Effect of a multifaceted intervention on potentially inappropriate prescribing in older patients in primary care: a cluster randomised controlled trial (the OPTI-SCRIPT study)

The problem

Potentially inappropriate prescribing (PIP) (use of medicines that introduce a greater risk of adverse drug-related events where a safer, as effective alternative is available) is common in older people and can result in increased morbidity, adverse drug events and hospitalisations. The prevalence of PIP in Ireland in those aged ≥ 70 years is 36% with an associated expenditure of over €45 million. The aim of this study is to determine the effectiveness of a multifaceted intervention in reducing PIP in Irish primary care.

The approach

A cluster randomised controlled trial (RCT) was conducted with 21 GP practices based in the greater Dublin area and 196 patients, all of whom were identified as having PIP. Practices were allocated using minimization to intervention or control arms after baseline data collection. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provided recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level 

feedback on PIP. The primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions. Secondary outcomes included incidence rates of drug-specific outcomes, well-being and beliefs about medication. Routinely collected national Irish prescribing data were also analysed, acting as an additional contemporary national comparison.

Findings

All 21 practices and 190 patients were followed up (6 patients were lost). At intervention completion, there was a significant reduction in the proportion of patients in the intervention group with PIP compared to control (OR 3.06 95% CI 1.43, 6.53). The average PIP in the intervention group was also significantly lower than control (0.70 v 1.19 p=0.004). In the control group, the incidence rate for PIP was 1.42 times the incidence rate for the intervention group. The intervention had a statistically significant effect in reducing proton pump inhibitor (PPI) prescribing but not on the other PIP drug-specific secondary outcomes. There was no difference in patient self-reported outcomes of well-being and beliefs about medication. Analysis of national prescribing data indicated that nationally PIP increased during the study period. A process evaluation highlighted that patient information leaflets were not used at all.

Consequences

The study found that a multifaceted intervention incorporating academic detailing with a pharmacist and medicines review with web-based pharmaceutical treatment algorithms that provide alternative treatment options is effective in reducing PIP in primary care. This reduction in PIP was attributable to reduction in PPI prescribing. Implementing a system of structured reviews for older patients with PIP in Irish primary care may be effective but formal resourcing of such services would need to be considered.