Table 3 Themes and Context Mechanism Outcome Configurations (CMOCs)

Healthcare professional roles, responsibilities and relationships

1. When conducting a multidisciplinary medication review (c), having a clear process with defined roles and responsibilities (m) can lead to higher acceptance rates of deprescribing recommendations by health care professionals leading to a safe reduction in number of medications taken by older people (o)

Campin et al. (2017)

Stuhec et al. (2021)

Romskaug et al. (2019)

Van de Meer et al. (2019)

Cardwell et al. (2020) (the opposite CMOC was confirmed)

Clark et al. (2003)

2. When a medication review is carried out in primary care (c), if the pharmacists are involved and well-integrated within the multidisciplinary team (m) there will be a reduction in inappropriate prescribing (o) because integration will aid decision-making through closer relationships and better communication between HCPs (o)

Lenaghan et al. (2007)

Parkinson et al. (2021)

Stuhec et al. (2021)

Denneboom et al. (2007 (a) (b)

Van de Meer (2019)

Lenander et al. (2014)

Khera e al (2019)

Hazen et al. (2019)

Clark et al. (2020) the opposite CMOC was confirmed)

Trenaman et al. (2022)

Jamieson et al. (2023) (the opposite CMOC was confirmed ) Stakeholder consultation

3. When medication review involves a multidisciplinary approach (c), lack of trusted and healthy relationships between GPs and Pharmacists (m), leads to less deprescribing recommendations accepted and agreed resulting in unsuccessful deprescribing processes (o)

Bryant et al. (2010)

Clark et al. (2020)

Jamieson et al. (2023)

Stakeholder consultation

4. When a multidisciplinary medication review is carried out (c), if a pharmacist is involved in the process (m), then this gives health care professionals greater confidence to deprescribe medication (o)

Stakeholder consultation

5. When conducting medication reviews (c), if GPs are actively involved and engaged in the process (m), then the pharmacists' recommendations are more likely to be accepted by GPs and communicated to patients (o)

Parkinson et al. (2021)

Jamieson et al. (2023) (the opposite CMOC was confirmed)

6. When pharmacists make deprescribing recommendations to the patients’ GP (c), there will be higher acceptance rates of the recommendations by GPs (o) if the recommendations are related to safety issues (i.e., potentially inappropriate or high-risk prescribing) rather than cost (m)

Cardwell et al. 2020

7. When delivering medication reviews to older people (c), involving and utilising the skills of more healthcare professionals (e.g. HCAs, pharmacy technicians, social prescribers) (m) could make the medication review process more efficient and reach out to more patients (o)

Stakeholder consultation

8. When medication reviews are conducted in collaboration between a health care professional from primary care and a geriatrician (c) combining the strengths of both specialties (m) there are more drug withdrawals and reduced dosages (o) resulting in positive effects on patients’ health-related quality of life (o)

Romskaug et al (2020)

9. When conducting medication reviews within primary care, (for example, following patient discharge from hospital) (c), improving information continuity between primary and secondary care (m) and involving patients’ secondary care consultants (m) could support primary care teams to have more informed discussions with patients about any changes in their medications (o)

Stakeholder consultation

Sheehan et al. (2022)

Bayliss et al. (2022)

10. Clear planning and recording of the rationale for prescribing, treatment goals, and length of treatment at the point of prescribing (m) could support HCPs in their conversations with patients about their medicines and support patients to anticipate, prepare for and engage in discussion around the continuing need for medications and facilitate their informed decision-making about deprescribing medicines (o) as part of the medication review process (c)

Stakeholder consultation

Healthcare professional training and education

11. When conducting a medication review by the MDT (c), providing training that incorporates experiential learning theory and collaborative direct patient care (m) leads to improvement in their knowledge and skills of polypharmacy and complex medication management, and significant reduction in the number of medications prescribed to older patients (o)

Mecca et al. (2019)

12. When conducting a medication review by the MDT (c), providing Goal Attainment Scaling training focusing on individualized goal-setting and measurement among older patients (m), leads to a reduction in the number of medication prescribed (o)

Verdoorn et al. (2019)

Format and process of the medication review: Efficiency of a multidisciplinary process

13. When carrying out a medication review for older people (c), using an explicit or implicit tool to help identify any potentially unnecessary or inappropriate medications (m), may assist HCPs to make recommendations to deprescribe, resulting in a reduction in numbers of prescribed medications (o)

Denneboom et al. (2007) (a) (b)

Williams et al. (2004)

Campins et al. (2017)

Mecca et al. (2022)

Khera et al. (2019)

Foubert et al. (2019)

14. When medication reviews are conducted by GPs and pharmacists in collaboration (c), they are unlikely to carry out and sustain engagement in the process (o) if it is too time-consuming to deliver (m)

Leendertse et al. (2013)

Sheehan et al. (2022)

Bayliss et al. (2022)

15. If a medication review involves patients with complex needs (c), then the co-location of pharmacists in primary care settings allows face-to-face communication (m) which facilitates timely shared-decision making between HCPs (o)

Dalin et al. (2019) (the opposite CMOC was confirmed)

Van de Meer et al. (2018) (the opposite CMOC was confirmed)

Cardwell et al. (2020)

