Process evaluation of the SPPiRE trial: a GP delivered medication review of polypharmacy, deprescribing and patient priorities in older people with multimorbidity

Conference:

SAPC ASM 2022 - UCLan

Talk Code:

5D.2

Presenter:

Caroline McCarthy

Co-authors:

Caroline McCarthy (1), Ivana Pericin (2), Susan M Smith (1,3), Bridget Kiely (1), Barbara Clyne (1)

Author institutions:

1) HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2 2) School of Social Work and Social Policy, Trinity College Dublin, Dublin 2 3) Department of Public Health and Primary Care, Trinity College, Dublin 2

Problem

More evidence based interventions are needed to improve outcomes for the growing population of older people living with multimorbidity and polypharmacy. The Supporting Prescribing in Older Patients with Multimorbidity in Primary Care (SPPiRE) intervention incorporated professional education and a web guided GP-delivered medication review focusing on potentially inappropriate prescribing (PIP) and deprescribing, and addressed patient treatment priorities. The SPPiRE cluster randomised controlled trial targeted patients aged ≥65 years and prescribed ≥15 repeat medicines in Irish primary care. SPPiRE reported a significant but small effect in reducing the number of medicines (incidence rate ratio 0.95, 95% CI; 0.899-0.999, p=0.045), but had no effect on PIP. The aim of the SPPiRE process evaluation was to explore intervention implementation, participant experiences and the potential for system wide implementation.

Approach

SPPiRE was set in 51 general practices throughout Ireland, who recruited 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines. The process evaluation used mixed methods. Quantitative data on SPPiRE reviews for intervention patients was collected from the SPPiRE website. Qualitative data was collected with purposive samples of intervention GPs (18/26) and patients (27/208) via semi-structured telephone interviews. All interviews were transcribed verbatim and analysed thematically.

Findings

Despite standardised training, intervention delivery varied among GPs; 163 of 208 (78.4%) intervention patients had a SPPiRE medication review, the most common reason for not having a review was insufficient GP time. GPs recorded at least one PIP in 130 of patients who had a medication review (79.8%), with a mean of 1.79 (SD1.4) PIP per patient. By comparison at least one PIP was identified in 92.3% of intervention patients by the blinded pharmacist at baseline outcome assessment, with a mean of 2.49 PIP (SD1.6) per patient. Medication changes were recorded in 96 of 282 (34%) PIP identified by GPs. GPs felt it easier to change medicines if the patient was well known to them and more difficult if the medicine had been initiated elsewhere. GPs identified 226 different priorities with 128 patients (78.5%), most commonly treating pain and other symptoms and this process resulted in medication change(s) in 51 patients (31.3%). GPs and patients had mixed views on the usefulness of assessing patient treatment priorities, but overall patients felt reassured and GPs felt a routine medication review for these patients would be beneficial but lack of integration into practice software systems and resources were identified as barriers to future implementation.

Consequences

GPs deprescribed a small but significant number of medicines but they identified less PIP than the pharmacist, which may explain the lack of effect seen on PIP in the main trial. GPs and patients viewed the intervention positively, but implementation will depend on resourcing and integration into practice management systems.

Submitted by:

Caroline McCarthy

Funding acknowledgement:

This research is funded by the Health Research Board Primary Care Clinical Trials Network (CTN-2014-011).