Abstract Introduction Frail older adults who reside in long-term care facilities (LTCFs) are at a higher risk of adverse drug events due to potentially inappropriate medications (PIMs). Deprescribing is a safe and effective method of reducing PIMs. Despite the benefits, there is evidence that deprescribing is not being conducted. The DEFERAL strategy was designed to support healthcare professionals (HCPs) to deprescribe PIMs for frail older adults in LTCFs. DEFERAL consists of a three-monthly multi-disciplinary team (MDT) deprescribing review, incorporating evidence-based deprescribing tools. It is conducted in person at the LTCF, targeting one pre-determined class of PIMs, organised by a nurse champion on site.[1] Aim To test the DEFERAL strategy, focusing on implementation outcomes of acceptability, feasibility, appropriateness and fidelity while collecting intervention data on deprescribing decision-making. Methods A feasibility study was conducted, recruiting a convenience sample of two LTCFs in the South-West of Ireland. The LTCFs required a general practitioner, pharmacist and nurse to be eligible. To be included in the deprescribing review, patients were required to be ≥65 years, frail, prescribed ≥1 antihypertensive and to have no deprescribing contraindications. The study followed a hybrid type three design,[2] focusing on implementation outcomes whilst collecting intervention data. HCP feedback was collected using a post-meeting survey, which was emailed to HCPs or available in paper format via the on-site nurse champion. Data were analysed quantitatively. Open-ended comment boxes were analysed using content analysis. Data on intervention outcomes were collected using a summary sheet documenting meeting attendance, recruitment and decision-making, and were analysed quantitatively. Results The survey was completed by ten HCPs (83.3%). Of completed surveys, 100% (n=10) agreed that the DEFERAL strategy was acceptable and appropriate to support deprescribing and 90% (n=9) agreed that it was feasible to undertake. The majority (90%) of HCPs indicated that they completed their designated roles exactly as described; however, qualitative feedback described site-specific modifications. In Site 1, the wider MDT were not engaged as intended and the site did not facilitate the education and screening phase as described. Site 2 introduced an additional resource to facilitate documentation of clinical measurements to support deprescribing decision-making. From a total of 90 residents, 56 (62.2%) were prescribed ≥1 antihypertensive medication. Of those resident at the time of the review, 16 (29.6%) patients were eligible and deprescribing occurred for six patients (37.5%) through dose reduction of antihypertensive medications. Documented reasons for not deprescribing included fear of negative consequences and inappropriate blood pressure measurements. Conclusion The DEFERAL strategy led to successful deprescribing of antihypertensive medications in LTCFs, supported with positive feedback on implementation outcomes. A strength of the strategy is its universal nature. DEFERAL could be adjusted to support deprescribing for different PIMs, patient cohorts or organisational structures in LTC. The strategy provides a blueprint to support medication reviews in LTC, integrating the pharmacist into routine practice. Future research is required to test the strategy for effectiveness, considering the site-specific modifications. A study limitation was the lack of completion of the follow-up survey, limiting the completeness of the feedback on the strategy. References 1. Heinrich CH, McHugh S, McCarthy S, Curran GM, Donovan MD. Multidisciplinary DEprescribing review for frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement. Research in Social and Administrative Pharmacy. 2023;19(8):1202–13. 2. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012 Mar;50(3):217–26.

