Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

Abstract

BackgroundInappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients’ priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.MethodsThe study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older.Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward’s discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines.Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients’ quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.DiscussionSo far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.Trial registrationISRCTN, ISRCTN18427377. Registered 11 January 2018Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0839-1) contains supplementary material, which is available to authorized users.

Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial

“…Furthermore, compared with unidirectional communication, consensus and close collaboration between hospital specialists and follow-up care providers in medication reviews may lead to higher acceptance rates of medication plans postdischarge. 57 58 Especially for older patients with multimorbidity, SDM and medicines optimisation should not be restricted to one patient and one clinician in one consultation, rather integrated and interprofessional approaches are needed. 38 48 With deeply engrained paternalistic practices in many countries, implementing medication review with SDM requires significant behaviour change of both clinicians and patients.…”

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals

“…The study was designed as an effectiveness-implementation hybrid trial set in hospitals in German-speaking Switzerland. 29 Ethics approval was granted by the Ethics Committees Zurich and Bern, Switzerland (BASEC2018-00215). Here we present the effectiveness outcomes of this prospective, double-blind, cluster-randomized parallel-controlled trial following up hospitalized older patients with polypharmacy for 6 months after discharge.…”

Implementation of a complex intervention to improve hospital discharge: process evaluation of a cluster randomised controlled trial

“…The study protocol for the full trial has been published elsewhere. 9 The intervention was a patient-centred discharge procedure including critical medication review combined with a communication stimulus between HPs and GPs. The implementation strategy included (1) a 2-hour teaching session for senior HPs in internal medicine wards and rehabilitation hospitals who instructed junior HPs, (2) a checklist facilitating the medication review (online supplemental appendix 1) and ( 3) two adaptations to the discharge letter (reorganisation of the medication lists so that medication changes could easily be identified by the aftercare GP, and invitation to the GP to discuss potential changes of the medication plan).…”

“…20 Participants The recruitment procedure is described in the study protocol. 9 We questioned chief physicians who decided about participation in the study, senior and junior HPs who were directly involved in the delivery of the intervention to patients, and GPs as downstream receivers of the intervention. Patients were not directly questioned.…”

“…We therefore performed a two-armed cluster randomised controlled trial (RCT) investigating the effect of a medication review and improved information transfer at hospital discharge for patients aged 60 years or older with polypharmacy on rehospitalisation rates. 9 The intervention was implemented via a teaching session and patient-centred checklists for HPs, and adaptations to the discharge letters. The complex intervention involved multiple sites, different levels of healthcare providers and different time points during the patients' hospital stay.…”