Implementing medication review for patients with multimorbidity in primary care: a pilot cluster-randomised controlled trial across two different health care systems on the Island of Ireland

Conference:

SAPC ASM 2021 - virtual

Talk Code:

P1.24.02

Presenter:

Prof Andrew Murphy

Co-authors:

Lisa Hynes1, Collette Kirwan1, Andrew W Murphy1, Nigel Hart2, , Sarah Mulligan3, Claire Leathem4, Laura McQuillan2, Marina Maxwell4, Emma Carr1, Scott Walkin3, Caroline McCarthy5, Colin Bradley6, Molly Byrne7, Susan M Smith5, Carmel Hughes8, Maura Corry9, Patricia M Kearney10, Geraldine McCarthy3, M

Author institutions:

1Health Research Board Primary Care Clinical Trials Network Ireland, National University of Ireland, Galway, Ireland; 2School of Medicine, Dentistry & Biomedical Sciences, Queen’s University, Belfast, Northern Ireland; 3Sligo Medical Academy, National University of Ireland, Galway, Ireland; 4Northern Ireland Clinical Research Network (Primary Care), Northern Ireland; 5HRB Centre for Primary Care R

Problem

While international guidelines recommend regular medication reviews in the management of patients with multimorbidity, evidence on how to implement reviews in primary care is limited. The MyComrade intervention is an evidence-based, theoretically-informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care. This pilot study aimed to evaluate the feasibility of a definitive trial of the intervention across contextual variations in two neighbouring health systems (Republic of Ireland (ROI) and Northern Ireland (NI)).

Approach

A pilot cluster-randomised controlled trial was conducted (clustered at general practice), utilizing pre-specified progression criteria (‘traffic-light system’) for recruitment of practices and patients, retention of practices and patients and intervention implementation. The intervention involved pairs of GPs in ROI, and a GP and Practice-Based Pharmacist in NI conducting joint medication reviews guided by a predetermined prescribing tool. Control practices delivered usual care. Eligible patients were aged over 18 years and prescribed at least 10 regular medications. Data on the number of medication reviews conducted, prescribing outcomes, patient-related outcomes and healthcare utilisation were collected at baseline, 4 and 8 months. Qualitative interviews were conducted with a maximum variation sample of 21 practice staff and 20 patient participants to assess the acceptability and implementation of the intervention.

Findings

Of the 283 practices (44 in ROI, 239 in NI) invited to participate, n=38 (13%) (20 in ROI, 18 in NI) expressed interest and 15 (39%)(8 in ROI, 7 in NI) were eligible and consented to participate. Of 83,364 (33,414 in ROI, 49950 in NI) patients registered at the 15 practices, 1,115 (1.3%) (545 in ROI, 570 in NI) were deemed eligible and invited to participate, from which 121 patients (11%)(76 in ROI, 45 in NI) consented to participate.

Seven practices (4 ROI, 3 NI) were randomised to, received and implemented the MyComrade intervention. At the time of submission, progression criteria were met for practice and patient retention (>80% remained in study ‘green’). Practice recruitment required a longer timeframe (>3months, ‘orange’) and patient recruitment numbers were <50% (‘red’) than stated progression criteria. All sites implemented the intervention as specified and without undue difficulty, indicating fidelity. Additionally, preliminary qualitative analysis demonstrates acceptability and appropriateness of the intervention, indicating feasibility (orange).

Consequences

Despite challenges with practice and patient recruitment, the pilot demonstrated that a definitive trial of the MyComrade intervention is practicable with amendments. When recruited, practices and patients did not find participation unduly burdensome, which is creditable considering caseload vulnerability and the context of the Covid-19 pandemic. The intervention was found to be feasible and acceptable to implement, and promises to be a novel contribution to evidence-based care for patients living with multimorbidity and polypharmacy.

Submitted by:

Collette Kirwan

Funding acknowledgement:

Cross-border Healthcare Intervention Trials in Ireland Network (CHITIN), UK and Ireland. CHITIN is a unique partnership between the Public Health Agency in Northern Ireland and the Health Research Board in Ireland. CHITIN is funded by EU INTERREG VA programme, managed by the Special EU Programmes Body with match funding from the Departments of Health in Northern Ireland and the Republic of Ireland