Abstract
BackgroundInappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients’ priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.MethodsThe study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older.Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward’s discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines.Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients’ quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.DiscussionSo far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.Trial registrationISRCTN, ISRCTN18427377. Registered 11 January 2018
Highlights
Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients
Interventions to reduce polypharmacy—which exist in variable grades of complexity, feasibility and dissemination—have so far mainly been adopted by specialists like geriatricians or pharmacologists but are not widely used at the crucial interface between hospital physicians (HPs) and general practitioners (GPs) [12,13,14,15,16,17,18]
This is surprising given that suitable discharge interventions have the potential to considerably reduce readmission rates and extend readmission times: studies have shown reductions of 30-day readmission rates between 15% and 50% [19, 20], and a recent systematic Cochrane review demonstrated a relative risk reduction of 13% (RR 0.87; 95% Confidence interval (CI) 0.79–97) for readmission after planned discharge interventions [21]
Summary
Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. Interventions to reduce polypharmacy—which exist in variable grades of complexity, feasibility and dissemination—have so far mainly been adopted by specialists like geriatricians or pharmacologists but are not widely used at the crucial interface between hospital physicians (HPs) and general practitioners (GPs) [12,13,14,15,16,17,18] This is surprising given that suitable discharge interventions have the potential to considerably reduce readmission rates and extend readmission times: studies have shown reductions of 30-day readmission rates between 15% and 50% [19, 20], and a recent systematic Cochrane review demonstrated a relative risk reduction of 13% (RR 0.87; 95% CI 0.79–97) for readmission after planned discharge interventions [21]. Time to readmission could be extended by one third (from 12 to 18 days) in a frail population of older adults (≥ 60 years) by a transitional care program [22]
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