Baseline characteristics of older patients with significant polypharmacy recruited to the SPPiRE trial.

Problem

Supporting prescribing in older patients with multimorbidity in Irish primary care (SPPiRE) is an ongoing cluster randomised controlled trial that was designed to evaluate the effectiveness of an individualised web guided medication review in reducing potentially inappropriate prescribing and polypharmacy. The population under investigation are adults in primary care aged ≥ 65 years who are prescribed ≥ 15 medicines. This cohort was targeted as a national Irish dispensing database indicated that approximately 5% of Irish adults aged 65 years and older are on ≥15 medicines and the first nationally published multimorbidity guidelines in the UK recommended targeting patients on ≥15 medicines as they are at particular risk of adverse medication related events. The aim of this study is to describe patient uptake rates for the SPPiRE trial and to describe baseline characteristics of this population.

Approach

Quantitative data collected for the purpose of the trial’s CONSORT participant flow is summarised using descriptive statistics. Patient characteristics including demographics and patient reported outcome measures (PROMs) obtained from baseline questionnaires are presented using descriptive statistics.

Findings

Between April 2017 and December 2019, 3,113 patients from 74 practices were identified by running a patient finder tool; 1,790 of these were deemed eligible to participate giving an eligibility fraction of 57.5%. The most common exclusion criteria were nursing home residents and those cognitively unable to participate. Of the 1790 eligible patients, 422 were ultimately recruited and randomised, giving an enrolment fraction of 23.6%. Fifty-two patients from 23 different practices were excluded prior to randomisation as the practices failed to recruit a sufficient number of participants. The mean age of recruited patients was 76.5 years (SD 6.8 years) and 58.4% were female. The average number of self-reported GP visits over the previous year was 8.5 visits per person (SD 7.1) and 22% of patients reported seeing their GP at least once per month. With respect to health related quality of life (EQ-5D) scores a sizeable proportion reported scores in the severe or extreme impairment domains for mobility (27%), activities of daily living (25%) and pain (29%). The median score on a multimorbidity treatment burden questionnaire was 16 (IQR 8) which represents a medium treatment burden.

Consequences

Providing evidence based care for patients with multimorbidity is challenging, given their heterogeneity but also given that they are frequently excluded from clinical trials, however recruitment in this population who have complex multimorbidity has particular challenges. The process was slow and involved significant time input from recruited GPs and study personnel and almost a third of these practices were ultimately excluded as they failed to recruit a sufficient number of patients. Baseline data suggests that recruited patients have a significant disease and treatment burden.