How can policies impact the relational process of deprescription in specific territories? A realist review protocol with an initial theory. Authors

Jean Macq ^1,2* Maria Lopez Toribio ^1,2 Anne Spinewine ^1,3

• ¹ Université Catholique de Louvain, Louvain-la-Neuve, Belgium
• ² IRSS - Research Institute of Health and Society, Brussels, Belgium
• ³ CLIP - LDRI - UCLouvain, Brussels, Belgium

Reducing low-value care by deprescribing is a priority. However, current policies often fail due to healthcare provider resistance, lack of incentives, and poor patient engagement. We believe this is due to insufficient focus on the relationships between key agents in the deprescribing process, making 'one-size-fits-all' interventions ineffective.Our goal is to understand 'how, why, for whom, and in what contexts' policies affect large-scale deprescribing.To achieve our research aim, we propose an inductive an abductive and retroductive phases.The inductive phase involved an exploratory review of the literature, leading to the development of an initial theory presented in this article. The initial theory includes three interconnected hypotheses:(a) the success of deprescription depends on the behaviors and interactions of specific agents within the deprescription process. (b) These interactions are influenced by power and trust dynamics, creating either a vicious or virtuous causal loop. (c) The impact of policy on the deprescription chain depends on its ability to address the diversity of the deprescription process and the agents within a given territory, considering dimensionality, ruggedness, and context-specificity.The abductive phase will test the initial theory's applicability, while the retroductive phase will propose new mechanisms to update it. This forms the core of our realist literature review. After screening, selected articles will assess how well the initial theory explains policy impacts on the deprescription process in specific context. Our article analysis will combine semantic and latent content analysis for the abductive phase, and retroductive analysis. Finally, we will compare the updated theory with existing frameworks.The ultimate purpose of this study is to guide policymakers by providing a framework for informed decision-making before implementing large-scale deprescription policies. Its originality lies in emphasizing the relational nature of the deprescription process and examining policy implementation through the lens of complexity.