The Care Home Independent Prescribing Pharmacist Study (CHIPPS)—a non-randomised feasibility study of independent pharmacist prescribing in care homes

Abstract

Background Residents in care homes are often very frail, have complex medicine regimens and are at high risk of adverse drug events. It has been recommended that one healthcare professional should assume responsibility for their medicines management. We propose that this could be a pharmacist independent prescriber (PIP). This feasibility study aimed to test and refine the service specification and proposed study processes to inform the design and outcome measures of a definitive randomised controlled trial to examine the clinical and cost effectiveness of PIPs working in care homes compared to usual care. Specific objectives included testing processes for participant identification, recruitment and consent and assessing retention rates; determining suitability of outcome measures and data collection processes from care homes and GP practices to inform selection of a primary outcome measure; assessing service and research acceptability; and testing and refining the service specification. Methods Mixed methods (routine data, questionnaires and focus groups/interviews) were used in this non-randomised open feasibility study of a 3-month PIP intervention in care homes for older people. Data were collected at baseline and 3 months. One PIP, trained in service delivery, one GP practice and up to three care homes were recruited at each of four UK locations. For ten eligible residents (≥ 65 years, on at least one regular medication) in each home, the PIP undertook management of medicines, repeat prescription authorisation, referral to other healthcare professionals and staff training. Outcomes (falls, medications, resident’s quality of life and activities of daily living, mental state and adverse events) were described at baseline and follow-up and assessed for inclusion in the main study. Participants’ views post-intervention were captured in audio-recorded focus groups and semi-structured interviews. Transcripts were thematically analysed. Results Across the four locations, 44 GP practices and 16 PIPs expressed interest in taking part; all care homes invited agreed to take part. Two thirds of residents approached consented to participate (53/86). Forty residents were recruited (mean age 84 years; 61% (24) were female), and 38 participants remained at 3 months (two died). All GP practices, PIPs and care homes were retained. The number of falls per participating resident was selected as the primary outcome, following assessment of the different outcome measures against predetermined criteria. The chosen secondary outcomes/outcome measures include total falls, drug burden index (DBI), hospitalisations, mortality, activities of daily living (Barthel (proxy)) and quality of life (ED-5Q-5 L (face-to-face and proxy)) and selected items from the STOPP/START guidance that could be assessed without need for clinical judgement. No adverse drug events were reported. The PIP service was generally well received by the majority of stakeholders (care home st...

Protocol for a cluster randomised controlled trial to determine the effectiveness and cost-effectiveness of independent pharmacist prescribing in care homes: the CHIPPS study

“…The intervention has been tested in a feasibility study [18]. It involves the PIP, in collaboration with the care home resident's GP, assuming responsibility for managing the medicines of the resident, including:…”

“…The aim of the study described in this protocol is to conduct a cluster RCT, with internal pilot, to compare the clinical and cost-effectiveness of a Care Homes Independent Pharmacist Prescribing Service (CHIPPS) with usual care. This is the final stage of a programme of work, divided into discrete work packages, following the Medical Research Council (MRC) guidance on the development and evaluation of complex interventions [15] which has reviewed the literature to select appropriate outcome measures [16], ascertained the views of stakeholders [17], developed a needs-based PIP training package (publication in preparation) and conducted a non-randomised feasibility study [18].…”

Deprescribing needs to be considered in the pharmacists’ prescribing role

“…In New Zealand and the United Kingdom, recent changes in the legislation have enabled suitably trained pharmacists to prescribe, and various studies have tested the feasibility of pharmacists initiating and deprescribing medications in multiple settings, such as nursing homes and general practice. 4,5 The pharmacists' expanded deprescribing role can be achievable with a teambased approach in which there is a clear delineation of roles and responsibilities, separating the prescribing from the dispensing pharmacist, as in New Zealand. 5,6 In Australia, many health practitioners can prescribe medications.…”

“…There is growing evidence internationally of the effectiveness of pharmacist prescribing roles that include medication cessation. In New Zealand and the United Kingdom, recent changes in the legislation have enabled suitably trained pharmacists to prescribe, and various studies have tested the feasibility of pharmacists initiating and deprescribing medications in multiple settings, such as nursing homes and general practice …”

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process

“…In 2012, the UK National Institute for Healthcare Research (NIHR) funded a programme to develop and test the concept of PIPs assuming responsibility for the provision of pharmaceutical care within the care home environment (CHIPPS) via a randomised controlled trial . The service was planned to involve, as a minimum, the pharmacist working closely with a resident’s GP to enable them to assume responsibility for authorisation of repeat prescriptions.…”