Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices—results of a cluster-randomized controlled trial

Abstract

BackgroundMultimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes. Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice. The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group: (a) structured medication counseling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication.MethodsWe conducted a cluster-randomized controlled trial with a follow-up time of 9 months. Participants were general practitioners (GPs) organized in quality circles and participating in a GP-centered care contract of a German health insurance. Patients aged >50 years, suffering from at least 3 chronic diseases, receiving more than 4 drugs, and being at high risk for medication-related events according to the assessment of the treating GP were enrolled. The tailored program consisted of a workshop for GPs and health care assistants, educational materials and reminders for patients, and the elaboration of implementation action plans. The primary outcome was the change in the degree of implementation between baseline and follow-up, measured by a summary score of 10 indicators. The indicators were based on structured surveys with patients and GPs.ResultsWe analyzed the data of 21 GPs (10 - intervention group, 11 - control group) and 273 patients (130 - intervention group, 143 - control group). The increase in the degree of implementation was 4.2 percentage points (95% confidence interval: −0.3, 8.6) higher in the intervention group compared to the control group (p = 0.1). Two of the 10 indicators were significantly improved in the intervention group: medication counseling (p = 0.017) and brown bag review (p = 0.012). Secondary outcomes showed an effect on patients’ self-reported use of medication lists when buying drugs in the pharmacy (p = 0.03).ConclusionsThe tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication reviews did not improve. No effect of the tailored program on the combined primary outcome could be substantiated. Due to limitations of the study, results have to be interpreted carefully. The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation.Trial registration number ISRCTN34664024, assigned 14/08/2013

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae– A scoping review

“…Our iterative searches returned 82 background papers (S3 File). Among retrieved papers, we deemed eligible and relevant 21 systematic reviews [33–53], 14 randomised controlled trials [54–67], 11 non-randomised controlled studies [68–78], 11 qualitative studies [79–89], and one mixed methods study [90] (S4 File). The systematic reviews, randomised controlled trials, cohort and controlled before-and-after studies each described and evaluated the processes or techniques QCs used.…”

“…This is often the starting point for mutual learning [23, 96, 99]. Depending on the country’s tradition, QCs might not be limited to GPs but involve other professionals in PHC, including practice assistants (in the Netherlands and Germany) or practice teams (in Scotland), who add perspectives to the QC process [59, 67, 82, 100–102]. Interprofessional collaboration and mutual learning may also involve practice nurses [103] or specialists invited to QCs to share expertise on a specific topic, e.g., pharmacists who contribute to a discussion on prescription patterns [75, 104, 105].…”

Drug-related problems in community-dwelling primary care patients screened positive for dementia

“…In this analysis, 25% of study participants had no medication list or the medication list was outdated according to the assessment of the study nurse. We cannot estimate if this rate of PwD is high or low because in German studies, the rate of elderly patients with polypharmacy who do not have a medication list differs greatly between 10% and 75% (Jäger et al , 2017 ). Nevertheless, these findings are relevant because the study participants took six prescribed drugs on average.…”

A case study of polypharmacy management in nine European countries: Implications for change management and implementation

“…Although many of the lessons from the SIMPATHY case studies have been discussed in the context of quality improvement, these principles have not previously been systematically applied to published polypharmacy management interventions. To date, interventions and recommendations to address polypharmacy have been primarily focused at the clinical level looking, for example, at strategies to improve prescribing or patient adherence [ 48 – 50 ]. Many interventions either fail to take into account, or do not report on, broader systems level issues, such as the need to change reimbursement models or employ a change management strategy to speed implementation as was highlighted in this analysis.…”