INTRODUCTION:Older people face higher risks of medicine-related harm due to polypharmacy and the use of potentially inappropriate medicines. Current treatment guidelines rarely specify when to stop medicines, leading to medicines often being continued indefinitely without a clear deprescribing plan. While deprescribing guidelines exist for some medicine classes, limited guidance is a major barrier to deprescribing. These new guidelines address this gap by providing structured recommendations that complement more detailed drug-specific deprescribing guidance, disease-specific therapeutic guidelines and non-pharmacological management resources. These guidelines were developed by a team of 72 experts, including consumer representatives, and were further shaped by feedback from public consultation and independent reviewers. MAIN RECOMMENDATIONS:The guidelines are intended for all healthcare professionals involved in prescribing, dispensing or administering medicines to older people. The guidelines specifically address polypharmacy and medicines commonly dispensed for regular use in people aged ≥ 65 years, as well as other medicines where there is evidence to consider deprescribing in this cohort. The guidelines provide 185 consensus-based recommendations and 70 good practice statements, covering both specific medicine categories and general deprescribing principles. The guidelines are structured into four areas: (1) when to deprescribe; (2) ongoing treatment needs; (3) how to deprescribe; and (4) monitoring requirements. CHANGES IN CARE AS A RESULT OF THE GUIDELINE:This guideline emphasises deprescribing as an integral part of the prescribing continuum. Applying a deprescribing approach encourages prescribers to consider the ongoing need for a medicine each time a prescription is re-issued, to balance benefits and harms as they evolve over time, and to ensure treatment decisions reflect an individual's goals through shared decision-making. The guideline was developed based on currently available evidence for deprescribing and expert multidisciplinary and consumer input. It supports health professionals in reviewing regular medicines, minimising harm and planning ongoing treatment or monitoring. The detailed guideline is available at https://deprescribing.com.

Patients with multimorbidity (having two or more chronic conditions) often face complex health decisions involving trade-offs, competing outcomes, and cumulative treatment burden. Shared decision-making (SDM) can support these decisions by applying values clarification: identifying what matters to a patient, a key component of SDM. Values clarification is particularly important for patients with multimorbidity, as separate disease-specific recommendations may conflict and overlook what matters to the patient. Despite its importance, values clarification is underused, particularly when communication is challenging. This challenge is especially seen in patients with limited health literacy, who often struggle to understand information, weigh alternatives, and articulate what matters to them. Multimorbidity and limited health literacy often co-occur, increasing both need and potential benefit of values clarification. Some tools can support values clarification, but most are not designed for patients with multimorbidity and limited health literacy. For these patients, SDM may need to start with values clarification, relying more on dialogue than on formal tools. Targeted training for healthcare professionals may help them navigate complex decisions and integrate patient values. Future work should focus on developing and evaluating methods in collaboration with patients and healthcare professionals, ensuring that SDM and values clarification are accessible, feasible, and genuinely person-centered.

BACKGROUND:Tuberculosis (TB) remains a critical public health challenge in India, where sustained patient engagement is essential for its effective management. Despite the pivotal role of health literacy, the ability to access, understand, appraise, and apply health-related information in treatment adherence and outcomes, few tools are TB specific, culturally attuned to India, and psychometrically validated. The Health Literacy Instrument for Adults (HELIA), developed in Iran, is a multidimensional, World Health Organization (WHO)-aligned measure with proven reliability and open access, making it an ideal candidate for adaptation. This study aimed to culturally adapt and validate the HELIA for use among adults receiving TB treatment in India (HELIA-TB). METHODS:An exploratory sequential mixed-methods design was employed for the cultural adaptation and psychometric validation of the HELIA-TB in Junagadh district, Gujarat, India, between March 2024 and March 2025. The qualitative phase included expert review, forward translation, cognitive interviews with adults with TB and  frontline healthcare workers, back translation, and pilot testing, following international cross-cultural validation guidelines. Findings from the qualitative phase directly informed item modification, simplification of terminology, and contextual adaptation of the HELIA-TB prior to quantitative psychometric validation. The finalized instrument was subsequently administered to 393 adults with TB to assess internal consistency, test-retest reliability, content validity, and construct validity. RESULTS:HELIA-TB retained the original five domains, access, reading, understanding, appraisal, decision-making with TB specific modifications. Internal consistency and test-retest reliability were high (α = 0.82-0.89 across domains; 0.86 overall; ICC = 0.88), and so was content validity (S-CVI/Ave = 0.92). Health literacy scores were significantly associated with treatment adherence (Cohen's d = 0.89, p < 0.001) and self-rated health (Cohen's d = 0.76, p < 0.001). No significant differences were observed by TB type or drug resistance status. CONCLUSIONS:The adapted HELIA-TB demonstrated satisfactory psychometric properties and may support assessment of health literacy and development of targeted TB care interventions in the Indian context.

