Abstract
BackgroundMedication safety for older persons represents an ongoing challenge. Inappropriate prescriptions – those with a high risk of evidence-based harm – persist in up to 25 % of seniors, and account for a significant proportion of avoidable emergency department visits. This project is the sequel to the EMPOWER study, in which a novel consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of benzodiazepine de-prescription resulted in a 27 % reduction of inappropriate benzodiazepine use at 6-month follow-up (number needed to treat (NNT) = 4). Failure to discontinue in the EMPOWER study was attributable to re-emerging symptoms among participants, prescribing inertia, and lack of knowledge and skills for substituting alternate therapy among physicians and pharmacists. To maximize de-prescription of inappropriate therapy, educational medication-risk reduction initiatives should be tested that simultaneously include patients, physicians and pharmacists. The objective of this trial is to: 1) test the beneficial effect of a new de-prescribing paradigm enlisting pharmacists to transfer knowledge to both patients and prescribers in a 2-pronged approach to reduce inappropriate prescriptions, compared to usual care and 2) evaluate the transferability of the EMPOWER study concept to other classes of inappropriate prescriptions.MethodsWe intend to conduct a 3-year pragmatic cluster randomized parallel-group controlled trial to test the effect of the new de-prescribing intervention compared to usual care for reducing 4 classes of inappropriate prescriptions from the 2012 Beers criteria among 450 community-dwelling older adults with polypharmacy. Inappropriate prescriptions will include benzodiazepines, sulfonylurea hypoglycemic agents, first generation antihistamines and non-steroidal anti-inflammatory drugs. The study population is community-dwelling older adults recruited from community pharmacies in Quebec, Canada. The intervention was developed based on a systematic review of the evidence for each medication. Participants in the experimental group will receive the written educational program following randomization and have their pharmacist send their physicians an evidence-based pharmaceutical opinion to recommend de-prescription and be followed for a year. The control group will be wait-listed for 6 months.DiscussionSystem change to effectively reduce medication risk among community-dwelling seniors requires a coordinated approach targeting physicians, pharmacists and patients. This trial will test the feasibility and effectiveness of a tripartite approach to de-prescribing.Trial registrationRegistered via ClinicalTrials.gov on 31 January 2014, identifier: NCT02053194.
Highlights
Medication safety for older persons represents an ongoing challenge
In a previous study [15], we developed and tested a consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of safer prescribing practices
This resulted in a 27 % discontinuation rate in the intervention group independent of patient factors [15] and EMPOWER provided proof of concept that directly targeting consumers as drivers of safer prescriptions can be effective for reducing medication risk
Summary
Inappropriate prescriptions – those with a high risk of evidence-based harm – persist in up to 25 % of seniors, and account for a significant proportion of avoidable emergency department visits This project is the sequel to the EMPOWER study, in which a novel consumertargeted written knowledge transfer tool aimed at empowering older adults to act as drivers of benzodiazepine de-prescription resulted in a 27 % reduction of inappropriate benzodiazepine use at 6-month follow-up (number needed to treat (NNT) = 4). In a previous study [15], we developed and tested a consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of safer prescribing practices This resulted in a 27 % discontinuation rate in the intervention group independent of patient factors [15] and EMPOWER provided proof of concept that directly targeting consumers as drivers of safer prescriptions can be effective for reducing medication risk
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