GP-delivered medication review of polypharmacy, deprescribing, and patient priorities in older people with multimorbidity in Irish primary care (SPPiRE Study): A cluster randomised controlled trial

Abstract

Background There is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care. Methods and findings We conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged ≥65 years with complex multimorbidity, defined as being prescribed ≥15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work. Conclusions The SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level. Trial registration ISRCTN Registry ISRCTN12752680.

Prevalence and global trends of polypharmacy in patients with chronic Liver disease: a systematic review and meta-analysis

“…We found an overall pooled prevalence of polypharmacy amongst patients with CLD at 31%. Despite the apparent disparity in the underlying liver pathology amongst the included studies, our period prevalence estimate provides the rst attempt at exploring the burden of this growing therapeutic morbidity in these cohorts of patients and falls within the "ballpark" reported in the general population (20)(21)(22)4). Data from pharmaco-epidemiological studies in patients with alternative morbidities such as people living with HIV/AIDS (PLWHA) has shown that amongst the factors that drive adverse consequences of polypharmacy in them includes the inherent propensity of parent ART drugs to bidirectional interactions; as well as the metabolizing pathways of some of the ART drugs which are highly polymorphic and therefore prone to pharmacogenetic interactions (23)(24)(25).…”

Development of an Electronic Tool to Assess Patient Preferences in Geriatric Polypharmacy (PolyPref)

“… 45 Supplementing the SENATOR recommendations with the patient’s individual preferences might substantiate the proposed medication changes and improve the outcome of this intervention as shown in the SPPiRE study, which also used the STOPP/START criteria but supplemented them with an assessment of patient priorities and whose recommendations were well received. 46 …”

“…45 Supplementing the SENATOR recommendations with the patient's individual preferences might substantiate the proposed medication changes and improve the outcome of this intervention as shown in the SPPiRE study, which also used the STOPP/START criteria but supplemented them with an assessment of patient priorities and whose recommendations were well received. 46 Besides the small sample size other limitations of our pilot study have to be addressed. Individuals who volunteer to participate in a study may be more open-minded and attentive during preference elicitation than other members of the target group.…”

Establishing the worth of deprescribing inappropriate medications: are we there yet?

“…Over the past 5 years, several multicentre randomised controlled trials (RCTs) have attempted to address some of these limitations. The SPPiRE (Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care) cluster RCT involving 51 Irish general practices enrolled 404 multimorbid patients aged 65 years or over and receiving 15 or more regular medicines 7 . Intervention practices accessed a website for clinicians to complete an education module and use a template for a once‐off patient medication review lasting 30–40 minutes.…”