Tuberculosis (TB) remains a significant public health concern, with India accounting for a substantial portion of the global TB burden. Effective disease management relies on patient adherence to treatment protocols and active engagement in healthcare processes. Health literacy, the ability to acquire, comprehend, and utilize health-related information, is a crucial factor in disease management and outcomes. However, the health literacy levels among TB patients in India have not been extensively studied and thus, this research aims to assess this among TB patients in Gujarat, India. A cross-sectional study was conducted amongst 393 primary care patients with active TB, using a Health Literacy Instrument for Adults (HELIA) tool that was adapted and validated in the local language. Data was analyzed using SPSS 17.0, with statistical significance taken as p < 0.05. The findings revealed that 67.1

Background: Tuberculosis (TB) remains a significant public health concern, with India accounting for a substantial portion of the global TB burden. Effective disease management relies on patient adherence to treatment protocols and active engagement in healthcare processes. Health literacy, the ability to acquire, comprehend, and utilize health-related information, is a crucial factor in disease management and outcomes. However, the health literacy levels among TB patients in India have not been extensively studied and thus, this research aims to assess this among TB patients in Gujarat, India. Method: A cross-sectional study was conducted amongst 393 primary care patients with active TB, using a Health Literacy Instrument for Adults (HELIA) tool that was adapted and validated in the local language. Data was analyzed using SPSS 17.0, with statistical significance taken as p < 0.05. Result: The findings revealed that 67.1% of TB patients had limited health literacy, particularly among those with lower educational levels and unemployed. Higher health literacy was associated with better treatment adherence (OR=4.69, 95% CI:3.2-7.79), while patients with chronic conditions exhibited lower health literacy (OR=4.8, 95% CI: 1.23-9.8). Although TB patients demonstrated higher health literacy in the decision-making domain, they faced significant challenges in the appraisal domain. Conclusion: The findings suggest that health literacy may play an important role in the management of TB. Efforts to enhance health literacy could potentially contribute to improved treatment adherence and better overall outcomes.

Introduction Values clarification, a key but under-implemented component of shared decision-making (SDM), involves identifying what matters to a patient relevant to a health decision. It is especially important for patients with limited health literacy (LHL), who often struggle to express preferences. General practitioners (GPs) play a central role in facilitating this process, yet their experiences are underexplored.Aim To explore how GPs experience values clarification with patients with LHL, the challenges they face, and which support or strategies they consider helpful to better integrate values clarification into decision-making.Methods We conducted semi-structured interviews with 15 GPs purposively selected from practices in lower socioeconomic areas. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.Results Four themes emerged: GPs consider values clarification important but challenging; it goes hand in hand with problem analysis; trust and continuity of care are essential foundations; and relatives can support and hinder the process. GPs described two contrasting situations: patients with LHL adopting a passive role, prompting a more paternalistic approach, and patients with LHL with strong expectations that can conflict with clinical guidelines. GPs expressed needs for training, prompts or scripts, and strategies to explore expectations before consultations.Conclusion Values clarification in the context of SDM with patients with LHL is complex and context dependent. Given their ongoing relationships with patients, GPs are well-positioned to facilitate this. GPs’ experiences indicate that values clarification may occur throughout the consultation - often intertwined with problem analysis - reflecting the dynamic nature of SDM in general practice.

