Development and evaluation of an intervention to reduce potentially inappropriate medication prescribing in older adults with polypharmacy

Abstract

Objective: In this programme of research, the researcher aimed to develop and evaluate a pharmacist-facilitated intervention to identify and reduce potentially inappropriate medication prescribing for older adults with polypharmacy (defined as individuals aged 65 years and over dispensed 11 or more unique long-term medications). The research is divided into two broad phases in sequence. The objective of Phase One was to develop an information technology (IT) triage tool to triage older adults with polypharmacy based on their risk of potentially inappropriate medication-related harm within New Zealand’s healthcare context. The developed IT triage tool was used to refine a pharmacist-facilitated intervention. It combines the IT triage tool with an electronic audit and feedback (EAF) tool and pharmaceutical care to reduce potentially inappropriate medication prescribing for older adults with polypharmacy. The objective of Phase Two was to evaluate the feasibility of implementing the refined pharmacist-facilitated intervention in a general practice clinic by evaluating the process, resources, management, and scientific objectives. Design: Phase One used a mixed methods approach, and Phase Two was a non-randomised mixed-method feasibility study. Method: In Phase One, an expert panel group was comprised of pharmacists, general practitioners, geriatricians, and nurse practitioners. Using the panel group, nominal group technique (NGT) was combined with a review of the Beers Criteria to gather a list of potentially inappropriate medication indicators to correct for older adults with polypharmacy. The gathered indicators were then validated in a two-round modified Delphi analysis. The IT triage tool was programed in Qlik® software using the gathered potentially inappropriate medication indicators. Indicators that were judged ‘very important’ by group consensus were translated into ‘diagnosis’, ‘chemical’, ‘dose’ and ‘therapeutic group’ categories to search the Ministry of Health Pharmaceutical Collection formulation file and MidCentral District Health Board Emergency Department and International Statistical Classification of Diseases and Related Health Problems (ICD-10) data. The IT triage tool then searched the Pharmaceutical Collection’s unique dispensing identification file data to triage older adults with polypharmacy based on the number of potentially inappropriate medication indicators met. In Phase Two, patient participants were recruited from one general practice clinic in the New Zealand Mid-Central region over a one-month recruitment period to receive the refined pharmacist-facilitated intervention. Quantitative and qualitative data were collected throughout the feasibility study. The researcher analysed quantitative data according to progression criteria to determine whether progression to a randomised controlled trial (RCT) was acceptable or if further modifications were required. The researcher used thematic analysis to analyse qualitative data to identify facilitators and barriers to implementation. Results: In Phase One, 82 potentially inappropriate medication indicators comprised of 23 indicators from the NGT and 59 indicators from the Beers Criteria were included in the modified Delphi analysis. From the modified Delphi analysis, 21 indicators were judged ‘very important’, 31 indicators were judged 'important', nine indicators were judged ‘somewhat important’, and zero indicators were judged ‘low importance’, to correct for older adults with polypharmacy. The programed IT triage tool produced four primary outputs: potentially inappropriate medication indicators ranked by older adults with polypharmacy count, older adults with polypharmacy ranked by potentially inappropriate medication indicator count, dispensing pharmacies ranked by older adults with polypharmacy count, and prescribers ranked by older adults with polypharmacy count. In Phase Two, the feasibility study established that the refined pharmacist-facilitated intervention succeeded in the progression criteria measures, including patient participant recruitment, the retention rate of participants, and participants’ adherence to the intervention protocol. However, there were also elements within the procedures that could be modified. These included broadening the eligibility criteria and engaging with a recruitment agency to support participant recruitment; including a preliminary meeting between the participant, the pharmacist and a study team member; supporting pharmacists to maintain a patient-centred approach and adopting the ‘Hui Process’ for Kaumatua during patient consultations; extending the eight-week follow-up period; extending the time allocated for pharmacists to conduct the patient consultation; streamlining the Participant Information Sheet (PIS)/Consent Form (CF). Conclusions: In Phase One, the developed IT triage tool can enable clinicians to triage older adults with polypharmacy at risk of potentially inappropriate medication-related harm to receive an early clinical intervention. In Phase Two, the feasibility study determined that the intervention procedures were feasible with additional modifications before implementation as an RCT. The refined pharmacist-facilitated intervention may offer a novel approach to reducing potentially inappropriate medicines-related harm for older adults with polypharmacy.