Abstract
BackgroundWe developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews. No effect on the primary outcome was found. This process evaluation aimed to identify factors associated with outcomes by exploring nine hypotheses specified in the logic model of the tailored programme.MethodsThe tailored programme was developed with respect to identified determinants of practice and consisted of a workshop for practice teams, elaboration of implementation action plans, aids for medication reviews, a multilingual info-tool for patients on a tablet PC, posters and brown paper bags as reminders for patients. The tailored programme was evaluated in a cluster randomized trial. The process evaluation was based on various data sources: interviews with general practitioners and medical assistants of the intervention group and a survey with general practitioners of the intervention and control group, written reports on the implementation action plans, documentation forms for structured medication counselling and the log file of the info-tool.ResultsWe analyzed 12 interviews, 21 questionnaires, 120 documentation forms for medication counselling, 5 implementation action plans and one log file of the info-tool. The most frequently reported effect of the tailored programme was the increase of awareness for the health problem and the recommendations, while implementation of routine processes was only reported for structured medication counselling. The survey largely confirmed the usefulness of the applied strategies, yet the interviews provided a more detailed understanding of the actual use of the strategies and several suggestions for modifications of the tailored programme.ConclusionsThe tailored programme seemed to have induced awareness as a first step of behaviour change. Several modifications of the tailored programme may enhance its effectiveness such as conducting outreach visits instead of a workshop, improved targeting, provision of evidence, integration of tools into the practice software and information materials in tailored formats.Trial registrationThis study is linked to an outcome evaluation study with the registration ISRCTN34664024, assigned 14/08/2013.
Highlights
We developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews
Sample The tailored programme (TP) was delivered to primary care practices in one larger area in South Germany that participated in a special care contract of one large German health insurance (HZV AOK Baden-Württemberg) [29] and in “quality circles” comprising small group meetings of General practitioner (GP) of one local area [30]
The inclusion criteria for patients were age >50 years, diagnosis of at least three chronic conditions based on a previously published diagnosis list [31], repeated prescription of four different drugs, high risk for adverse drug reactions (ADR) according to the subjective assessment of the treating GP and mental and physical ability to participate in the study
Summary
We developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews. No effect on the primary outcome was found This process evaluation aimed to identify factors associated with outcomes by exploring nine hypotheses specified in the logic model of the tailored programme. We developed and evaluated a tailored programme (TP) to improve the implementation of recommendations, which address different areas of care: Recommendation A on communication about medication: All patients with polypharmacy and additional risk factors for medication problems should receive structured medication counselling (SMC) at least once per year. A separate appointment should be planned for SMC [9, 10]
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