Abstract Introduction Deprescribing, the systematic process of stopping or altering inappropriate medicines, has been suggested as a safe, effective and appropriate process to optimise prescribing for older adults (1). There is still a lack of understanding of how best to implement sustainable deprescribing in long-term care (LTC). Aim Design a theory-driven implementation strategy, based on consensus from healthcare professionals (HCPs), to facilitate their engagement with deprescribing for frail older adults in LTC. Methods This study consisted of three phases and was designed in conjunction with HCPs working in LTC. Firstly, barriers and enablers to deprescribing in LTC previously identified by the research team were mapped to behaviour change techniques (BCTs) (2). Secondly, a Delphi survey of HCPs (General Practitioners (GPs), Pharmacists, nurses, geriatricians and psychiatrists of old age) was conducted to select feasible BCTs to support deprescribing. HCPs were purposively sampled and recruited via email, divided into HCPs working in Ireland and internationally. Experts were identified from existing professional relationships, engagement with LTC or deprescribing research. Using the results from the Delphi process, the literature on deprescribing interventions and research team knowledge, the BCTs which could form components of an intervention in LTC were shortlisted based on was acceptability, effectiveness, affordability, safety and equity (APEASE). Finally, a roundtable discussion was held with a purposeful, convenience sample of GPs, Pharmacists and nurses working in LTC in Ireland, to prioritise the previously identified barriers/enablers and operationalise the proposed deprescribing strategies created from feasible BCTs and identify the most important strategy to facilitate deprescribing. Results Overall, 34 BCTs were mapped to previously identified barriers/enablers to deprescribing in LTC. For the Delphi survey, 33 HCPs were invited, 20 agreed and it was completed by 16 participants. The Delphi consisted of two rounds. Participants reached consensus that 26 of the BCTs could feasibly be implemented in LTC. Following the APEASE assessment, 21 BCTs were considered eligible for operationalisation. The roundtable discussion, consisting of eight HCPs, identified that lack of resources (time, staffing, technology), was the most important barrier to address. The agreed implementation strategy to enhance engagement with deprescribing processes was an education session prior to a multidisciplinary team (MDT) meeting, led by a nurse from the LTC setting. This was designed from 11 BCTs, including action planning, social support and environmental restructuring addressing the predominant barrier. Incorporating the MDT reduces the burden which would exist if the responsibility was placed on one HCP. Meeting at the LTC site addresses the insufficient technology, as patient information is available. Conclusion This study describes an implementation strategy design process following principles of behavioural and implementation science. Engaging targeted end users throughout the process allows for the creation of a strategy which is intended to address the main perceived barrier to deprescribing of insufficient resources. A limitation of this study is the specificity of the intervention for Irish LTC context, which may have different staffing and organisational structures compared to international healthcare systems. References 1. Ibrahim K, Cox NJ, Stevenson JM, Lim S, Fraser SDS, Roberts HC. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatrics. 2021 Apr 17;21(1):258. 2. Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing Interventions [Internet]. 1st ed. Silverback Publishing; 2014 [cited 2022 Jan 11]. Available from: https://books.google.ie/books/about/The_behaviour_change_wheel_a_guide_to_de.html?id=1TGIrgEACAAJ&source=kp_book_description&redir_esc=y

Background Implementation researchers often combine the Theoretical Domain Framework (TDF) and Consolidated Framework for Implementation Research (CFIR) in their studies. However there is some debate on the merits of using multiple frameworks—whether they contribute to results or provide superfluous analysis. Our recent research combined the TDF and CFIR to identify determinants to widespread incorporation of patient held medication lists (PHML) in healthcare practice. The aim of this report is to provide guidance on the use of the TDF and CFIR; by assessing the degree of overlap between the two frameworks in their application to interviews about PHML. Methods Semi-structured telephone interviews were conducted with healthcare professionals (HCPs) and non HCPs (people taking multiple medicines and caregivers).Interview data were transcribed and analysed using the TDF and CFIR. Within paired domains substantial intersection/overlap across constructs and domains within the two frameworks was classified as > 75% of coding references, consistent intersection/overlap was defined as > 50% and ≤ 75%, average intersection/overlap was defined as ≤ 50% and > 25% and non-substantial intersection/overlap was classified as ≤ 25% of coding references. Results Interview data were collected from 39 participants – 21 HCPs and 18 non HCPs. Mapping of TDF domains to CFIR domains/constructs identified key determinants in six TDF domains: Environmental context & resources, Beliefs about capabilities, Beliefs about consequences, Social influences, Behavioural regulation and Social/professional role & identity ; and five CFIR domains: Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individual and Process. A pattern of substantial intersection/overlap in coding emerged with broad TDF domains such as Environmental context & resources often linked to well-defined CFIR domains and constructs (e.g. design quality & packaging within Intervention Characteristics). Broad CFIR constructs such as knowledge & beliefs about intervention within Characteristics of Individuals also linked to more descriptive TDF domains like Beliefs about capabilities . In addition there was some unexpected non-substantial intersection/overlap in coding with the TDF domain Social influences less frequently linked to the CFIR Inner Setting domain and constructs such as networks and communications. Conclusions Identifying intersections/overlaps in coding between CFIR and TDF can assist interpretation of findings in implementation research. The strengths of each framework were exploited in a reciprocal process which provided more information to broad/poorly defined domains and enabled identification of implementation determinants and innovation determinants.

