Title: CompreHensive geriAtRician-led MEdication Review (CHARMER)
Funder: Department of Health and Social Care

Abstract: Background: Ageing affects the body s drug handling processes resulting in the risk of harm from medicines potentially outweighing the benefits. Patients, carers and GPs expect medicines to be reviewed in hospital, and any medicines with a greater risk of harm than benefit to be stopped before harm occurs (proactive deprescribing). 50% of patients are prescribed at least one medicine where the harms outweigh the benefits, however, only 6% of these patients have an inappropriate medicine proactively deprescribed in hospital. The research team have established the barriers and enablers (determinants) to geriatricians and hospital pharmacists increasing the number of older patients in hospital for they proactively deprescribe. We have also identified six behaviour change techniques (BCTs) that are suitable for addressing these determinants. Aims: Over 58 months, to develop and test an intervention to target the determinants of geriatrician and hospital pharmacist proactive deprescribing in order to enable estimation of effectiveness and cost-effectiveness. Methods: WP1 (9 months): With no current standardisation of outcome measures for use within hospital deprescribing trials, resulting in disparate practice with limited underpinning evidence, we will develop a core outcome set drawing on COMET recommendations. We will use modified Delphi (n=120-150) to identify a suitable primary outcome measure for this trial. WP2 (10 months): We will develop the intervention using two rounds of co-design workshops with stakeholders (n=8-10) to characterise the six BCTs and operationalise them into an intervention package. We will also develop a questionnaire investigating the mechanism of action of the intervention BCTs. WP3 (16 months): We will test intervention and trial procedures over three months in four hospitals, each recruiting two geriatricians and two pharmacists. To supplement quantitative data, we will observe intervention delivery in all four hospitals to test the fidelity framework and identify enhancements to the intervention and trial procedures. We will additionally interview hospital staff responsible for intervention delivery and all recipients of the intervention (geriatricians and pharmacists). We will use these data together with data from a, to undertake pre-trial modelling of the intervention. We will purposively sample (n=24) patients and carers for telephone interviews to explore experiences of trial participation and service delivery by geriatrician and pharmacist participants. WP4 (34 months): We will phase recruitment of 44 hospitals over 14 months, randomise each to intervention or control and allow six months for each site to recruit 110 patients. This will provide 90% power at 5% significance for detecting a 20% difference in proactive deprescribing between intervention and control hospitals. WP5 (58 months): We will undertake dissemination activities and refine the strategy throughout the programme and convene a strategy workshop with key stakeholders (n=8-10), to prepare a detailed plan for the intervention to be more widely implemented and adopted.

Lay abstract: The issue As we get older, our bodies are less able to handle some medicines. Medicines that were once effective and safe, can become less beneficial, with increased risk of harm. Half of older people in hospital are prescribed a medicine with a safety risk but these medicines are rarely stopped. Nine out of ten patients and carers believe that risky medicines should be stopped in hospital and that doctors should start the discussion. To make this happen, we need to change doctor and pharmacist behaviour so that the idea of stopping medicines in more likely to be discussed with patients. Our research with 54 doctors and pharmacists working with older people, found one thing that helps (drawing attention to prescribers who successfully stop risky medicines) and four things that hinder (wrong belief that patients don t want to stop, pharmacists being unavailable when stopping decisions could be made, thinking that doing nothing is safer than stopping and medicine stopping is not a hospital priority). Aims In older people's wards we aim to: &bull; develop our approach to increasing discussions with patients about stopping medicines by using what helps and removing what hinders &bull; develop a list of things that people think are important to measure when stopping medicines in hospital &bull; design and carry out a study testing whether our approach works and is value for money &bull; make discussions about medicines stopping in hospital important &bull; develop a way for getting our approach to be used in all hospitals Plan We will work with patients, carers, and staff from hospital and community to develop a way to change pharmacist and doctor behaviour so that risky medicines are more likely to be stopped. They will also help us to design a study comparing hospitals using our approach with hospitals carrying on as usual. After small-scale testing, we will test our approach in 22 hospitals and see if more medicines are stopped compared to 22 hospitals without our approach. We will also see whether our approach has benefits to patients, such as preventing hospital readmissions or improving quality of life. We will also calculate the cost of our approach in such a way that the government can compare it with other services. Four patient and public members will be fully involved throughout: from research management and design to delivery and presentation. Sharing our findings and impact We have designed the study so our approach can be easily taken up in different hospitals and will make the information on how to do this freely available. Throughout the research, we will plan how and with whom to share our findings; this will be led by a public member experienced in changing national practice.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE