Carl Willers

Research problem and specific questions Deprescribing is a novel concept relating to a process where medications are reduced or stopped in order to avoid medication-related harms and improve patient outcomes. This proposal addresses two main challenges for deprescribing: (1) integrating deprescribing in routine care for older adults

(2) adapting deprescribing activities to the Swedish context, a country where deprescribing have yet to be introduced.Data and methodThis mixed-method project combines register-based data analysis, with qualitative research and participatory design. We use a mixed approach in order to: (a) describe the current deprescribing activities in Sweden (nation-wide register data covering all older adults in Sweden)

(b) gain detailed knowledge of the barriers and facilitators for deprescribing activities among patient and health care professionals (qualitative research and survey)

and, (c) creating a roadmap for future deprescribing interventions in Sweden (co-design of health care interventions). We believe that that the selected methods are the necessary steps to introduce relevant and patient-centered deprescribing activities in Sweden.Plan for project realisation This participatory research project will be executed in three steps. First, we will conduct analysis of register data to have an up-to-date understanding of the need, current activities, and efficacy and safety of deprescribing in Sweden. Second, we will conduct a series of interviews with patients and health care professionals focusing on barriers and facilitators for deprescribing in the Swedish context, and invite health care professionals to rank their most needed resources to routinely conduct deprescribing. Based on the two first steps, we will conduct a series of workshops with stakeholders (patient representatives and different health care professionals) to co-design a deprescribing intervention that is feasible and scalable in the Swedish setting.RelevanceThe novel process of deprescribing has the potential to reduce the high levels preventable medication-related harms in older adults. Medication-related harms lead to much individual suffering and high economic cost. Ideally, this project will improve medication use in older adults by shifting the attention from prescribing to deprescribing. By including end-users throughout the project, we believe that this project will be highly relevant for patients, policy makers, and health care providers.

Older adults make up approximately 20% of the Swedish population. The ongoing demographic development, with an ageing population and a continuously larger proportion of older adults, leads to continuously increasing demand for appropriate and efficient geriatric care. One particularly critical moment in the continuum of care for older adults is the transition between different responsible authorities, between regional and municipal care.The project consists of four phases and the aims are (I) to map and assess the situation in terms of health, care activities and resource use after discharge, (II) analyse associations with care-transition outcomes, (III) based on phase I-II, generate viable ideas for addressing and improving the situation, and (IV) implement new and improved ways of working as well as perform a post-implementation evaluation of effects (IV). The design of the study is closed cohorts based on registry data (phases I-II) together with an experience-based co-design (phase III), implementation and evaluation (phase IV).The data set leveraged in phases I-II consists of patient records from geriatric care, health care utilization data for six months after discharge extracted from the Stockholm Regional Healthcare Data Warehouse, socioeconomic data from Statistics Sweden, and data from the National Board of Health and Welfare on social services and death cause. In phase III, an experience-based co-design approach will be leveraged to develop a new model for the coordination of care, where the synthesised knowledge from phases I-II will be used as a base. In phase IV, the co-designed new model of coordination of care will be implemented. To be able to draw adequate conclusion from the outcome analyses, data on the process of implementation will be collected, and frequency of readmission will be the primary outcome measure to evaluate the effect of new ways of working. Costs of readmission will be computed before and after implementation.