Abstract Background A Health Research Board (HRB) four-year research study, which commenced in January 2023, seeks to explore the process of carrying out Health Impact Assessments (HIAs) with a view embedding the approach as normal practice in local and national policy development in Ireland. Methods A theoretical framework has been constructed to develop an HIA implementation model. The framework is based on the all-island Institute of Public Health Ireland's HIA guidance. The theoretical framework will examine factors affecting HIA implementation, using both the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT). An action research methodological approach will be used to gather data on the experiences that participants will reflect on while doing the HIA. Participants included in the study will be the members of the two HIA Steering Groups created for each HIA (12 participants in each HIA) and policy end-users of the HIA evidence from the city council and government ministries (20 participants for each HIA). Results The theoretical framework will be applied to two HIAs, in order to generate data in creating the HIA implementation model. HIA 1, commencing October 2023, will be conducted on the local government Cork City Development Plan. HIA 2, commencing January 2025, will be carried out on the Irish Government's Climate Action Plan. Preliminary results on the application of the theoretical framework to HIA 1 will be presented, as well as reflections for the planned HIA 2. Conclusions For the first time in Ireland and beyond, a theoretical framework has been developed employing innovative methodological approaches to building a contextualised HIA implementation model. Using action research in assessing the implementation of HIA, with a view to analysing the lived experience of Steering Group members as they conduct the HIAs, and policy end-users, will ensure an enhanced HIA implementation model. Key messages • The development of an innovative theoretical framework for the study of HIA. • The building of HIA capacity in Ireland using the newly revised Institute of Public Health guidance.

Abstract Background Multimorbidity and polypharmacy often result in numerous interactions with different Healthcare Professionals (HCPs) and many transitions of care. Keeping up-to-date medications list in people taking medicines and/or carers can reduce medication errors at care transitions. The HSE National Quality Improvement team is working on a national medication safety campaign which encourages people to keep lists. However, there is limited information about perceptions of Patient-Held Medication Lists (PHML) in clinical practice. The aim of this study was to examine attitudes to PHML among people taking/managing multiple medicines, HCPs; and how lists are used in practice. Methods Purposive sampling was employed and recruitment through relevant organisations, social media and snowballing methods. Semi-structured telephone interviews were conducted with 39 people; HCPs (N=21), patients/caregivers (N=18). Interviews were transcribed and thematically analysed with behavioural frameworks - the Consolidated Framework for Implementation Research (CFIR) and Theoretical Domains Framework (TDF). Results Three core themes were identified: Attitudes to PHML; Function and preferred features of PHML and Barriers and facilitators to future use of PHML. All participants thought keeping medication lists had benefits for both people and HCPs (e.g. empowering, improving adherence). All who were taking medicines used lists and found them useful in particular situations (e.g. emergencies). However, HCPs and patient/caregiver groups expressed concerns about their accuracy. It was felt that some individuals may have difficulties keeping an accurate PHML (e.g. older adults, on multiple/changing medications). The participants also differed on the level of detail that should be included in PHMLs. Most patients favoured simple lists but HCPs reported the lack of detailed information in PHML may be an issue. Conclusion Common concerns about the accuracy of PHML and diverging opinions on list content need to be addressed. Health promotion strategies which focus on promotion of lists by key HCPs and provide people with a variety of list options could increase the wider implementation of PHMLs.

