Award Title: Learning from proactive deprescribing experiences within the Care Homes Independent Pharmacist Prescribing Study to develop national policy regarding deprescribing in care homes for older people
Funder: Department of Health and Social Care

Abstract: Research question  What are the individual and system level behaviour change components required to enable the creation of policy to inform and drive effective implementation of proactive deprescribing within the care homes setting?   Background  Approximately half of older care home residents are prescribed at least one inappropriate medicine which can predispose them to adverse outcomes such as falls, morbidity and hospitalisation. It is therefore important that inappropriate medicines are discontinued in a timely manner i.e. interventions implemented which effectively facilitate proactive deprescribing.  The NIHR funded Care Homes Independent Pharmacist Prescribing Study (CHIPPS) was designed to estimate the effectiveness and cost-effectiveness of pharmacist independent prescribers (PIPs) assuming responsibility for medicines optimisation in care homes. The process evaluation found that proactive deprescribing varied within the 25 pharmacist prescribers from 3 medicines per 20 residents to 28 medicines. We will use this experience to elucidate the barriers and enablers associated with deprescribing in the care home environment and develop appropriate policy.  Aim  To develop policy to support effective implementation of proactive deprescribing within care homes.  Objectives    Describe the types of medicines commonly proactively deprescribed in CHIPPS and characterise variation in this behaviour within CHIPPS intervention care homes.  Identify enablers and barriers to proactive deprescribing within CHIPPS intervention care homes.  Identify the mechanisms of action leading to proactive deprescribing and their linked Behaviour Change Techniques (BCTs).  Develop policy to support creation of the appropriate environment, training and inter-professional and patient relationships to implement proactive deprescribing in care homes.   Methods  Phase 1: Secondary analysis of the existing CHIPPS proactive deprescribing data to identify trends and variation in practice.  Phase 2: Identify a purposive sample (according to Phase 1 trends) of CHIPPS practitioners and conduct semi structured interviews, informed by the Theoretical Domains Framework (TDF), to identify and prioritise the barriers, enablers and therefore relevant TDF domains pertinent to proactive care home deprescribing.  Phase 3: Based on Phase 2 data, for each identified TDF domain, identify all possible BCTs, to address the barriers and enablers. Convene a modified Nominal Group Technique workshop to facilitate target audience selection and characterisation of BCTs to support implementation of proactive care home deprescribing.  Phase 4: Convene a policy development and dissemination working group of national opinion leaders to develop the policy to include guidance for addressing broader structural and system level considerations. Disseminate policy at national, regional and local levels.  Timelines for delivery  Months 0-3: Phase 1    Ethical approval obtained Phase 2  Expressions of interest for Phase 2 participants   Months 3 to 8: Phase 2    Ethical approval obtained for Phase 3  Participants for Phase 3 identified and recruited  Data analysis iterative as data collated  Phase 4 meeting organised   Month 9 -10: Phase 3  Months 11-12: Phase 4    Policy dissemination to target audiences   Dissemination and Impact   Dissemination through relevant policy leads such as NHS England and Improvement, Department of Health and Social Care and deprescribing networks.  Impact will be better design of interventions to facilitate proactive deprescribing and ultimately more timely discontinuation of medicines whereby risks outweigh the benefits.

Lay Abstract: Aim  The aim of this project is to use what we have learned from placing 25 pharmacist prescribers in care homes across England, Scotland and Northern Ireland, to develop policy about how to support healthcare professionals to stop medicines that are no longer benefiting older people in care homes.  Background  We know that residents in care homes for older people regularly receive large numbers of medicines and are exposed to large numbers of medication errors. One approach is to stop medicines which are either no longer necessary or could possibly cause harm in the future. Within a large scale research project which we undertook across the UK, we found that some pharmacists were more likely to stop medicines than others. If we understand why this is more common in some care homes than others, then we can develop policy to support all care homes to stop medicines that are not beneficial or possibly harmful.  Methods  Firstly, we will look at why and how prescribing changed within our large study to help us understand what medicines people were more or less willing to stop and who was more or less likely to stop them. This will help us to identify who we want to talk to in order to find out why this does and doesn t occur and what things need to change to make this more likely. We will interview general practitioners, pharmacists and care home managers from the research study to help us understand what happened and why.  From these interviews we will look for common descriptions of what prevents medicines from being stopped and what helps. We will use the information we get from these interviews tells us what things we could possibly do to make things better. We expect that this will give us a long list of options and therefore we will work with a group of experts who work in and with care homes to agree which options are best.  Finally, using standard methods, we will develop a draft policy document and approach to getting our plan into practice. This will be presented to people responsible for implementing policy to obtain their feedback on how best to do this.  Patient and public involvement  The two patient and public involvement members who supported our previous large project  will continue with us on this project management committee. They have inputted into our project proposal, and will be actively involved in all stages.  Dissemination  We will design our policy to increase its chances of being put into practice and present it to the national lead pharmacist and individuals responsible for improving medicines use and care for residents within care homes.

Research Activity Codes: 7.3 MANAGEMENT AND DECISION MAKING
Health Categories: GENERIC HEALTH RELEVANCE