BACKGROUND:Since patients increasingly have online access to their diagnostic test results, general practitioners (GPs) have reduced control over how this information is communicated. This shift introduces new challenges in communication and interaction with patients and requires a better understanding of how GPs experience and manage communication in an evolving digital healthcare landscape. OBJECTIVES:To explore GPs' experiences and perceived challenges in communicating information about diagnostic test results to patients in the context of increasing digital accessibility. METHODS:In 2024, we conducted a qualitative study using semi-structured interviews with purposively sampled Dutch GPs in the Netherlands. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Key themes reflecting experiences and challenges related to the communication of diagnostic test results were identified. RESULTS:Eighteen participants were interviewed in the study. Three overarching themes emerged from the data: (i) managing patient expectations; (ii) purpose-driven communication strategies; and (iii) balancing efficiency and patient engagement in communicating test results. CONCLUSIONS:GPs considered patients' online access to diagnostic test results a double-edged sword-while it may support more efficiency in the healthcare process, it also introduces communication challenges, particularly due to patients' misinterpretation of clinically insignificant findings and the use of medical jargon in reports. These findings highlight the need for tailored communication strategies and improvement of information provided in online patient portals.

BACKGROUND:Unnecessary vitamin tests are among the most frequently mentioned low-value care practices among Dutch general practitioners (GPs). Understanding drivers for vitamin testing from a GP's perspective is key for developing effective interventions. OBJECTIVES:This study explored GPs' perspectives on drivers of vitamin D and B12 testing, focusing on potential differences between GPs in practices with high and low testing rates, using the Capability, Opportunity, and Motivation Model of Behaviour (COM-B) behavioural science framework. METHODS:Laboratory data from 57 primary care centres (PCCs) in the South of the Netherlands (2016-2019) identified the 15 PCCs with the lowest and highest vitamin testing rates. Thirty GPs, one per PCC, were purposively sampled to ensure variation in testing rate and background. Semi-structured interviews (May-July 2020) covered general perceptions, as well as social, cognitive, and motivational factors. Interviews were analysed by mapping factors driving vitamin testing to the COM-B model. RESULTS:Several medical and non-medical factors affecting vitamin D and B12 test ordering in general practice were identified, which could be linked to all three COM-B components at the GP (e.g. education), patient (e.g. informational material), and service level (e.g. laboratory forms). CONCLUSION:Education, feedback on testing behaviour, evidence-based patient informational material, clear evidence-based guidelines, and modification of laboratory request forms by adding test costs and indications of at-risk groups were identified by participants as promising strategies to reduce unnecessary vitamin testing.

PURPOSE:To explore stakeholders' views on acceptable and feasible strategies for discussion of treatment options and risk communication with people with limited health literacy (LHL in the context of shared decision-making (SDM)). METHODS:This qualitative descriptive study used purposive sampling to conduct focus groups with stakeholders including experts in health literacy, SDM, or risk communication (RC); experienced General Practitioners (GPs); and individuals with LHL. Each session included a brief presentation defining SDM, option talk, and RC, followed by an introduction to various RC strategies and decision aids to facilitate discussion. Verbatim transcripts were analysed by two independent researchers using inductive and deductive content analysis. RESULTS:Five focus groups were conducted, involving experts (two FGs, n = 5 and n = 6), GPs (one FG, n = 8) and people with LHL (two FGs, 2x n = 3). Experts and GPs emphasised the need to tailor communication to the patient's context and noted challenges in identifying patients with LHL. All participants highlighted the importance of using illustrations of treatment options (e.g., knee injections) to support the discussion of options. Views on the level of detail required for RC varied, with some GPs questioning whether RC was understandable to people with LHL. Most people with LHL preferred RC in natural frequencies and icon arrays but noted that RC can fan fear. GPs found contextualisation (e.g., comparing the probability of a treatment outcome with the probability of a car accident) a helpful strategy, but patients found it confusing. Decision aids were seen as supportive for RC. Overall, people with LHL preferred their doctor to discuss options face-face with them, using a layered step-by-step manner, adding details on RC as preferred by patients. CONCLUSION:SDM for people with LHL benefits from a tailored, layered approach with visual aids. These strategies are potentially useful for all patients, but further research is needed to confirm this.

