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

Problem

There is a rising prevalence of multimorbidity and polypharmacy, particularly in older patients. There is a need for evidence based medicines management interventions for this population. The SPPiRE trial aimed to assess the effectiveness of a GP-delivered intervention in reducing significant polypharmacy and potentially inappropriate prescribing (PIP) in older people with multimorbidity and significant polypharmacy in Irish primary care.

Approach

We conducted a cluster-randomised controlled trial among 51 practices and 404 patients aged ≥65 years and prescribed ≥15 medicines. Following baseline data collection, practices were allocated using minimisation for location and size. Intervention GPs received online educational support material and conducted web-based individualised medication reviews with participants, including screening for PIPs and identification and management of individual treatment priorities. Control GPs delivered usual care. An independent blinded pharmacist assessed primary outcomes which were the number of medicines and the proportion of patients with any PIP. Secondary outcome measures included medication related measures such as the number of medicines stopped and started and the number of PIP and patient reported outcome measures including health related quality of life, patients’ attitudes towards deprescribing and treatment burden. We performed intention-to-treat analysis using random-effects regression.

Findings

Recruited participants had significant disease and treatment burden at baseline and recruitment was challenging, requiring more time and resource than planned. Participants had a mean age of 76.5 years (SD 6.52), mean number of medicines of 17.21 (SD 3.54) and 93% had at least one PIP. Interim analysis of 90% of patients followed up to date indicated a small but significant reduction in the number of medicines in the intervention group (IRR 0.95, 95%CI; 0.89–0.99, p=0.03). The adjusted odds of having at least one PIP in the intervention versus control group was 0.32 (95%CI; 0.11–0.94, p=0.04), though interpretation of this measure is limited by the low numbers with no PIP, and an inconclusive effect on secondary PIP measures. With respect to secondary prescribing related measures, there was a significant number of medicines stopped (IRR 1.49, 95%CI; 1.18–1.19) and a reduction in the proportion of participants prescribed ≥ 15 medicines (OR 0.32, 95%CI; 0.16–0.62) in the intervention compared to the control group. There was no effect on any patient reported outcome measures, but this was limited by a reduced questionnaire response rate at follow up (56%).

Consequences

Given the challenges recruiting and retaining this patient group, future similar studies could target patients with moderate rather than severe disease burden who may have greater capacity to participate in a medicines review and prioritisation process. While the effect on PIPs is unclear, SPPiRE was effective in reducing the number of medicines, which would have a significant impact at a population level.