Abstract
BackgroundOlder people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes.MethodsThis study consists of 2 stages: Stage I – a two-arm parallel-group cluster-randomised clinical trial, and Stage II – process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients’ goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient’s GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS).OutcomesThe primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR.DiscussionThis study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults.Trial registrationThe trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.
Highlights
Older people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events
This study is expected to add to the evidence that the combination of Clinical Decision Support System (CCDSS) supporting medication review can improve prescribing and clinical outcomes in older adults
We hypothesise that the combination of pharmacistled medication review (HMR) and a CCDSS intervention that incorporates validated deprescribing tools and patient-centred guides may reduce the proportion of older adults using anticholinergic and sedative medications and improve clinical outcomes in communitydwelling older adults
Summary
Study design This study will be performed in two stages. Stage I consists of the cluster-randomised clinical trial, and Stage II will be the process evaluation of the implementation of the CCDSS in the HMR service. Goals of careb aat the time of the HMR interview; bonly for patients in the intervention arm of the study PhARIA The Pharmacy Access/Remoteness Index of Australia – quantifies degree of remoteness (geographic and professional) [47], OTC Over-the-counter, PRN when required, MGL Morisky, Green, Levine Scale [48], rPATD revised Patients’ Attitudes Towards Deprescribing [34], rPATDCog Revised Patients’ Attitudes Towards Deprescribing for people with Cognitive impairment [35], DBI Drug Burden Index [28], FCI Functional Comorbidities Index [49], NHCCSFSI National Home and Community Care Services Functional Screening Instrument [50], SPPB Short Physical Performance Battery [51], GP General practitioner ↑↓ = changes diagnosis of dementia and subgroup analyses is planned on these participants [10]. Version 12, 2018) will be used for data management and each patient (or carer) participant will
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