Appropriate Polypharmacy in Older People in Primary Care

In the past, prescribing many medicines (polypharmacy) was seen in a negative light. However, because people are living longer and have several medical conditions at the same time, views on polypharmacy have changed. The challenge is to have the correct balance between enough medicines and too many medicines. Members of the research team have developed a new approach to achieving this balance. This approach has been tested in two general practices in Northern Ireland (NI). The approach (intervention package) currently consists of two parts: (1) a video showing how general practitioners (GPs) can prescribe appropriate polypharmacy for older patients, and (2) an appointment system for patients to visit a GP to have their medicines reviewed. As the intervention package was developed and tested in NI, further testing needs to be carried out in NI and the six border counties of the Republic of Ireland (ROI; Cavan, Donegal, Leitrim, Louth, Monaghan, and Sligo). This will be done in three stages or phases. In phase 1, which is now complete, 13 GPs were interviewed across 12 practices in the six border counties in the ROI; shown the video, asked about this new approach and asked if any changes are needed before doing more testing. In the next two phases (Phase 2 \& 3) a small study will be carried out involving 12 practices: six practices in NI and six practices in the six border counties in the ROI and approximately 10 patients per practice. GP practices will either receive the intervention package and conduct medication reviews with recruited patients (intervention group) or continue to treat recruited patients as usual (control group). Interviews with up to 10 GPs and six members of practice staff (i.e. those involved in implementing the intervention within each practice) respectively in the six intervention group practices will also be conducted at the end of the intervention. Patients from the six intervention group practices will be asked to complete a feedback questionnaire after the delivery of the intervention (i.e. after completion of their final follow-up questionnaires).

Design: We will perform a pilot cluster randomised controlled trial where 12 GP practices will be randomly assigned (6 GP practices per arm) to the intervention group versus usual care. Randomisation will be stratified according to location (Northern Ireland /Republic of Ireland - Cavan, Donegal, Leitrim, Louth, Monaghan and Sligo). GP practices will be randomly allocated to the intervention or usual care arm after patient screening and recruitment. A total of 120 patients (60 per study arm, approximately 10 patients, randomly selected, per GP practice) will be enrolled into the study.

Design: Pilot cluster randomized controlled trial

Unit of randomization: GP practice.

Unit of analysis: Patient and GP practice.

Setting: Practices located in Northern Ireland will be recruited via Research Nurse(s) from the Northern Ireland Clinical Research Network (NICRN - Primary Care). In the Republic of Ireland a Research Nurse(s) from Trinity College Dublin will recruit GP practices located in the border counties of Cavan, Donegal, Leitrim, Louth, Monaghan and Sligo.

Study aim: The overall aim of the study is to undertake a pilot cluster randomised controlled trial (cRCT) of a theory-based intervention targeting prescribing of appropriate polypharmacy in primary care (PolyPrime) to assess the feasibility of a definitive cRCT of the PolyPrime intervention.

The main study objectives are:

* To test approaches to sampling, recruitment and retention of GP practices
* To test approaches to screening, recruitment and retention of patients
* To test the feasibility of using medication appropriateness (assessed using the STOPP/START criteria) as the primary outcome in a future cRCT
* To identify the intervention's likely mechanism of action
* To assess if the intervention was delivered and received as intended (intervention fidelity)
* To identify the resources used in the set-up and delivery of the intervention and their associated costs
* To assess the feasibility of a future cost-effectiveness analysis
* To further validate the Medication-Related Burden quality of life (MRQ-QoL) tool
* To obtain estimates of effect size between groups, cluster size and intraclass correlation coefficients (ICCs) to inform the sample size calculation for a full RCT

Recruitment strategy for patients: Each recruited general practice will be asked to recruit 10 older patients meeting the inclusion criteria (i.e. over 70 years old, receiving four or more regular medicines, not cognitively impaired, not have a terminal illness, resident in the community, be in receipt of a valid general medical services (GMS) card in the Republic of Ireland, or for Northern Ireland patients, registered for NHS primary care services and registered with and/or regularly attending the practice for a minimum of 12 months). Each recruited GP practice will also display a patient recruitment poster in their practice waiting areas. Posters will direct patients to ask at reception if they are interested in taking part in the study.

The GP Practice Manager (or equivalent) will screen patient records facilitated and supported by the research nurses. Each practice will identify and filter potentially eligible participants via patient records. This will be done in batches depending upon the size of the practice list. Patients will be screened on the basis of the inclusion/exclusion criteria as specified in the protocol. A screening log will be provided to practices to record screening and recruitment activity, including the reason(s) for not being enrolled on the study. The screening log will be kept securely at the practice and no identifying data will leave the practice.

Intervention delivery: The intervention (video) will be delivered to recruited GPs allocated to the intervention arm using the 'Riverside' software programme. This software programme allows electronic, multimedia material to be delivered to healthcare professionals and students. GPs will be provided with a single generic username and password that will allow them to access the video on a secure online server. Prior to the commencement of the study, all participating GPs will be provided with instructions from the researcher on how to access the video. The researcher will be fully contactable during the study to answer any questions or queries that participating GPs may have about accessing the video.

Once consented, patients recruited by the GP practices allocated to the intervention arm will be asked to attend two appointments (telephone or online consultations where a face-to-face consultation is not possible) at a time convenient to them to have their medicines reviewed by a GP in addition to their usual care. Patients recruited by the GP practices allocated to the control arm will continue to receive usual care.

Data will be collected from recruited GPs, recruited patients and practice records. Recruited patients will be asked to complete a number of questionnaires relating to their general well-being and use of the health service (e.g. hospital admissions) at baseline, six months and nine months post-initial medication review in the intervention arm and the equivalent time points in the control arm. The follow up time points for the control arm will be based on the average length of time from the completion of baseline data collection to six and nine months post initial medication review in the intervention arm. Patient data (including medical history, clinical conditions, biochemical data (i.e. test results) and prescribed medications) will also be collected from GP records at baseline, six months and nine months by a Research Nurse from the Northern Ireland Clinical Research Network (NICRN Primary Care) or Trinity College Dublin (TCD).

At the end of the intervention, interviews will be conducted with up to 10 GPs and six members of practice staff (i.e. those involved in implementing the intervention within each practice) respectively in the six intervention arm practices. GPs will be asked about their views on the support provided by the research team; the intervention package (and supporting materials); study procedures (e.g. screening, recruitment, etc.), while practice staff will be asked about their views on the study procedures (e.g. screening, recruitment, etc.) and acceptability of the intervention. Patients from the six intervention group practices will be asked to complete a feedback questionnaire after the delivery of the intervention (i.e. after completion of their final follow-up questionnaires). Patients will be asked about their views on the study procedures (e.g. completing questionnaires, recruitment etc.) and acceptability of the intervention.

Who is funding the study: HSC R\&D Division Cross-border Healthcare Intervention Trials in Ireland Network (CHITIN), UK and Ireland

Eligibility Criteria:
Inclusion Criteria:

* Patients must be ≥70 years
* Patients must be receiving four or more regular medicines
* Patients must be resident in the community
* Patients must be in receipt of a valid general medical services (GMS) card in the Republic of Ireland, or in the case of Northern Ireland patients, registered for NHS primary care services
* Patients must be registered with and/or regularly attending the practice for a minimum of 12 months

Exclusion Criteria:

* Care home residents
* Patients who are cognitively impaired
* Patients with a terminal illness
* Involved in other Investigational Medicinal Product (IMP) or medicines management studies