COMPLETED: MODIFY: The development and iMplementation Of a multidisciplinary medication review and Deprescribing Intervention among Frail older people in primarY care

Principal Investigator: Dr Kinda Ibrahim

Project team: Eloise Radcliffe, Dr Simon Fraser, Clare Howard, Professor Paul Rutter, Professor Susan Latter, Claire Sheikh, Dr Lawrence Brad, Dr Mark Lown, Dr Alejandra Recio-Saucedo, Dr Kat Bradbury, Dr David Culliford, Dr Maria Chorozoglou, Cynthia Russell (PPI lead).

Further PPI involvement from:Pam Holloway, Neil Wilson, Rajneesh Kaur

Additional support from Renee Servin and Lucy Murphy (Medical students)

Partners: University of Portsmouth, Westbourne Medical Centre, Wessex Health Innovation Network, PresQiPP, NIHR CRN Wessex

Summary of findings

1 in 3 people aged 65 and older take 5 or more medicines every day (polypharmacy). Some of these drugs may no longer be appropriate. They could increase the risk of falls, hospital admission, or even death, especially among people who are frail (and less able to recover from injury and illness). Deprescribing (reducing, stopping or switching drugs) is safe for some conditions, medications and in settings such as primary care. But Health Care Professionals (HCPs) may face problems with carrying this out. Problems may include a lack of time for HCPs, and HCPs and patients may be concerned about stopping medication which was first prescribed by a specialist. Previous research highlights that this problem could be addressed by teams of HCPs from different disciplines, including practice pharmacists, working together on the medication review and deprescribing process.

The research team reviewed 28 studies on older people in primary care to explore what makes medication review and deprescribing work best in a team of HCPs.

Alongside this, the research team carried out in-depth interviews with ten older patients and three of their family carers, and focus groups with 26 health care professionals working in eight different GP practices. This helped the team to understand different experiences of medication reviews and deprescribing, and how this process can work best.

Based on the results the team suggested ways to improve deprescribing in primary care.

They include:

• clear roles and responsibilities for HCPs, with good communication between team members, and pharmacists integrated within teams

• training and education on deprescribing for HCPs

• routine discussions about deprescribing when prescribing, with medication reviews tailored to patients’ needs and preferences, and addressing any questions or concerns

• involvement of patients and informal carers, and trusted relationships with professionals allowing continuity of care.

Based on the results the research team developed an intervention to improve medication review and deprescribing for older people with frailty and taking 10 or more medicines, to target those who would benefit most.

The intervention has five phases:

1) Identification on practice databases of older patients aged 75 and over living with frailty, prescribed 10 or more medications, to be invited for a medication review

2) Preparation for HCPs, through using deprescribing tip sheets and a digital tool to help prioritise medication for deprescribing (with training provided)

3) Written information leaflet sent to patients and carers about the purpose of medication review and the reasons for potentially stopping or changing medications

4) The HCP (mainly a practice pharmacist) will conduct a person-centred medication review taking into account patient and carer needs and preferences. They will involve other HCPs members based on their expertise, and document and share any agreed changes with patients and other staff members if needed;

5) Tailored written follow-up plans to be given to patients and carer, and further contact arranged if needed.

See NIHR Alert - How to deprescribe in Primary Care which features this research

How we shared these findings

Conferences and dissemination to Health Care Professionals

•European Clinical Pharmacy Society conference, October 2022, Prague, Czech Republic 2022 (oral and poster)

•Faculty of Medicine Conference, University of Southampton, June 2023 (oral and poster)

•Health Services Research and Pharmacy Practice conference, Cork, Ireland 2023 (oral and poster)

•ARC Wessex collaborating for impact showcase event, June 2023

•Society for Academic Primary Care conference, Brighton, July 2023

•South West Society for Academic Primary Care conference, Cardiff Wales, March 2024

•International Conference on Deprescribing, Nantes, France September 2024

Other presentations and talks

•Invited to present MODIFY at the Society for Academic other presentations Primary Care Medicines Optimisation Special Interest Group, 12th March 2024

•Invited to present on deprescribing at the CRN national event on Multimorbidity in May 2023.

