to patients’ medicines (O) because they are worried about damaging relationships with the original prescriber as well as between the original prescriber and the patient (M).
CMOC10: When healthcare professionals don’t have dedicated time (C) they may be less likely to make changes to patients’ medications (O) because they do not have the emotional and cognitive capacity to consider complex issues (M).
CMOC11: When healthcare professionals do not have time (C) they may find it difficult to fully consider a patient’s care goals (O) because they are forced to prioritise what they spend their time on (M).
Influence of patient-level factors
CMOC12: When patients believe medicines are a sign of good care (C) doctors may be reluctant to consider deprescribing (O) because explaining and justifying any deprescribing is more emotionally and cognitively taxing (M).
CMOC13: When patients believe their medicines are providing them with benefits (C) doctors may find it difficult to discuss deprescribing (O) because explaining and justifying any deprescribing is more emotionally taxing (M).
CMOC14: When patients believe a medicine might be working or will work in the future (C) they are likely to want to continue taking it (O) because they hope they are doing something to help their condition (M).
CMOC15: When patients believe their medicines as keeping them alive (C) healthcare professionals may find it difficult to discuss deprescribing (O) because they don’t want their patients to feel they have abandoned them (M).
CMOC16: When patients view medicines as prolonging their lives (C) they may be reluctant to stop taking them (O) because they view deprescribing as a sign that they aren’t worth keeping alive anymore (M).
CMOC17: When patients believe medicines are providing them with benefits (C) patients may be reluctant to discontinue them (O) because they are afraid of negative consequences (M).
CMOC18: When families or carers perceive medicines to have a benefit for the patient (C) healthcare professionals may be reluctant to consider deprescribing (O) because they feel pressured not to do so (M).
CMOC19: When families/carers are involved in a patient’s healthcare (C) patients may be more able to engage in decision-making about their medicines (O) because they feel supported by them (M).
Shared decision-making
CMOC20: When healthcare professionals involve patients in the medication management process (C) they are more likely to make better decisions about medication (O), because of their shared expertise (M).
CMOC21: When healthcare professionals are aware of a patient’s perspectives and beliefs about medicines and their goals of care (C) they are more likely to achieve patient-centred outcomes (O) because the patient is understood (M).
CMOC22: When healthcare professionals involve patients in the decision-making process (C) they are more likely to make defendable decisions about medications (O), because of their shared responsibility (M).
Continuity of care and development of trust
CMOC23: When patients are presented with conflicting recommendations about their medication by health care professionals (C), their trust may decrease (O), because they don’t know who to believe (M).
CMOC24: When patients and their carer/family are asked to change their usual medication by a health care professional they are unfamiliar with (C), they may be reluctant (O), because they are concerned the person does not know what is best for them personally (M).
CMOC25: When a health care professional demonstrates to a patient they understands their needs and goals (C) the patient is more likely to trust them (O) because they believe the heath care professional is acting in their best interest (M).
CMOC26: When a patient trusts their healthcare provider (C) they may be more likely to consider changes to their medication (O) because they believe their healthcare professional is acting in their best interest (M).
CMOC27: When healthcare professionals know that they will be able to follow-up a patient (C), they are more likely to try deprescribing (O), because they are reassured they will be able to manage potential harms (M).
Monitoring
CMOC28: When a clinician judges that a patient may benefit from a change in medication (C), they are likely make small incremental changes (O) because they are concerned about causing harm to the patient (M).
CMOC29: When a harms minimisation process is provided by clinicians during medication changes (C), patients are more willing to make these changes (O), because they feel reassured (M).
CMOC30: When a patient provides feedback to a clinician about the effects of a medication change (C), they are more likely to make an informed decision about its value (O), because of their new knowledge (M).
CMOC31: When healthcare professionals are aware of a patient’s current perspective and beliefs about their medication (C), patients are more likely to consider medication change (O) because they feel understood (M).
Multidisciplinary approach
CMOC 32: When healthcare professionals can draw on the skills and expertise of colleagues (C) they feel more confident in making prescription changes (O) because they feel re-assured that they are making safe and optimal prescribing decisions (M).
CMOC33: When healthcare professionals can discuss complex cases with colleagues (C) they feel more confident about making medication changes (O) because they feel supported (M).
CMOC34: When healthcare professionals work collaboratively (C) they can improve continuity of care (O) and their understanding of their patients’ needs (O) because they can share workload (M).