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals’ perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM. Methods and analysis: Primary qualitative studies will be identified using a systematic search of electronic databases and supplementary searching. We selected ‘best-fit framework synthesis’ as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively. Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42019145483].

Background Screening for depression and diabetes distress in people with type 2 diabetes (T2DM) in primary care is increasingly recommended but implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of screening recommendations can improve understanding of aspects that work, and those which are difficult to implement. We aim to synthesise the available qualitative evidence on healthcare professionals’ perceived barriers and enablers to recognising possible depression and diabetes distress in people with T2DM using validated screening tools compared to clinical questioning or no screening. Methods Primary qualitative and mixed method studies were identified using systematic database searching of six databases and supplementary searching. We selected ‘best-fit framework synthesis’ to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. We selected the theoretical domains framework (TDF) as the a priori best fit framework as the TDF is derived from existing behaviour change theories. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical-Appraisal-Skills-Programme) and the GRADE-CERQual (Grading-of-Recommendations-Assessment-Development-and-Evaluation-Confidence-in-the-Evidence-from-Reviews-of-Qualitative-research) respectively. The study is registered on the international Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019145483). Results Ten primary qualitative studies were identified from five countries; England (n=4), China (n=1), the Netherlands (n=3), Australia (n=1), Canada (n=1). No studies on detection of diabetes-distress were identified. Data extraction and analysis is ongoing. Tentative findings indicate that primary care health professionals experience barriers and enablers to detection unique in T2DM populations; symptom overlap, perceptions of role and responsibilities, the perceived value of screening in the T2DM population, and integrating screening protocols into T2DM review visits. Additional barriers to depression screening in the T2DM population; mental health stigma, patient-clinician relationship, were pertinent to depression screening in primary care populations more generally. Discussion Findings may (1) improve understanding of how depression can be more appropriately identified in people with T2DM in primary care settings from a health care professional perspective, (2) inform the design of future depression screening interventions or (3) inform depression screening recommendations for people with T2DM. The application of recommended qualitative evidence synthesis approaches i.e. RETREAT, GRADE-CERQual, enhances the overall robustness of the study. The protocol is available at https://hrbopenresearch.org/articles/2-26/v2.

Background Evidence-based healthcare innovations require complementary evidence-based implementation strategies to support their translation into practice. Efforts to test, refine and replicate implementation strategies are frustrated by insufficient description. Our aim was to examine the extent to which implementation strategies could be specified using the Behaviour Change Technique (BCT) taxonomy, a behavioural science tool for describing the active ingredients of interventions. Methods The data source was a compilation of 73 implementation strategies, developed through evidence synthesis and expert consensus. The definition of each strategy (n=73) was deductively coded using the BCT Taxonomy, containing 93 discrete techniques. A typology was developed iteratively to categorise the extent of overlap between strategies and BCTs. The number of BCTs per strategy and extent of overlap was estimated. In the next stage, 3 experts will independently rate 1) their level of agreement with the categorisation and 2) level of agreement with the BCT(S) identified within each strategy. Results During preliminary analysis, 87 BCTs were coded across 73 strategies (average 1.2 per strategy). Five types of overlap were identified. For 8% of strategies (n=6), there was direct overlap between the strategy description and BCT (e.g. strategy: remind clinicians/BCT: prompts and cues). For 36% of strategies (n=26), there was at least 1 BCT clearly subsumed under the strategy description which could be used to guide initial operationalisation (e.g. strategy: provide clinical supervision/BCT: restructure social environment). For 26% of strategies (n=19), a BCT(s) was probably subsumed under the strategy given its definition and/or title but other BCTs were possible depending on how the strategy is operationalised (e.g. strategy: visit other implementation sites/BCT: social comparison). For 11% (n=8), there were no BCTs clearly indicated in the strategy definition or title (e.g. strategy: make training dynamic). Finally, 19% of strategies (n=14) did not focus on behaviour change to support implementation (e.g. strategy: access new funding). Conclusion Many implementation strategies require further specification in order to apply them in a setting, relying on assumptions and inference on the part of the intervention developer, be it researcher or practitioner. This creates an opportunity for inconsistent application and limits the potential for replication and synthesis of evidence of effectiveness. This study is the first step towards moving from general descriptions of implementation strategies to full descriptions of their active ingredients. This is essential to understand how strategies at an organisational and professional level can lead to observable changes in individual behaviour.

