Implementation of inter-departmental Collaborative Medication Review to reduce potentially inappropriate medication use in hospitalized elderly patients: A mixed methods study protocol
Authors: Kumar Aravinda , Konduru Rajesh Kumar , Rajaram Saranya , M Manikandan , Natarajan Anusha , Cherian Jerin Jose , Bagepally Bhavani Shankara , Purty Anil J , Iqbal Nayyar , S Dineshbabu , S Sudharsanan , Topno Isabella , CH Manjunatha 
Published: October 2024

Background: The inappropriate use of multiple medications, known as polypharmacy, is a growing concern for the elderly population in India, who are often prescribed multiple medications due to comorbid conditions. This can lead to serious adverse health outcomes, increased healthcare costs, and reduced quality of life. Screening tools, such as the Medication Appropriateness Index (MAI) and the STOPP/START criteria, can help identify potentially inappropriate medications (PIMs), and interventions, such as medication review clinics and prescribing audits, can help improve appropriateness. Collaborative medication review (CMR) involving a team approach is important to ensure that patients receive the best possible care. However, the cost of these interventions remains a concern, especially in countries where healthcare spending is high for the elderly population.
Methods: This study will be conducted in 5 phases, where phase 1 involves developing a scoping review on CMR practices, followed by phase 2, which involves the drafting of SOPs to formulate the CMR team in the Indian context, defining their individual roles and responsibilities, the constitution of the CMR team, and training of the CMR team; phase 3 will assess the efficacy of CMR via standardized tools such as the MAI and STOPP/START criteria; and phase 4 will assess the challenges and barriers in the implementation of collaborative medication review (CMR) in the Indian health care setting. The final phase, phase 5, will evaluate the costs incurred in the implementation of CMR from a health system perspective. The study design will be a multicentred mixed-method study, where the qualitative component will assess the feasibility of collaborative medication review via in-depth interviews and focused group discussion to explore the challenges in the implementation of interdepartmental collaborative medication review to reduce PIM use in hospitalized elderly patients. The quantitative component of the study will be a quasi-experimental pre- and postinterventional study involving 280 hospitalized elderly participants' prescriptions from the admission day until 30 days post discharge by the CMR team members to estimate the costs incurred for the implementation of CMR in healthcare settings from the health care provider perspective and a reduction in the percentage of potentially inappropriate medications using the STOPP/START criteria, the medication appropriateness index (MAI) and post discharge adverse events. The assessment tool for hospital admissions related to medications-10 (AT-HARM10) will be used to identify hospital admissions related to medications.
Discussion: The findings of this study provide valuable insights into the implementation and effectiveness of CMR in the Indian healthcare setting. This study helps to understand the facilitators of and barriers to implementing interdepartmental collaborative medication review (CMR) and the cost incurred in its implementation from a healthcare provider perspective in an Indian healthcare setting. Healthcare professionals from different departments or disciplines work together to review the medication needs of elderly patients, who more commonly suffer from multiple chronic conditions. This approach addresses the challenges of managing multimorbidity in India, such as professional isolation, inadequate guidelines and evidence-based medicine, and barriers pertaining to shared decision-making by treating clinicians. The collaborative medication review process allows for a more comprehensive and coordinated approach to medication management, potentially improving patient outcomes and reducing healthcare costs.
Trial registration: The study has been registered with the Clinical Trials Registry–India (CTRI/2024/06/069220) registered on 19/06/2024.