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Table 4 Detailed programme theory—this table provides a detailed explanation of the DExTruS framework shown in Fig. 5 (numbers in brackets refer to CMOCs)

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

What to do Why do it? Anticipated outcomes
SUPPORTIVE INFRASTRUCTURE
 ▪ Policy and incentive structures (1, 2)
 ▪ Clarity of professional roles (5)
 ▪ Building skills and confidence in primary care clinicians (6–8)
 ▪ Recognising distinct generalist and specialist expertise equally and enable ways to work in MULTIDISCIPLIANARY TEAMS (32–34)
 ▪ CONTINUITY OF CARE (23–27, 29)
Provides PERMISSION and so motivation of and prioritisation for staff (3, 10, 11)
Reduces concerns from making changes (2) and cognitive and emotional load (1–8)
Increases knowledge needed to make decisions (6–8)
Allows healthcare professionals to draw on a broader range of expertise (32) and share workload (34)
Overcomes professional inertia associated with uncertainty (7, 8) and concern about professional relationships (9)
Healthcare professionals feel more confident and supported (32, 33, 34) and able to manage potential harms (27)
Enhances patient TRUST (23–25) and may help facilitate shared-decision making (20–22)
Enhanced TRUST between patients and healthcare professionals
Patients more likely to consider changes
Reduced medication related anxiety/fear
Achieve patient-centred outcomes
Patient and professional satisfaction
CONSISTENT ACCESS TO HIGH QUALITY RELEVANT DATA
 ▪ Contextual data: what meds, why, in context of individual patient (4)
 ▪ Informational CONTINUITY OF CARE (23)
Enhances TRUST between patient, their carers and healthcare professionals (23–25)
SHARED EXPLANATION of meaning and purpose of medications in the context of daily living, recognising and acting on patients’ lived experiences and priorities
 ▪ Recognise and (re)frame meaning and value of meds with patients (12, 14, 15)
 ▪ SHARED DECISION MAKING (20–22): Recognise/negotiate expertise of patient and family (19) to support sharing the load (20), understanding (21) and responsibility (22).
Recognises patient’s agendas and their implications (12–19)
Avoids patient perceptions of abandonment (15, 16), maintains hope, optimism (14)
Builds patient/family TRUST through a shared sense of working for “my best interests” (23–26)
Shared understanding (21) and responsibility (22) with patient and family, which may help to make defendable decisions (1 and 2).
TRIAL AND LEARN
 ▪ MONITORING (28–31)—tailored prescribing through incremental change (28), harm minimisation (29), with follow-up and CONTINUITY (27, 30,31)
Enables patient perspectives to be heard following changes (30,31) and may enhance TRUST (31)
Overcomes professional inertia associated with uncertainty of outcomes (7) and fear of negative consequences (15–17)