AusTAPER Pilot: Team Approach to Polypharmacy Evaluation and Reduction A pilot study for older patients in General Practice

Feasibility of implementing a practical guidance that fosters teamwork and integration in primary care between dispensing community pharmacists and GPs to address polypharmacy in older people Intervention (TAPER) TAPER is a web based application (available at eg. https://meds.tapermd.org) which can be used as a generic tool for a collaborative medication review between patient, GP and community pharmacist. At an initial consultation between the study pharmacist and the participant, data will be entered on the participant’s medications, dosages and indications; any reported side effects; the participant’s priorities and preferences for treatment; and medication-related data such as blood pressure and creatinine (if known). Using the medication history, participant’s preferences for care and perceived medical problems, the TAPER App tool performs a ‘machine screen’ comprising i) interaction checker; and ii) listing of potentially inappropriate medicines (including the Screening Tool of Older Person's potentially inappropriate Prescriptions, the Beers List, anticholinergic & serotonergic burden, and QT prolonging drugs). This screen is also supported by existing evidence based resources providing Numbers Needed to Treat/Harm, and decision aids for deprescribing where available, and tapering guidelines. The focus is on maintaining essential medicines while supporting reduction in medicines known to be associated with adverse reactions causing emergency presentation and/ or unplanned admission to hospital, and those in which risk frequently outweighs benefit (eg anticholinergics, sedatives, opiates, proton pump inhibitors). Decisions will be informed by the individual participant’s priorities, including functional and symptom treatment goals. A preliminary plan is produced by TAPER, based on information collected at the baseline assessment, and after this initial consultation between the study pharmacist and participant. This plan is then further refined with a consultation between the GP and participant. In this step, the GP may use the TAPER tool to enter new information or modify information already in TAPER. A prioritised medication plan is created at this stage. The emphasis is on ‘pausing and monitoring’ medications with planned follow-up and agreed criteria for restarting medications if necessary. The GP can discuss the plan and any concerns with the study pharmacist if required. The TAPER medication withdrawal plan is then used to record the planned monitoring parameters and track progress during subsequent follow-up consultations, as a seamless clinical and decision support pathway. The key steps (in detail) for TAPER are: 1) Study pharmacist consultation: The participant will be engaged in a face-to-face medication-focused interview with a study pharmacist (around 15-20mins). This will usually be conducted at the person’s home, as this is where people feel most comfortable and the most accurate medication histories are undertaken. If the participant wishes to have a support person present, a relative/person responsible/carer or advocate can be present at this interview. Information will be collected about medications taken, indications for medications and other medication-related information if available (such as blood pressure creatinine, falls history), prioritised functional and symptom goals for medical treatment, overall preferences for care (using a tool covering 4 domains developed from our systematic review and participant focus group feasibility work) and perceived medicine problems or side effects. The medication data and this information will be entered into the TAPER app. Through application of automated filters within the TAPER App, potentially inappropriate medications, medication interactions and warnings will be identified and flag medications which are candidates for discontinuation or dose reduction. 2) The study pharmacist will then carry out a comprehensive medication review focused on medications suitable for discontinuation or dose reduction informed by this list, reported medication-related adverse effects from the participant, and reviewing the participant’s goals for treatment. The study pharmacist will make recommendations based on this review and add these to the TAPER clinical pathway. This information, including all the supporting information and the machine screen dashboard data will be available to the clinic GP for review at their consultation, and will also be cut and pasted into the community pharmacist’s record, to avoid double data entry (TAPER Snapshot). The TAPER Snapshot format is structured to allow for integration into any clinical records software package. 3) GP consultation: The participant will have a face-to-face appointment with their GP to discuss medications that may be suitable for a pause-and-monitor trial of discontinuation or dose reduction. The appointment length may be a standard consultation (around 15-20mins), or extended (depends on the number of medications a person takes/are being targeted). The GP will have available the study pharmacist generated accurate medicine list with flagged recommendations, and evidence and tools to support deprescribing linked to the TAPER App. The GP may modify or add information to the tool if necessary. S/he will discuss the participant’s priorities and preferences for care, and these will inform a prioritised plan for appropriate discontinuations and a template for monitoring frequency, duration and criteria for medicine recommencement. As part of this process, the GP will either endorse or modify the study pharmacist’s recommendations in the tool, review again with the participant and commence the pause-and-monitor deprescribing plan. If medications have been prescribed by a specialist, the GP/study pharmacist will follow the GP’s usual clinical process for seeking specialist advice if appropriate. This approach addresses key barriers to deprescribing, such as fears of a return of the original condition and withdrawal effects. Patients report these can be overcome by knowing about the withdrawal process and understanding they can restart the medication if needed. A person’s participation in the AusTAPER Pilot study will cease once his/her final AusTAPER plan has been agreed. It is anticipated participation will be around 10-12 weeks. The GP/participant may consider implementing the recommendations in the participant’s AusTAPER plan, however follow-up and monitoring of implementation(s) is not within the scope of this Pilot study.