The effects of calculating and communicating to General Practitioners a Drug Burden Index (DBI) in elderly patients discharged from the Emergency Department- a pilot study

Name of intervention: Drug Burden Index (DBI) tool The initial stage of this study (the pre-intervention phase) will assess the extent of multiple medication use within the RNSH ED patient cohort. This will be accomplished by conducting an audit of medication use amongst the study cohort. A sequential sample of 250 patients who are over the age of 65 years, without significant cognitive impairment (ie Six Item Screener score of >4), who have presented to the ED and have been discharged to home, will be selected. Patient records relating to that ED presentation will be scrutinised and information regarding medications taken will be extracted for analysis. The data to be collected is detailed in the ‘Data collection’ section below. Intervention phase: subject to confirmation from the audit that polypharmacy is indeed a concern, the study will then evaluate the benefits, if any, of communicating elderly patients’ Drug Burden Index scores to their GPs. We will use convenience sequential sampling to recruit our study population. The study will run for 12 months. Recruiting will be continuous throughout the first six months of the study or until the target sample size of 250 participants is achieved, whichever occurs first. The pre-audit will be conducted by a Research Pharmacist (RP). Potential participants will be approached by the RP after the decision has been made to discharge them to home. The RP will introduce him/herself and ask the patient if they are interested in hearing about a research project which they could potentially participate in. The RP will give a short verbal explanation of the project, and if the person indicates that they are interested, will provide the potential participant with an information sheet and consent form. The RP will go through these documents with the person if required and will answer any questions about the project. If the person decides to participate they will be requested to sign the Consent form. It will be made clear to all potential participants that their participation is entirely voluntary, can be withdrawn with no consequences at any time, and that their care will be completely unaffected by their decisions in this matter. We will calculate a DBI for all elderly patients who present to the ED prior to their discharge home. All patients discharged from Australian EDs are required to be given a Discharge Referral Note (DRN) documenting their ED assessment and treatment. The DRN is also transmitted electronically to the patient’s nominated GP and it is feasible to e-attach the ED-calculated DBI to the patient DRN. In addition, we will follow-up consenting patients by telephone one month and six months after their discharge from ED to ascertain whether their GPs have acted upon the DBI information in their patients’ DRN. We will then attempt to re-calculate repeat DBIs to compare against the ED-calculated value, and thus gain insights into how effective and sustainable the DBI/DRN approach is in influencing GP prescribing behaviour. Data collection: Pre-intervention phase: The following data will be collected: Medical Record Number (MRN), Age, Gender, Presenting problem(s), any relationship of presenting problems to medications taken, the number of presentations during a) the previous month and b) the previous year; and the generic names and 24-hour dosage of medications with: Anticholinergic, Sedative, or Vasodilating properties, beta or calcium channel blockers, and analgesics. These data will be collated by a Doctor or Research Pharmacist from First Net. The pre-intervention phase will be conducted subject to a waiver of consent Intervention phase: Data collection point 1: collate information collected as part of routine ED procedures regarding participants’ prescribed medications, record reason for ED presentation Data collection point 2: collect information on participants’ prescribed medications during first (1 month post-discharge) telephone interview Data collection point 3: collect information on participants’ prescribed medications during second (6 month post-discharge) telephone interview, and information regarding having been re-admitted to an ED. The burden of each individual medication (B) is calculated by the following equation: B = D/(d + D) where: D is the daily dose taken by the subject, and d is the minimum efficacious daily dose. . For each medication, the drug burden can range from 0 to 1. A value of 0.5 indicates the dose to be the minimum recommended daily dose. The Burden, B, may be due to effects associated with anticholinergic drugs (BAC) or sedative drugs (Bs), respectively. The Drug Burden Index is defined as the sum of the burdens of the anticholinergic and sedative properties of medications (Hilmer 2009). Assuming that the anticholinergic and sedative effects of different drugs are additive in a linear fashion, it is postulated that BAC and BS are proportional to a linear additive model of pharmacological effect. Therefore, Total Drug Burden (DBI) = BAC + BS where: BAC and BS each represent the linear additive sum of D/(d + D) for every anticholinergic or sedative drug to which the subject is exposed. And: D is the daily dose taken by the subject: and d is the minimum efficacious daily dose. DBI results can be categorised as low-, medium-, or high-range. The latter two categories are associated with the most adverse effects and indicate that the patient’s prescribed medications should be reviewed with the aim of removing unnecessary medications and making other adjustments as appropriate. For this study, a low (individual) drug burden is defined as <0.5, a ‘medium’ is defined as between 0.51 and 1.0 and high drug burden is defined as more than or equal to 1.01. This study will run for 12 months. The pre-intervention phase will commence in July 2017 and will be completed within that month. Recruiting for the intervention phase will commence in August 2017 and will be ongoing until 250 participants are recruited, or until the end of January 2018, whichever occurs first. Follow-ups will occur from the beginning of September 2017 until the completion of the project in July 2018.