Background One-third of the Dutch population has limited health literacy (LHL), making it difficult for them to access, understand, appraise, and apply health information. Patients with LHL often adopt a more passive role in shared decision-making (SDM), relying on their doctor to make decisions. A key element of SDM is values clarification: understanding what matters to the patient including their values, preferences, and circumstances. Values clarification remains under-implemented in healthcare settings, despite its relevance to patients with LHL.Aims This study aimed to explore SDM in general practice consultations, focusing on values clarification, as observed by researchers and perceived by general practitioners (GPs) and patients with LHL and multimorbidity.Methods We video-recorded consultations between 20 GPs and 55 patients with LHL and multimorbidity. Subsequently, GPs and patients independently rated perceived SDM using SDM-Q-9. We used OPTION5 to quantitatively measure observed SDM. We qualitatively analyzed how and when values clarification occurred during consultations.Results The observed average SDM performance (OPTION5, range 0–100) was 10.6 (SD 8.2). GPs rated their SDM performance at 64.7, while patients rated it at 88.9 (SDM-Q-9, range 0–100). Qualitative analysis showed that values clarification was about multiple types of preferences, goals, and concerns. GPs typically initiated values clarification by proposing a treatment option and checking if the patient agreed, rather than deliberating collaboratively. This sample of patients with LHL rarely initiated values clarification, but if they did, it mostly occurred early in the consultation when they shared their reason for encounter.Discussion Observed SDM was low. We saw discrepancies between observed and experienced SDM, possibly due to the difference in how instruments measure SDM, or clinicians overestimating their SDM behavior. Patients reported even higher SDM levels than GPs, suggesting differing understandings or social desirability. Shared understanding of the problem seems an important requirement for values clarification. Values clarification was mainly initiated by GPs, but often resembling a paternalistic approach. Asking more open-ended questions may improve values clarification. Future research into perspectives and needs of GPs and patients with LHL could improve values clarification and SDM in general practice.

OBJECTIVE:Inappropriate polypharmacy increases the risk of medication-related issues. Adequate management of polypharmacy is a challenge involving different healthcare professionals, complex decision-making and ideally including patient involvement. The objective of this scoping review was to provide an overview of national recommendations for medication management of patients with polypharmacy in primary care. METHODS:A scoping review of clinical practice guidelines focusing on medication management in adults with polypharmacy, applicable to primary care was performed. Databases (G-I-N, Turning Research into Practice and PubMed), network, and a global report were screened for guidelines published after 2000 in English, Dutch, German, Spanish, French, or Russian. Raw data were extracted in duplicate using an extraction framework focusing on strategies, involvement of professionals, patient involvement, and implementation. Qualitative content analysis was used. Guideline quality was assessed using AGREE-II. The study was registered with the Open Science Framework. RESULTS:Eight guidelines originating from eight countries were included. The most common recommended strategy was a medication review conducted by a general practitioner and/or a community pharmacist. Tasks and target population differed per guideline. Most guidelines recommended involving the patient in the process, mostly to elicit the patient's experiences and treatment goals. Few guidelines included advice on the implementation of recommendations. Three out of eight guidelines were of good quality (AGREE-II score >70% in 5/6 domains). CONCLUSIONS:Most guidelines recommended a medication review, with patient involvement, as a strategy for medication management in polypharmacy in primary care. Guidance on task division and implementation of guidelines in practice was less clear. This review illustrates room for guideline improvements.

BACKGROUND:For people in receipt of palliative care, where polypharmacy is common and medication burden is high, there remains limited knowledge around the decision-making processes that underpin deprescribing; for example, recent deprescribing studies have focused on wider issues of identifying polypharmacy in palliative care contexts. However, little is known about the specific challenges of, and preferences towards, decision-making to support the deprescribing for people in receipt of palliative care. AIM:To explore decision-making processes that underpin deprescribing approaches, based on the experiences of people in receipt of palliative care, and their family member(s). DESIGN:An explorative qualitative study involving in-person semi-structured interviews, analysed using reflexive thematic analysis. SETTING/PARTICIPANTS:Twenty-five semi-structured interviews were conducted with people in receipt of palliative care (n = 25), where 12 of these interviews were undertaken as dyads, with both the patient and a family member together. Interviews were undertaken across a range of settings, spanning: hospice outpatient day units (n = 11), hospice inpatient wards (n = 4), care home (n = 1) and patients' own homes (n = 9), and involved people with diverse diagnoses (including: cancer 52%, heart failure 20%, motor neurone disease 12%, pulmonary fibrosis 4% and chronic obstructive pulmonary disease 4%). RESULTS:Two overarching themes were developed - the first reflected the need to address patient understanding by 'laying the foundations of deprescribing decision-making'. The second theme, 'having a voice in deprescribing decision-making', reflected desires to (pro)-actively involve patients and their family member(s) within these processes. CONCLUSION:There is a need to take a balanced, person-centred and shared approach to deprescribing decision-making for people receiving palliative care. Co-design strategies offer one approach to further explore this.

