None listed
Conditions
Brief summary
There is an urgent and growing need to minimise iatrogenic harm from potentially inappropriate polypharmacy (PIP) in ageing populations with multimorbidity. ‘Deprescribing’ aims to minimise PIP. It is the process of clinician-supervised identification and withdrawal (or dose reduction) of medicines where the harms exceed the benefits in the context of an individual patient’s care goals, current function, life expectancy, values and preferences. General practitioners (GPs), with tacit knowledge of, and an ongoing relationship with, their patients, play a central role in coordinating and delivering healthcare to older patients who are prescribed medicines for multiple health conditions. Research suggests that patients are receptive to discontinuing medicines if their general practitioner feels it is appropriate and worthwhile. This study aimed to assess the feasibility, effectiveness and safety of a multi-faceted GP-led intervention to minimise PIP in community-living older Australians. Unlike most other deprescribing studies, this intervention leveraged the existing therapeutic relationship between GPs and their usual patients and used an individually-tailored versus a drug class-specific approach to deprescribing. Recognising the time constraints for GPs in routine care and the potential facilitative role of pharmacists in deprescribing, GPs had the option of referring patients to one of the participating pharmacists for a Home Medicines Review to augment the deprescribing process in this study.
Interventions
The intervention consisted of:
1) one five-hour face-to-face interactive deprescribing training workshop for GPs and accredited pharmacists (i.e. pharmacists accredited to undertake Home Medicines Reviews [HMRs]);
2) a 30-minute face-to-face deprescribing consultation between GPs and their usual patients to undertake a comprehensive review of their medicines (CMR) using a standardised software template co-designed by GPs; (1)
3) Option for GPs to refer patients for an HMR by one of the partic
The intervention consisted of: 1) one five-hour face-to-face interactive deprescribing training workshop for GPs and accredited pharmacists (i.e. pharmacists accredited to undertake Home Medicines Reviews [HMRs]); 2) a 30-minute face-to-face deprescribing consultation between GPs and their usual patients to undertake a comprehensive review of their medicines (CMR) using a standardised software template co-designed by GPs; (1) 3) Option for GPs to refer patients for an HMR by one of the participating pharmacists with full access to the patient’s medical record. The interactive training workshop was facilitated by a consultant general physician with expertise in deprescribing and an accredited pharmacist experienced in CMR. The workshop involved: 1) one-hour didactic presentation of the evidence around potentially inappropriate polypharmacy (PIP) and deprescribing; 2) three-hour interactive session applying principles of the CEASE deprescribing framework (see below) to two case studies, during which evidence summaries and support resources were presented and barriers and enablers to deprescribing in practice were discussed; and 3) one-hour session to co-design a software template for use in deprescribing appointments which reminded GPs when to consider deprescribing a medicine and served as a tool for collecting data on changes to medicines, including their rationales (as per reference 1). CEASE PRINCIPLES(2) • Obtain a best possible medication history • Reconcile medication and diagnosis list & verify indications • Estimate patient risk of adverse drug events • Review utility of each medication • Prioritise targets for deprescribing & formulate agreed plan • Implement and monitor the deprescribing plan The intervention was targeted at the clinician level, with quantitative and qualitative measures gathered at the clinician and patient level. The aspects of the intervention were informed by principles of behaviour change and an awareness of barriers and enablers to deprescribing in primary care which the investigators had identified in previous studies. (3, 4) At all times the patients remained under the care of their usual GP. 1. Anderson K, Foster MM, Freeman CR, Scott IA. A multifaceted intervention to reduce inappropriate polypharmacy in primary care: research co-creation opportunities in a pilot study. Med J Aust. 2016;204(7 Suppl):S41-4. 2. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. 3. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ open. 2014;4(12):e006544. 4. Anderson K, Foster M, Freeman C, Luetsch K, Scott I. Negotiating “Unmeasurable Harm and Benefit”. Qual Health Res. 2017:1049732316687732.
Sponsors
University of Queensland
Study design
Allocation
Non-randomised trial
Intervention model
Other
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
There were three participant groups. 1. General practitioners: Working in primary health care and caring for community living older people with polypharmacy; available to attend a deprescribing training workshop in August or September 2015 (intervention arm only); and working the equivalent of four or more, three-hour sessions per week (to ensure adequate access for patients to their usual GP). While it was intended to recruit a diverse sample of GPs based on age, years of experience and gender balance, it was anticipated that GPs who had been in practice for a longer period may see a higher proportion of older patients compared to more recently qualified GPs. It was therefore accepted that the eligibility criteria may naturally lead to the recruitment of more experienced GPs and this was accepted as a limitation of the study. 2. Pharmacists: Experienced in and/or actively conducting Home Medicines Reviews (HMRs) (5 or more years since attaining accreditation preferred); available to attend a deprescribing training workshop in August or September 2015; willing to travel to provide HMR services to patients of recruited intervention practices. 3. Patients: Active patient of the practice as defined by the Royal Australian College of General Practitioner (RACGP) standards (i.e. had attended the practice three or more times in the past two years) and a regular patient of one of the GPs recruited to the study; aged 65 years or older and living in the community (and not in a Residential Aged Care Facility); taking eight or more regular medicines as listed in the GPs' electronic medical records; capacity to give consent; proficient in speaking and reading English; and contactable by telephone.
Exclusion criteria
1. General practitioners: Primarily caring for people aged 65 years or older with polypharmacy residing in aged care facilities (as this was not the care setting of interest). 2. Pharmacists: Conducting medicine reviews primarily for residents in aged care facilities (as this was not the population of interest). 3. Patients: Confusion, cognitive impairment, mental health disorders with psychosis and/or communication difficulties (as documented or confirmed by the patient’s GP) that would preclude informed consent; terminal illness (life expectancy less than six months); a Home Medicines Review (HMR) in the 12 months prior to recruitment.
Outcome results
None listed