Team Approach to Polypharmacy Evaluation and Reduction for General Practice patients: the Australian TAPER (AusTAPER) study

Participants in the intervention group will receive the The Team Approach to Polypharmacy Evaluation and Reduction (TAPER) intervention. TAPER is a structured pathway for a comprehensive medication review by the pharmacist and general practitioners (GPs) with input from the patient aimed at reducing medication burden. The ‘Team’ in this intervention model refers to the patient, pharmacist and GP. The focus is on maintaining essential drugs while supporting potential reduction in medicines that are: (i) having an adverse effect, (ii) risk outweighs benefit, (iii) medications that are no longer of benefit or reasons for talking them are unclear and (iv) potential medication benefit that is no longer aligned with goals of patient. TAPER uses a web-based application (available at https://meds.tapermd.org) to facilitate the decision making process. TaperMD performs a ‘machine screen’ comprising a drug-drug interaction checker and listing of potentially inappropriate medicines. TaperMD also provides links to existing evidence-based tools providing Numbers Needed to Treat/Harm, decision aids for deprescribing and where available, and tapering guidelines. The key steps for TAPER are: 1. Study pharmacist consultation: The participant will be engaged in a medication-focused interview with a study pharmacist. Information will be collected about medications taken, dosages, indications for medications and other mediation-related information if available, any perceived or known medicine problems or side effects, prioritised functional and symptom goals for medical treatment, and overall preferences for care. This data will be entered directly into TaperMD. Through application of automated filters within the TaperMD program, a list potentially inappropriate medications, medication interactions and warnings will be identified and flag medications which are candidates for discontinuation or dose reduction. The study pharmacist will then carry out a comprehensive medication review and engage the participant in a discussion about medications suitable for discontinuation or dose reduction informed by this list, reported medication-related adverse effects and the participant’s goals for treatment. The study pharmacist will then make recommendations (referred to as the preliminary plan) based on the discussion and comprehensive medication review, and add these to the TAPER clinical pathway. This preliminary plan, all supporting information and the machine screen dashboard data will be available to the participant's GP for review. The study pharmacist will make an appointment with the GP to discuss the recommended TAPER plan prior to the GP meeting with the patient/participant, if the GP is available/wishes to do so. 2. GP consultation: Approximately one week (and less than 2 weeks) after the study pharmacist/participant meeting, the participant will have an appointment with their GP to discuss medications that may be suitable for a ‘pause and monitor’ trial of discontinuation or dose reduction as described in the preliminary plan. The GP will have available the pharmacist generated accurate medicine list with flagged recommendations and evidence and tools to support deprescribing linked to the TaperMD program. The GP may modify or add information to the TAPER plan if necessary. S/he will discuss the participant’s priorities and preferences for care, and these will inform a prioritised medication plan for appropriate discontinuations and a template for monitoring frequency, duration and criteria for medicine recommencement. If medications have been prescribed by a specialist, the GP/study pharmacist will follow their usual clinical process for seeking specialist advice if appropriate. If the participant wishes to have a support person present, a relative or carer can be present at this interview. The prioritised medication plan will be cut and pasted into participant’s record in the GP’s eMR using the TAPER Snapshot function. The TaperMD software can then be used to record the planned monitoring parameters and track progress of the TAPER medication withdrawal plan during subsequent follow-up consultations, as a seamless clinical and decision support pathway. 3. Review and then ‘pause and monitor’ discontinuation: Follow-up appointments will be made as clinically indicated by monitoring and follow-up needs of individual participants. It is anticipated these will occur 2 weeks after any new medication changes but will be ultimately be at the GP’s discretion. If there are no changes being made to a person's medications, then the timing of monitoring visits will be determined by the GP and participant. At each monitoring visit, participants will have a brief GP consultation to review progress with the TAPER plan, and address any concerns as clinically appropriate.