Team Approach to Polypharmacy Evaluation and Reduction (Pharmacy)

Study Overview
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Brief Summary
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In an aging population, most seniors suffer from multiple chronic conditions. When the number of medications taken is ≥5 (polypharmacy), the burden of taking multiple concurrent medications can do more harm than good. Seniors take an average of 7 regular medications and studies link polypharmacy with adverse effects on morbidity, function and health service use. However, it is not clear to what extent these are reversible if medication burden is reduced. This trial will test the effects on medication numbers and patient health outcomes of an intervention to polypharmacy. This study will test a program focused on medication reduction number and dose. Prioritizing medications according to the patient's preference as reducing the dose also reduces the risk of drug side effects. Patients, aged 70 years of age or older and taking ≥5 medications will receive the TAPER program. The program involves information gathering from the patient, including systematically seeking patients priorities and preferences, medication review with the pharmacist and then a consultation with the family doctor. The intervention is focused on discontinuing/reducing the dose of medications where possible using a 'pause and monitor' framework to assess the need for restart. An electronic program that detects drug adverse effects and flags potentially inappropriate medications will be integrated into an electronic clinical pathway incorporating monitoring and follow-up systems. This study will examine whether implementing a deprescribing care pathway with community pharmacists as point-of-entry can signal improvements in prescribing and patient health outcomes in older adults with polypharmacy.

Detailed Description
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This study uses a single-arm, longitudinal cohort feasibility design. Patients will receive the intervention following baseline data collection. Initial baseline data collection from the patient will include information on demographics, medications, and illness characteristics. The patient will then attend an appointment with a pharmacist to review medications appropriate for discontinuation/dose reduction, after which the patient will meet with their family physician to discuss patient preferences for discontinuation/dose reduction. Both health care providers will have access to TaperMD, a web-based program linked to evidence and tools to support reduction in polypharmacy. Follow-up research assessments will take place at one week, 3 months and 6 months (study end). Outcome assessments and a semi-structured interview will take place at the 6 month appointment.

Official Title
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Team Approach to Polypharmacy Evaluation and Reduction Pharmacy

Conditions
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Multi-morbidity, Medication Therapy Management, Polypharmacy

Intervention / Treatment
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* Other: Medication reduction


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged 70 years of age or older Patient must have a family doctor Participating family doctor as most responsible provider Currently taking 5 or more long-term medications Has not had a recent comprehensive medication review Patient willing to try discontinuation Exclusion Criteria: English language or cognitive skills inadequate to understand and respond to rating scales Terminal illness or other circumstance precluding 6 month study period

Ages Eligible for Study
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Minimum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Intervention Model: Single Group Assignment
Interventional Model Description: Single-arm, longitudinal cohort feasibility study.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: TAPER<br>The intervention is medication reduction. This arm is comprised of: Medication reconciliation Identification of patient priorities for care Identification of medications that are potentially appropriate for discontinuation/dose reduction Linked pharmacist/family physician consultations with patient to discuss medication with intention to reduce Identification of medications for trial of discontinuation/dose reduction (shared decision making) Pause of medication and clinical monitoring | Other: Medication reduction<br>* Systematic approach to reduction in polypharmacy.<br>* Other names: Medication discontinuation/dose reduction;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility (recruitment number) | Number of people who are invited to participate in the study. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility (proportion consented) | Number of participants who consent divided by the number of potential participants invited. | 6 months | 
| Feasibility (proportion completed) | Number of participants who complete 6-month data collection divided by the number of people who consented. | 6 months | 
| Feasibility (barriers to recruitment) | Challenges to recruitment as identified by pharmacists via field notes and interviews. | 6 months | 
| Feasibility (time to complete surveys) | Total time to complete all surveys | Baseline, 6 months | 
| Feasibility (capacity for pharmacist to implement) | Challenges regarding implementation for pharmacists from field notes and interviews | 6 months | 
| Feasibility (issues with TaperMD tool) | Communication between pharmacists and research team noting TaperMD issues from regular meetings. | 6 months | 
| Feasibility (missing data) | Nature and percentage of missing data. | 6 months | 
| Feasibility (variance of measures) | The calculated range of scores for surveys (where applicable) | Baseline, 6 months | 
| Feasibility (intervention implementation proportion) | Number of plans containing deprescribing actions divided by the total number of plans. | 6 months |