Aili Veronica Langford

Introduction: Equity is recognised in the decision‐making within Australian health technology assessment (HTA), although limited studies describe how these considerations are operationalised in practice. We aimed to explore the experiences and views of a range of HTA actors, to understand how equity is considered in HTA processes. Methods: Semi‐structured interviews were conducted with 21 participants including sponsors, members of patient or consumer representative groups, non‐government organisations and interest groups, economists preparing or assessing HTA submissions and people in government‐appointed roles, including HTA committee members. Interview transcripts were analysed using reflexive thematic analysis. Results: Reflexive thematic analysis produced three overarching themes. Firstly, equity can be considered in decision‐making, but its role is not transparent, and equity meaningfully impacts decision‐making in few circumstances. Secondly, there are institutional, ideological and methodological challenges that impede the consideration of equity in HTA. Ambiguous guidance and public summary documents mean the inclusion, evaluation and appraisal of equity‐relevant information depends on the individual, creating inconsistency. In the absence of a clear equity definition, HTA actors frame equity in ways that serve their own purposes, creating confusion and tension within a reactive process. Decision‐makers face a dilemma between evidence‐based medicine paradigms, which predominate, and patient or lived experience evidence. Limited knowledge of public values on equity priorities constrains decision‐maker ability to integrate equity concerns into recommendations. Thirdly, HTA actors express a preference for incremental and pragmatic HTA reform. They wish to maintain a deliberative approach to decision‐making with qualitative equity information but see scope to adopt strategies such as Citizens' juries or case studies trialling the use of equity‐informed economic evaluations. Conclusions: This study constructed a detailed understanding of how equity is considered by HTA actors, the challenges faced, and generated potential strategies to better consider equity in Australian HTA.

Background: Insomnia is common in people living with dementia and older adults. While clinical guidelines recommend non-pharmacological treatment as first-line therapy, insomnia is often managed with benzodiazepine receptor agonists (BZRAs), which carry a significant risk of medication-related harm. Objective: To explore what influences decisions to engage with pharmacological and non-pharmacological insomnia treatments among older adults, people living with dementia and their carers. Methods: Semi-structured interviews were conducted with three participant groups (people living with dementia, their carers, and older adults). The interviews were conducted and transcribed in Zoom. Participants identified and prioritized factors that influence their treatment decisions. Thematic analysis was conducted in NVivo to generate themes that described how participants’ beliefs and experiences influenced their preferences. Results: From 19 interviews with 20 participants (Median age range = 65–74 years, 37% female), 14 factors were identified. Risk of side effects (n = 10) and effectiveness (n = 7) were most commonly prioritized and frequently reported across all participant groups. Medication side effects on cognition and daytime sedation were frequent concerns. Underpinning these factors were five main themes determined from thematic analysis, including: beliefs about sleep and insomnia, treatment expectations and experiences, external influences, treatment characteristics, and barriers to treatment. Conclusions: Decisions about insomnia treatments are influenced not only by expected and/or experienced treatment effectiveness, but also by perceived risks and health beliefs. Integrating these perspectives into clinical decision-making may help reduce medication-related harm and promote safer, acceptable alternatives.

Background: Clinical guidelines routinely contain recommendations about initiating therapies, but less frequently address deprescribing ( medication dose reduction or discontinuation ). Routine integration of deprescribing recommendations into guidelines may enhance their reach, adoption, and impact. Objective: To elicit the perspectives of Australian healthcare professionals on the preferred content, language, and format of deprescribing recommendations for inclusion in clinical guidelines. Design: A qualitative study using semi-structured interviews. Participants: Twenty-four medical doctors, pharmacists, and registered nurses were interviewed. Approach: Open-ended questions on what constitutes a complete, clear, and implementable deprescribing recommendation were posed. Participants were asked to identify features of example deprescribing recommendations that they found to be useful or not, justifying their reasoning. A thematic framework analysis was conducted using the Guideline Language and Format Instrument (GLAFI). Key Results: Three overarching themes were generated. Theme 1— a higher content and evidentiary threshold for deprescribing recommendations compared to prescribing recommendations —reflected participants’ perceptions that deprescribing is more complex than medication initiation. Consequently, a higher standard for what constitutes an acceptable, feasible, and clinically useful deprescribing recommendation was described. Theme 2— balancing clarity and comprehensiveness —explored the tension between participants’ desire for succinct and uncomplicated recommendations, and their want for detailed and comprehensive deprescribing instruction. Theme 3— optimizing the location of deprescribing recommendations —explored differing preferences on the location of deprescribing recommendations, with some participants favoring co-location with prescribing recommendations to promote proactive deprescribing, and others preferring a standalone section to enable inclusion of broader deprescribing principles and strategies, beyond medication-specific advice. Conclusions: Healthcare professionals considered the content, language, and format of deprescribing recommendations to be intrinsic to implementability. Deprescribing-specific factors, particularly the operational complexity of how to deprescribe and risk-framing considerations, extended beyond GLAFI’s principles. These findings highlight opportunities to improve future deprescribing recommendations and to strengthen implementability frameworks for de-implementation.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The primary objective is to assess the effects of implementation interventions aimed at improving the uptake of evidence‐based opioid deprescribing by healthcare professionals for adults with chronic non‐cancer pain, compared with no intervention. The secondary objectives are: To explore whether the effects vary by intervention type (e.g. audit and feedback), target (e.g. healthcare organisations), setting of implementation intervention (e.g. primary care) and duration of opioid use (e.g. < 12 months, ≥ 12 months). To summarise the availability and principal findings of eligible economic evaluations of the implementation interventions.

Deprescribing, the patient-centered process of reducing or stopping a medication when the potential harms outweigh the likely benefits, has emerged as a promising strategy to mitigate opioid-related harm. Typically, opioid deprescribing occurs at the individual level, however, adopting a policy-driven approach could expand its reach and impact. To date, prescription opioid control policies that have been implemented with the intention of reducing opioid use and harm have often resulted in unintended consequences. In this article we discuss whether and how the concept of opioid deprescribing can be operationalized at a policy level. We review the goals, challenges and consequences of opioid control policies, explore how they intersect with system-level factors, and propose pathways for developing and implementing future opioid deprescribing policies. We argue that the development and implementation of patient-centered opioid deprescribing policies are both essential and feasible, if key challenges such as structural stigma and the complex interplay between pain and opioid use disorder are recognized and addressed. Robust evaluation frameworks will also be critical for monitoring outcomes and refining interventions. By prioritizing patient and provider needs, and carefully considering pertinent system-level factors, policymakers may be able to foster more effective and compassionate opioid management and reduce opioid-related harm.