OBJECTIVES:We explored patient attitudes and experiences around their involvement throughout the digital interdisciplinary consultation (DICO) process and identified its influencing factors. DICO is defined as asynchronous, targeted communication between GPs and hospital specialists via a secure electronic application where patient-specific information is shared, and clarification or guidance is sought concerning a clinical question. METHODS:We conducted a qualitative study in the Netherlands. A conceptual framework was iteratively developed to identify phases of DICO where patient involvement is possible, drawing on literature research and expert meetings. Data from three interrelated studies performing semi-structured interviews regarding patients' experiences with various types of DICO were triangulated. The conceptual framework was expanded with factors influencing the degree of patient involvement at each phase, based on the findings from the patient interviews. RESULTS:We analyzed 27 patient interviews. Patients viewed DICO as an initial step in care, with limited active involvement required. From the perspective of the patient, the decision to initiate DICO is typically made by the GP, often without patient input. GPs initiate DICO for various reasons and patient involvement varies depending on the reason. Key factors influencing involvement as perceived by patients include the GP-patient relationship, particularly trust, the nature of the medical problem (e.g., urgency and severity), and patients' needs and preferences. Patients appreciated post-DICO discussions, particularly in cases of uncertainty, and considered shared decision making important when DICO leads to health decisions. CONCLUSIONS:The study highlights how the level of patient involvement in DICO varies depending on the reason for initiating DICO, the nature of the medical problem, patients' needs and preferences, and the GP-patient relationship. PRACTICE IMPLICATIONS:Findings from this study show patient involvement in DICO is context-dependent; GPs should tailor involvement across multiple DICO phases, especially when providing feedback on the outcome of DICO. Findings can contribute to future guidelines for effective, patient-centered DICO implementation.

BACKGROUND:In orthopedics, the use of patient decision aids (ptDAs) is limited. With a mixed-method process evaluation, we investigated patient factors associated with accepting versus declining the use of the ptDA, patients' reasons for declining the ptDA, and clinicians' perceived barriers and facilitators for its use. METHODS:Patients with an indication for joint replacement surgery (N = 153) completed questionnaires measuring demographics, physical functioning, quality of life (EQ-5D-3L), and a visual analog scale (VAS) pain score at 1 time point. Subsequently, their clinician offered them the relevant ptDA. Using a retrospective design, we compared patients who used the ptDA (59%) with patients who declined (41%) on all these measures as well as the chosen treatment. If the use of the ptDA was declined, patients' reasons were recorded by their clinician and analysed (n = 46). To evaluate the experiences of clinicians (n = 5), semistructured interviews were conducted and thematically analyzed. Clinicians who did not use the ptDA substantially (<10 times) were also interviewed (n = 3). RESULTS:Compared with patients who used the ptDA, patients who declined use had higher VAS pain scores (7.2 v. 6.2, P < .001), reported significantly worse quality of life (on 4 of 6 EQ-5D-3L subscales), and were less likely to receive nonsurgical treatment (4% v. 28%, P < .001). Of the patients who declined to use the ptDA, 46% said they had enough information and felt ready to make a decision without the ptDA. The interviews revealed that clinicians considered the ptDAs most useful for newly diagnosed patients who had not received previous treatment. CONCLUSION:These results suggest that the uptake of a ptDA may be improved if it is introduced in the early disease stages of hip and knee osteoarthritis. HIGHLIGHTS:Patients who declined the use of a patient decision aid (ptDA) for hip and knee osteoarthritis reported more pain and worse quality of life.Most patients who declined to use a ptDA felt sufficiently well informed to make a treatment decision.Patients who declined the ptDA were more likely to have received prior treatment in primary care.Clinicians found the ptDA to be a helpful addition to the consultation, particularly for newly diagnosed patients.