Background Diabetic retinopathy is a common complication of diabetes affecting the blood vessels at the back of the eye. Despite evidence that diabetic retinopathy screening (DRS) is effective, uptake continues to be sub-optimal in many countries, including Ireland. As routine management of type 2 diabetes largely takes place in primary care, it is arguably the best setting in which to implement interventions to improve DRS uptake. This study aims to develop a theory-based implementation intervention to improve uptake. Methods A four-stage systematic development process was undertaken. Target behaviours were identified through a multi-phase sequential mixed methods study involving key stakeholder interviews (n=19), and an audit of screening attendance in two primary care centres. Barriers and enablers to uptake were identified through coding interviews with patients (n=48) and health care professionals (HCP) (n=30) using the Theoretical Domains Framework (TDF). Barriers and enablers were mapped to behaviour change techniques (BCTs) to develop intervention content. The APEASE (affordability, practicability, effectiveness, acceptability, side effects and equity) criteria was used to select the components. Effectiveness was determined through a rapid evidence review. Feasibility, local relevance and acceptability of the intervention were identified through consensus group meetings with patients (n=15) and HCPs (n=16), and key stakeholder consultation, including the national DRS programme. Results Three key behaviours were identified; one HCP-level (registration of patients for screening), and two patient-level (consent for the programme to hold their details, and attendance). Modifiable patient barriers and enablers were associated with six TDF domains. Barriers included confusion between screening and routine eye checks (‘Knowledge’), forgetting (‘Memory, attention, decision processes’), anticipation of a negative result (‘Beliefs about consequences’). Enablers included a recommendation from friends/family or HCPs (‘Social Influences’), recognising the importance of screening for early detection (‘Beliefs about consequences’), ownership over their condition (‘Identity’), and being in a routine of attending tests (‘Beliefs about capabilities’). HCP barriers included the time to register patients which was impeded or supported by practice resources (‘Environmental context and resources’), and a lack information on screening uptake in their local area (‘Knowledge’). Following the consensus meetings, consultation and evidence review, ten BCTs were included and operationalised as an implementation intervention targeting professionals (reimbursement, training, audit/feedback and electronic prompt) and patients (face-to-face/phone reminder messages, GP-endorsed reminder letter and information leaflet). Conclusion A multi-stage process combining theory, consultation of multiple stakeholders and existing evidence, was used to develop a multifaceted implementation intervention, targeting both professional and patients, to increase uptake of DRS. The feasibility of delivering the intervention in primary care will be evaluated through a pilot trial.

