Patient and general practitioner experiences of implementing a medication review intervention in older people with multimorbidity: Process evaluation of the SPPiRE trial

Abstract

Introduction The SPPiRE cluster randomized controlled trial found that a general practitioner (GP)‐delivered medication review that incorporated screening for potentially inappropriate prescriptions (PIP), a brown bag review and a patient priority assessment, resulted in a significant but small reduction in the number of medicines and no significant reduction in PIP. This process evaluation aims to explore the experiences of GPs and patients and the potential for system‐wide implementation. Methods The trial included 51 general practices and 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines. The process evaluation used mixed methods and ran parallel to the trial. Quantitative data was collected from the SPPiRE intervention website and analysed descriptively. Qualitative data on medication changes were collected from intervention GPs (18/26) and a purposive sample of intervention patients (27/208) via semi‐structured telephone interviews. All interviews were transcribed verbatim and analysed using a thematic analysis. Qualitative and quantitative data were integrated using a triangulation protocol. Results The analysis generated two themes, intervention implementation and mechanisms of action, and both were underpinned by the theme of context. Intervention delivery varied among practices and 45 patients (28%) had no review, primarily due to insufficient GP time. 80% of reviewed patients had ≥1 PIP identified, 59% had ≥1 problem identified during the brown bag review and 79% had ≥1 priority recorded. The brown bag review resulted in the most deprescription of medications. GPs and patients responded positively to the intervention but most GPs did not engage with the patient priority‐setting process. GPs identified a lack of integration into practice software and resources as barriers to future implementation. Conclusion The SPPiRE intervention had a small effect in reducing the number of medicines and this was primarily mediated through the brown bag review. The context of resource shortages and deep‐seated views around medical decision‐making influenced intervention implementation. Patient or Public Contribution Qualitative data on the implementation of the medication review and their wider views on their medicines was collected from older people with multimorbidity through semi‐structured telephone interviews. Clinical Trial Registration The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).

Association between patient attitudes towards deprescribing and subsequent prescription changes

“…12 The Supporting Prescribing in older adults with multimorbidity in primary caRE (SPPiRE) trial was designed to assess the effectiveness of a web-guided medication review that supported GPs in deprescribing medicines that were no longer effective or appropriate. 13,14 There was a small reduction in the number of repeat medicines in the intervention group at follow-up (IRR 0.95; 95% CI: 0.899-0.999; p = 0.045) but no effect on potentially inappropriate prescribing and the intervention was acceptable to both GPs and patients. 12,15 See Figure S1 for an overview of the qualitative and quantitative evaluations of the SPPiRE intervention.…”

“…This study is a secondary analysis of patient reported outcome measure (PROM) data and prescription data collected from participants recruited to a cluster randomised controlled trial (RCT) in the Republic of Ireland 12 . The Supporting Prescribing in older adults with multimorbidity in primary caRE (SPPiRE) trial was designed to assess the effectiveness of a web‐guided medication review that supported GPs in deprescribing medicines that were no longer effective or appropriate 13,14 . There was a small reduction in the number of repeat medicines in the intervention group at follow‐up (IRR 0.95; 95% CI: 0.899–0.999; p = 0.045) but no effect on potentially inappropriate prescribing and the intervention was acceptable to both GPs and patients 12,15 .…”

Attitudes towards deprescribing in geriatric psychiatry: A survey among older psychiatric outpatients

“…For example, in the process evaluation of the SPPiRE trial, 30 many patients indicated that they were open to the idea of deprescribing but reluctant to deprescribe specific drug classes, such as benzodiazepines. 31 The hypothesis that application of the PATD/rPATD questionnaire outside an actual clinical situation might exaggerate patients' willingness to deprescribe treatment is supported by research demonstrating low predictive validity of the PATD questionnaire. 32 To better understand deprescribing willingness among older psychiatric outpatients, future research could use a revised version of the rPATD questionnaire focused on patients' psychiatric treatment or a specific group of psychotropics, such as the recently adapted and validated French version for benzodiazepine receptor agonists, 33 and preferably as part of an actual clinical situation.…”

“…It is reasonable to assume that some patients will likely put emphasis on certain medications when completing the questionnaire, meaning that it may not necessarily represent their attitudes towards their full medication list. For example, in the process evaluation of the SPPiRE trial, 30 many patients indicated that they were open to the idea of deprescribing but reluctant to deprescribe specific drug classes, such as benzodiazepines 31 . The hypothesis that application of the PATD/rPATD questionnaire outside an actual clinical situation might exaggerate patients' willingness to deprescribe treatment is supported by research demonstrating low predictive validity of the PATD questionnaire 32 .…”

Screening for Atrial Fibrillation by Digital Health Technology in Older People in Homecare Settings: A Feasibility Trial

“…Older people are often excluded from clinical trials due to advanced age, multimorbidity, and/or frailty [1]. Recruitment and retention of older participants are important challenges.…”