Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial
Authors: Holland Richard , Bond Christine , Alldred David P , Arthur Antony , Barton Garry , Birt Linda , Blacklock Jeanette , Blyth Annie , Cheilari Stamatina , Daffu-O'Reilly Amrit , Dalgarno Lindsay , Desborough James , Ford Joanna , Grant Kelly , Harry Bronwen , Hill Helen , Hughes Carmel , Inch Jacqueline , Maskrey Vivienne , Myint Phyo , Norris Nigel , Poland Fiona , Shepstone Lee , Spargo Maureen , Turner David , Watts Laura , Zermansky Arnold , Wright David 
Published: February 2023

Abstract

Objective
To estimate the effectiveness, cost effectiveness (to be reported elsewhere), and safety of pharmacy independent prescribers in care homes.

Design
Cluster randomised controlled trial, with clusters based on triads of a pharmacist independent prescriber, a general practice, and one to three associated care homes.

Setting
Care homes across England, Scotland, and Northern Ireland, their associated general practices, and pharmacy independent prescribers, formed into triads.

Participants
49 triads and 882 residents were randomised. Participants were care home residents, aged ≥65 years, taking at least one prescribed drug, recruited to 20 residents/triad.

Intervention
Each pharmacy independent prescriber provided pharmaceutical care to approximately 20 residents across one to three care homes, with weekly visits over six months. Pharmacy independent prescribers developed a pharmaceutical care plan for each resident, did medicines reviews/reconciliation, trained staff, and supported with medicines related procedures, deprescribing, and authorisation of prescriptions. Participants in the control group received usual care.

Main outcomes measures
The primary outcome was fall rate/person at six months analysed by intention to treat, adjusted for prognostic variables. Secondary outcomes included quality of life (EQ-5D by proxy), Barthel score, Drug Burden Index, hospital admissions, and mortality. Assuming a 21% reduction in falls, 880 residents were needed, allowing for 20% attrition.

Results
The average age of participants at study entry was 85 years; 70% were female. 697 falls (1.55 per resident) were recorded in the intervention group and 538 falls (1.26 per resident) in the control group at six months. The fall rate risk ratio for the intervention group compared with the control group was not significant (0.91, 95% confidence interval 0.66 to 1.26) after adjustment for all model covariates. Secondary outcomes were not significantly different between groups, with exception of the Drug Burden Index, which significantly favoured the intervention. A third (185/566; 32.7%) of pharmacy independent prescriber interventions involved medicines associated with falls. No adverse events or safety concerns were identified.

Conclusions
Change in the primary outcome of falls was not significant. Limiting follow-up to six months combined with a small proportion of interventions predicted to affect falls may explain this. A significant reduction in the Drug Burden Index was realised and would be predicted to yield future clinical benefits for patients. This large trial of an intensive weekly pharmacist intervention with care home residents was also found to be safe and well received.

Trial registration
ISRCTN 17847169.