Are two GPs better than one? Feasibility of an implementation intervention to support medication review in patients with multimorbidity

Problem

Multimorbidity is common in general practice, and is associated with polypharmacy and preventable drug-related morbidity. Despite such risks, general practitioners (GP) may avoid actively reviewing or rationalizing medications for multimorbid patients. To support better medication management in multimorbidity, we used behavioural theory and the findings of our original systematic review and qualitative study to develop an implementation intervention called MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE). Implementation interventions aim to improve patient care by promoting the uptake of best practice recommendations. In this study, we assessed the acceptability and feasibility of the MY COMRADE intervention in general practice.

Approach

The feasibility study was conducted with pairs of GPs, purposively sampled from continuing professional development meetings (CPD) in County Cork, Ireland. We asked each pair of GPs to conduct medication reviews on six patients that were prescribed at least ten regular medications, using the MY COMRADE approach. MY COMRADE utilizes five behaviour change techniques to support medication reviews: i) action planning of medication review; ii) allocation of protected time to conduct review; iii) collaboration by two GPs to conduct the review (peer support); iv) a prescribing checklist; and v) allocation of self-incentives (CPD points). Participating GPs’ experiences of the intervention were evaluated in qualitative interviews and the framework method was used to guide qualitative analysis.

Findings

Twenty GPs participated in the study. The median number of MY COMRADE medication reviews per pair was four (interquartile range 3-5.75). The use of peer support to implement medication review was acceptable to GPs and for many it was compatible with their usual behaviour in practice. In every collaborative review, GPs reported that recommendations for optimising medications and patient safety arose. The majority of recommendations involved deprescribing medications for which there was no apparent indication or no expected benefit. Many GPs felt that the collaborative, peer-supported approach to medication review would be time saving in the long-term, but a minority felt that the time implications of the intervention worked against its sustainability.

Consequences

This work responds to the call for interventions to support patient-centred prescribing in multimorbidity. Applying theory to empirical data has led to a novel intervention which has the potential to positively change GPs’ behaviour. The collaborative, peer-supported approach to medication review was acceptable to GPs, was compatible with a range of practice contexts, and consistently led to the generation of recommendations for medication optimisation. This feasibility study demonstrates the need for a larger scale trial of effectiveness of MY COMRADE, with respect to downstream outcomes such as treatment burden, medication-related morbidity and health care utilisation.