Evaluation of a multi-modal educational package for GP registrars in reviewing older patients’ medication regimens and deprescribing inappropriate medications

The educational package being evaluated is one that is being developed to be incorporated as part of the usual ongoing educational program of a single large Australian general practice vocational training organization. The outcomes in this training package will be compared using data from an ongoing cohort study, The Registrar Clinical Encounters in Training (ReCEnT), (an ongoing cohort study of GP trainees’ in-practice clinical and educational experiences and behaviours), with outcomes from other training organizations which have not incorporated the educational package. Thus, the study can be viewed as observational with evaluation of the educational package being nested within an ongoing cohort study. For the purposes of the ANZCTR format, however, we have classified the study type as Interventional. Similarly, in this document the educational package will be referred to as the ‘intervention’ rather than the exposure. The educational intervention consists of four components. The first two i.e. access to an online introduction module, and a 60 minute face-to-face session, will be delivered to GP registrars (graduate trainees in the Australian specialist GP vocational training program). The third is a webinar for clinical supervisors of these registrars based on the face-to-face presentation. The fourth is an optional joint GP registrar-supervisor education activity, which comprises a case-based discussion of evidence-based deprescribing for each trainee-supervisor dyad in their regular weekly one-on-one teaching meetings. Supervisors will also have pre-webinar access to the online introductory model. Supervisors are experienced GPs who oversee the within-practice education of registrars.. 1.. Online introduction module: The bulk of the background material will be included in the online module to allow a deeper exploration of practical approaches to deprescribing in the face-to-face session. This introduction module will include material on polypharmacy, inappropriate prescribing in older patients, evidence for deprescribing, an introduction to tools for assessing potentially inappropriate prescribing such as the Beer’s criteria and the Drug Burden Index and the role of general practitioners in the implementation of deprescribing. The module will also include a discussion of why polypharmacy is a priority for physicians. This module will take approximately 30-40 minutes to complete. It will contain links to supporting materials. The online module will be made available to registrars to work through individually at a time prior to the face-to-face session. They will be given a time frame of 2-3 weeks in which to complete the module. The module will also be made available to supervisors prior to their webinar.. 2. Face-to-face session: The face-to-face session will consist of a 60-minute educational presentation in a group setting with approximately 450 registrars scheduled as part of the standard training program for GP registrars delivered at GP Synergy, their Regional Training Organisation (RTO). The face-to-face session will be led by a geriatrician. A GP experienced in supervising GP registrars will provide further clinical relevance and expertise. In the face-to-face session, data on GP trainees' deprescribing, collected in the ReCEnT project, will be used to contextualize and reinforce the practical relevance and importance of the educational message (the ReCEnT data will be that of registrars who have participated in ReCEnT during 2016 and 2017). During the session, GP registrars, by means of clinical cases, will work through the main principles of rational deprescribing. Time will be devoted to the practicalities of how to go about deprescribing within a general practice setting, including how to determine if a patient has polypharmacy; determining the risks vs benefits of a continuing or of deprescribing a particular medicine; identifying opportunities for deprescribing; and how to employ a model of deprescribing. Examples tailored to the general practice setting will be provided. Aspects of patient opinion towards deprescribing will be covered as well as barriers inherent within the general practice setting and the registrar’s position within a host practice e.g dealing with older patients whose management the registrar may not usually engage with, and with whom registrars are less likely to have developed a deeper relationship. Collaborative models of registrars and supervisors working together to implement appropriate deprescribing will be promoted. Post-session supporting resources will be available as links in the Deprescribing online module to reinforce the workshop and provide practical resources including guides to deprescribing individual drug classes (e.g. benzodiazepines and anticholinesterases). The workshop session content will be constructed by the research team of GPs, GP vocational training educators, academic GPs, and a geriatrician researcher. The process will be informed by the current literature in the area and our recent work in documenting GP registrars' deprescribing including the prevalence and associations of deprescribing in older patients. 3. Supervisor Webinar: The webinar content will be a more succinct version of the face-to-face workshop session provided to registrars, because supervisors will be more aware of deprescribing and the mechanisms available for practical deprescribing. Supervisors find difficulty in deprescribing in cases where specialists originally established the prescription. Because this is an analogous dyad to that of the registrar-supervisor, approaches to managing the GP-specialist relationship will be covered. The webinar will emphasize potential models of supervisor-registrar collaboration in deprescribing for individual patients. 4. Joint registrar/ supervisor activity: Each registrar-supervisor dyad will be encouraged to include a case-based discussion of evidence-based deprescribing in their regular weekly one-on-one teaching meetings. The supervisor will be offered a set of three or four structured cases to include in the meeting. Other options, such as ‘random case analysis’ or audit of older patients’ clinical notes will be suggested. The joint registrar/ supervisor activity will be optional as the content of registrar-supervisor weekly meetings is at the discretion of the supervisors and registrars rather than the RTO. Who: The Face-to -face session and webinar will be delivered by Professor Sarah Hilmer (Geriatrician with particular expertise in adverse effects of medicines in older patients and in rational deprescribing), supported by an experienced GP supervisor (to be advised). Delivery Mode: Face-to-face delivery + online learning module + online webinar + provision of supporting resources, papers, links to appropriate online material. Number of times: The registrar educational session face-to- face will be delivered as one x one hour session. The supervisor educational intervention via webinar will be delivered as one x one hour session. The online module and supporting resources may be accessed as often as the participant requires. Location: The registrar face-to-face session will be delivered during a routinely-scheduled educational workshop in Sydney. The on-line module will be accessed by registrars and supervisors at sites convenient to them. The on-line webinar will be accessed by supervisors at sites convenient to them. The optional registrar-supervisor teaching session will be held in the practice premises of the particular registrar/supervisor dyad. Strategies used to monitor fidelity/adherence to the intervention: Attendance rolls : Face to face registrar session and supervisor webinar Website analytics ( On-line introduction module) How many registrars and supervisors have accessed the module and how many registrars and supervisors have completed the module will be recorded.