Background: To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. Methods: We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation. Discussion: This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Background Intervention development is a critical first step when conducting trials or observational studies. Research suggests that involving multiple stakeholders in this process increases the likelihood of developing interventions that are acceptable, engaging, feasible and effective. However, there is little guidance for researchers on the best ways to involve multiple stakeholders in a meaningful way. The aim of this Study Within A Trial (SWAT) is to identify the most suitable approach to involve patients and healthcare professionals in a consensus process to inform the development of the Improve Diabetes Eye-screening Attendance (IDEA's) intervention. Methods This is a qualitative study. Three meetings were held to establish consensus on the content and delivery of the intervention. Meeting included 1 patients only, meeting 2 included a combination of patients and healthcare professionals and meeting 3 included healthcare professionals only. Stakeholders were asked to agree on intervention components which target patients and general practices. Each meeting was audio recorded and field notes were taken. After the meeting, semi-structured telephone interviews were carried to explore stakeholders' experiences of taking part. Data were transcribed verbatim and managed using NVivo V12 software. Thematic analysis was performed to identify themes relating to members' experiences of taking part. Results All three meetings put forward feasible ideas which were incorporated into the final intervention. Each meeting had ideas which were not put forward by the other groups but were incorporated into the final intervention (Meeting 1=6 ideas, Meeting 2=2 ideas and Meeting 3=5 ideas). Thematic analysis suggests that stakeholders in meetings 1 and 3 felt comfortable expressing their opinions and grateful that they were given the opportunity to be heard. Stakeholders in meeting 2 felt they had to hold back on their opinions as they were aware that the other stakeholder group was in the room. They also felt that their contributions were undervalued by the other stakeholder group. Conclusion Involving patients and healthcare professionals together in a consensus process is not a suitable approach to involvement. This study will guide researchers on the most suitable approach to involve patients and healthcare professionals in a consensus process and will contribute to the evolving literature on the potential impact of involving multiple stakeholders in the intervention development process.

Background Cross country comparison facilitates examination of health-system and country-level similarities and differences on disease burden. Diabetes is a leading global health issue with outcomes influenced by psychological comorbidity. Diabetes is consistently associated with depression in different populations but any association is influenced by variations in prevalence, study design and measure used. We compared depressive symptom prevalence in older adults with and without diabetes across three health systems using a validated measure to examine the causal association between diabetes and depression. Methods We used data of adults aged 50 years and older, from three nationally representative ageing datasets; The Irish Longitudinal Study on Ageing (TILDA), the English Longitudinal Study on Ageing (ELSA) and the Health and Retirement Study (HRS). Data were collected during 2009–2011 (TILDA), and 2010 (ELSA, HRS). Variables; country, gender, age, education level, marital status and smoking status, were selected a priori using literature and a directed acyclic graph. Variables were self-report, with the exception of ‘country’, which was linked to the original dataset. The 20-item (cut-off-score>16;TILDA) and 8-item CESD (cut-off-score>3;ELSA and HRS) were used to categorise depression. Prevalence was presented as a percentage with corresponding 95% confidence intervals and group-specific differences presented using Pearson’s chi-square test for categorical data and Student’s t-test for continuous data. Binomial logistic regression examined the odds of depression by diabetes status, adjusting for pre-selected variables. Analyses of country-specific factors related to depression is ongoing. Data were analysed using Stata v15. Results Diabetes prevalence varied across the countries (Ireland; 8%[(95%CI:7.5–8.6), England; 11%(95%CI:10.6–12.0), USA; 22%[(95%CI:21.7–22.8); p<0.001]) and was consistently higher among males than females (Ireland; 10%(95%CI:8.9–10.8) vs. 6%(95%CI:5.3–6.7), England; 13%(95%CI:12.4–14.5) vs. 10%(95%CI:8.7–10.3), USA; 24%(95%CI:22.9–24.7) vs. 21%[(95%CI:20.3–21.8); p<0.001]). Depression prevalence was significantly higher among people with diabetes in all countries (Ireland; 12%(95%CI:9.8–15.1) vs. 10%[(95%CI:9.0–10.4), p=0.035], England; 34%(95%CI:31.0–37.0) vs. 22%[(95%CI:20.8–22.6):p<0.001], USA; 20%(95%CI:19.0–21.4) vs. 14%[(95%CI:13.6–14.7); p<0.001], in females (Ireland; 19%(95%CI:14.6–23.9) vs. 12%[(95%CI:11.0–12.9); p=0.001], England; 39%(95%CI:34.2–43.4) vs. 25%[(95%CI:24.0–26.6); p<0.001], USA; 24%(95%CI:21.9–25.3) vs. 16%[(15.4–16.9); p<0.001]), and in males (Ireland; 8%[(95%CI:5.3–10.8) vs. 7%[(95%CI:6.1–7.9); p=0.644], England; 30%(95%CI:25.8–33.9) vs. 17%(95%CI:15.7–18.3); p<0.001], USA; 16%(95%CI:14.4–17.7) vs. 11%[(95%CI:10.6–12.2); p<0.001]. After adjusting for all model variables, people with diabetes had 1.5 increased odds of depression compared to people without diabetes [(95%CI:1.4–1.6), p<0.001]. Conclusion In older people in three countries with different health systems, depressive symptom prevalence was (1) consistently higher among men and women with diabetes than non-diabetes counterparts and (2) varied across health systems. While use of self-report data may limit the accuracy of the results, use of the CESD to categorise depression and of large nationally representative datasets strengthens the study. Interrogation of additional country-level factors associated with depression will further explain variation in depressive symptom prevalence across health systems.