•Invited to present MODIFY at the CRN coordination Wessex Pharmacy Research Network meeting, 28th February 2024

•Presented MODIFY during a meeting with Prof. Tony Avery, the National Clinical Director for Prescribing, 1st March 2024

•Shared learning on MODIFY with Prof David Alldred and his team at Leeds, Jan 2022

•Introduced MODIFY at the Health Innovation Network Polypharmacy Community of Practice meeting, July 2022

Publications:

We published our findings from our realist review in BMC Geriatrics: https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-023-04256-8

Our publication was selected as an NIHR evidence alert, and promoted more widely     on social media to health care professionals and policymakers: How to deprescribe inprimary care - NIHR Evidence

Education of undergraduate an postgraduate students

•Plenary talk on polypharmacy and deprescribing to year 1 medical students in May 2024

•Invited talk by University Hospital Southampton at a General Internal Medicine Training day 16th September 2024, MODIFY presented to over 100 trainees

Public and patient engagement

Presentation and discussion of MODIFY at a Community medical science engagement session with 12 older people (via Communicare, a local social service organisation on 4th September 2024)

Lay Summary or research protocol

Background: A third of older people take five or more regular medications (polypharmacy) potentially increasing the risk of side-effects, hospital admission and death. These effects are higher among people living with frailty who lose their in-built reserves and become vulnerable to changes triggered by small events such as a change in medication. National recommendations suggest that medications taken by frail older people should be reviewed annually by their GPs to identify and reduce/stop inappropriate medications (deprescribing).Yet this does not happen routinely due to GPs’ lack of time, increased workloads and worries about stopping medicines. Recent recommendations suggest involving other non-medical prescribers such as practice pharmacists and advanced nurse practitioners (ANPs) in reviewing medications. However, it is unknown how staff could work together most effectively and whether they have any training needs.

Aim: This research will investigate how practice-pharmacists, ANPs and GPs could best work together with patients living with frailty to perform regular medication review.

Methods The study involves four work packages (WPs). We will review previous literature to identify what makes a successful medication review and how to safely reduce/ stop inappropriate medications (WP1). Interviews with GPs, practice-pharmacists, ANPs, frail older patients and carers will be conducted (WP2). These will discover views about where medication review should take place, the role of each of the involved parties in the process, type of medications that could be deprescribed, staff development and training needs, barriers and facilitators for implementation, and strategies to address these barriers. Information gathered from WP1&2 will be used to develop the intervention: a structured medication review process using pharmacists, ANPs and GPs most effectively and involving frail patients and their families in decisions about medications (WP3). The intervention will be refined further through a series of workshops with service users, clinicians and commissioners. A training programme to implement the intervention and increase staff confidence in reducing/ stopping medications safely will be developed and delivered to GPs, practice-pharmacists and ANPs based on the Polypharmacy Action Learning Sets approach adopted by the Wessex Academic Health Science Network (AHSN) . Finally, we will assess whether itis feasible and acceptable for staff in four GP practices to be trained and to implement the intervention with their patients (WP4).

Public Patient Involvement: Three PPI members have been involved in protocol development and refinement and will continue to contribute to the research study by for example being involved in developing research instruments and monitoring recruitment. Dissemination and

Impact: Working with colleagues in the Wessex AHSN and local clinical commissioners, we will be able to share our findings and training programme to the wider research and clinical community in Wessex and potentially influence practices and policies both locally and nationally.

Ibrahim, K., Cox, N.J., Stevenson, J.M. et al. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr 21, 258 (2021). https://doi.org/10.1186/s12877-021-02208-8

Pazan, F., Petrovic, M., Cherubini, A. et al. Current evidence on the impact of medication optimization or pharmacological interventions on frailty or aspects of frailty: a systematic review of randomized controlled trials. Eur J Clin Pharmacol 77, 1–12 (2021). https://doi.org/10.1007/s00228-020-02951-8

Radcliffe E, Servin R, Cox N, Lim S, Tan QY, Howard C, Sheikh C, Rutter P, Latter S, Lown M, Brad L, Fraser SDS, Bradbury K, Roberts HC, Saucedo AR, Ibrahim K. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatr. 2023 Sep 25;23(1):591 (2023). https://doi.org/10.1186/s12877-023-04256-8