Abstract
BackgroundElders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed.MethodsThis will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER’s processes.ConclusionWe are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement.Trial registrationClinicaltrials.gov NCT03689049; registered September 28, 2018
Highlights
Elders living with polypharmacy may be taking medications that do not benefit them
Common reasons for failure include lack of focus, negative emotions as the project rolls out, lack of influence of the quality improvement (QI) team, uncommitted leadership, and lack of cooperation between key stakeholders [63]. We address these challenges with a network of QI Collaboratives that builds on the Institute for Healthcare Improvement (IHI) Breakthrough Series model [64]
This study enables the identification of persistently complex patients, elders living with polypharmacy, for their family physicians and primary care teams
Summary
Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Complex patients In Canada and the USA, 5% of the population incur approximately two thirds of healthcare costs and are identified as patients with complex care needs [1,2,3,4,5,6,7]. Approaches to addressing care gaps in individuals with persistent complex needs could produce significant improvements in patient wellbeing and reduce healthcare costs
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