Supporting prescribing in older patients with multimorbidity and significant polypharmacy in Irish primary care (SPPiRE): a cluster randomised controlled trial protocol

Problem

Multimorbidity and polypharmacy are becoming more prevalent as our population ages. Half of people aged over 65 years have two or more chronic conditions, and half of those aged over 75 years have three or more. In Ireland in 2012, 5% of people aged over 65 years were prescribed 15 or more regular medicines. This level of multimorbidity and polypharmacy is associated with potentially inappropriate prescribing (PIP) and with adverse outcomes for patients including adverse drug reactions, medication errors, reduced adherence, increased hospitalisation and reduced quality of life. Previous research has shown that a web based medication review can reduce potentially inappropriate prescribing. There is also a growing body of evidence that supports a pragmatic and person centred approach to care for these patients. SPPiRE is a complex intervention comprised of professional education and a web guided structured medication review that will comprise of a prescription screen for PIP and directions to explore the patient’s priorities about treatment. The aim of this study is assess the effectiveness of the SPPiRE intervention in reducing PIP and polypharmacy in older patients with multimorbidity and significant polypharmacy in Irish primary care.

Approach

This study is a cluster randomised controlled trial, involving 30 general practices and 450 patients throughout Ireland. Practices will recruit older patients who are being prescribed at least 15 regular medicines and will then be randomised using minimisation to either intervention or control. All GPs will use a software tool to identify patients through the electronic health record. GPs in intervention practices will receive login details to a website where they will access a training video and a template for conducting a structured medication review, which they will undertake with each of their included patients. Control practices will deliver usual care over the six month study period. Primary outcome measures are the proportion of patients with any PIP and the number of repeat medicines. Secondary outcome measures include patient reported outcomes of quality of life and treatment burden.

Findings

Practice identification is ongoing at the time of writing and recruitment will begin at the end of February 2017.

Consequences

Patients with multimorbidity have frequently cited polypharmacy as a major concern. GPs caring for these patients have reported concern about the disorganisation and fragmentation of care. This pragmatic study is evaluating a generic intervention that is relevant across multiple medical conditions and will provide structure for GPs in rationalising medicines for this diverse and complex group of patients. At present there is no provision for a medicines review in the general medical services scheme (GMS) in Ireland. A parallel mixed methods process evaluation will explore the potential for system wide implementation of the SPPiRE intervention.