AimsTo define the burden of wound complications in patients with infra-inguinal bypass surgery.MethodsA retrospective review of 50 consecutive patients from January 2012 to July 2017. Data collected included patient demographics, operative details, length of stay (LOS) and postoperative complications.ResultsThe average age was 64 years (range 25-88 years) and 10 had a body mass index (BMI) ≥25 kg/m2. Pre-operative methicillin-resistant Staphylococcus aureus (MRSA) screening was performed in 17 patients (n=4 positive). Surgical antimicrobial prophylaxis (SAP) continued longer than 24 hours in 25. Surgical site infection (SSI) was the most common complication (n=10) and associated with female gender (p= 0.039), high BMI (p=0.017), shorter preoperative (p=0.039) and longer postoperative LOS (p=0.022). Three of 46 patients and four of 38 had graft occlusion at 30 days and one year respectively.ConclusionPre-operative co-morbidity (e.g., BMI reduction), and MRSA screening optimization and SAP are areas identified for improvement.

Background: Implementation strategies are needed to ensure that evidence-based healthcare interventions are adopted successfully. However, strategies are generally poorly described and those used in everyday practice are seldom reported formally or fully understood. Characterising the active ingredients of existing strategies is necessary to test and refine implementation. We examined whether an implementation strategy, delivered across multiple settings targeting different stakeholders to support a fall prevention programme, could be characterised using the Behaviour Change Technique (BCT) Taxonomy. Methods: Data sources included project plans, promotional material, interviews with a purposive sample of stakeholders involved in the strategy's design and delivery and observations of staff training and information meetings. Data were analysed using TIDieR to describe the strategy and determine the levels at which it operated (organisational, professional, patient). The BCT Taxonomy identified BCTs which were mapped to intervention functions. Data were coded by three researchers and finalised through consensus. Results: We analysed 22 documents, 6 interviews and 4 observation sessions. Overall, 21 out a possible 93 BCTs were identified across the three levels. At an organisational level, identifiable techniques tended to be broadly defined; the most common BCT was restructuring the social environment. While some activities were intended to encourage implementation, they did not have an immediate behavioural target and could not be coded using BCTs. The largest number and variety of BCTs were used at the professional level to target the multidisciplinary teams delivering the programme and professionals referring to the programme. The main BCTs targeting the multidisciplinary team were instruction on how to perform the (assessment) behaviour and demonstration of (assessment) behaviour; the main BCT targeting referrers was adding objects to the environment. At the patient level, few BCTs were used to target attendance. Conclusion: In this study, several behaviour change techniques were evident at the individual professional level; however, fewer techniques were identifiable at an organisational level. The BCT Taxonomy was useful for describing components of a multilevel implementation strategy that specifically target behaviour change. To fully and completely describe an implementation strategy, including components that involve organisational or systems level change, other frameworks may be needed.