Clark et al. (2020)

Stakeholder consultation

16. When conducting medication review by the pharmacist (c), if a pharmacist has access to patient records (m), then they are more likely to be able to make, document and share better-informed deprescribing recommendations to other HCPs in a timely and more efficient way, leading to higher implementation of their deprescribing recommendations (o)

Oboh et al. (2018)

Leendertse et al. (2013)( the opposite CMOC was confirmed)

Bryant et al.(2010)

Clark 2003 et al. (the opposite CMOC was confirmed)

Jamieson et al. (the opposite CMOC was confirmed)

17. When multidisciplinary teams are communicating to make decisions following a medication review (c), asynchronous communication using electronic tasking and messaging services is a useful and efficient means of communication

Stakeholder consultation

Format and process of the medication review: Mode of communication with patients

18. When HCPs conduct medication reviews (c), involving patients through face-to-face communication facilitates shared-decision making (m), leading to the reduction in medicines related-problems (o)

Oboh et al. (2018)

Hazen et al. (2019)

Trenaman et al. (2022)

Stakeholder consultation

19. When a pharmacist invites patients for a medication review (c), patients are unlikely to accept and engage in the process (o) if they have high treatment burden and have frequent visits to healthcare professionals, because they may have been reluctant to attend an additional appointment for the purpose of pharmacist review. Alignment of face-to-face medication review with other routine visits to reduce burden on patients could be useful (m)

Cardwell et al. (2020)

20. When an HCP conducts a medication review (c) the mode of communication should be tailored to the individual needs of the patient and their families (m) in order to involve and engage them in the process, which is likely to lead to a reduction in prescribing (o)

Stakeholder consultation

Format and process of the medication review: Patient follow-up support

21. When conducting a medication review (c), if a scheduled follow-up with the patient is part of the process (m), there is more likely to be a reduction in number of inappropriate medications (o)

Hazen et al. (2019)

Khera et al (2019)

Lenaghan et al (2007)

Trenaman et al et al (2022)

Stakeholder consultation

22. When conducting medication review (c) patients are more likely to have the confidence to accept and implement the deprescribing interventions (o) if deprescribing is offered as trial off medication that can be restarted anytime if needed (a ‘drug holiday’), with a planned follow-up with an HCP in place (m)

Stakeholder consultation

23. After conducting medication review and agreeing with a patient on changes in medication regime (c), lack of engagement and poor follow-up by HCPs (m) could lead patients to feel a sense of abandonment (c) leading to not meeting patients' expectations and lack of continuity of care (o) affecting relationships with HCPs (o)

Bryant et al. (2010)

Stakeholder consultation

Involvement and education of patients and informal carers

24. When pharmacists or advanced nurse practitioners invite patients for medication reviews (c), older people are less likely to participate and engage in the process and accept deprescribing recommendations (o) if they are unfamiliar with the role of pharmacists and advanced nurse practitioners (m)

Stakeholder consultation

25. When conducting a medication review with a patient (c), if the patient has good understanding of the rationale of stopping a medication (m), they are more likely to accept, carry out and sustain HCPs recommendations (o)

Oboh et al (2018)

Fixen et al. (2022)

Stakeholder consultation

26. When conducting medication reviews with high risk patients (c), educating patients and involving carers in reasons and decisions about medications mean they feel more engaged in the process (m) leading to accepting deprescribing recommendations and a reduction of the number of medications (o)

Lenaghan et al. (2007)

Fixen et al. (2022)

Stakeholder consultation

27. When conducting a medication review (c), focusing on patient preferences and priorities (m), means patients are more engaged in in the process leading to acceptance in any changes in their medication regime (o)

Oboh et al (2018)

Parkinson et al (2021)

Hazen et al (2019)

Verdoorn et al. (2019)

Stakeholder consultation

28. When communicating deprescribing decisions (c), patients are more likely to accept the recommendations (o) if they have a trusted relationship with the HCP (m)

Stuhec et al (2021)

Stakeholder consultation

29. When conducting medication reviews in primary care (c), patients are less likely to accept deprescribing recommendations from HCPs in primary care (o) if medication are prescribed by a consultant because patients believe they have specialist knowledge and therefore may be of the opinion that the medicines are to be taken indefinitely

Stakeholder consultation

30. When having a medication review (c), if a patient feels anxious about the consequences of stopping a medication or views them as essential to their well-being (m) then they are less likely to accept deprescribing recommendations from health care professionals (o)

Stakeholder consultation

31. When conducting a medication review (c) starting with a simple deprescribing change that can lead to noticeable improvements in symptoms by patients (‘quick win’) (m), can lead to patients being more likely to accept and implement further deprescribing recommendations (o)

Stakeholder consultation

32. When conducting medication reviews with patients who have informal carers, including those living with cognitive impairment, (c), if informal carers are involved and engaged in the process (m), this will help the patient to feel more supported to implement any changes in medication (o)

Sheehen et al (2022)

Stakeholder consultation

33. When conducting medication review(c) informal carers are more likely to engage in a medication review and deprescribing process if they experience treatment burden related to medication management of their relatives (m), leading to increase in uptake of deprescribing recommendations (o)

Stakeholder consultation