Nursing home team-care deprescribing study: a stepped-wedge randomised controlled trial protocol

Abstract

Introduction: An ageing population has become an urgent concern for Asia in recent times. In nursing homes, polypharmacy has also become a compounding issue. Deprescribing practice is an evidence-based strategy to provide a better outcome in this group of patients; however, its implementation in nursing homes is often challenging, and prospective outcome data on deprescribing practice in the elderly is lacking. Our study assesses the implementation of team-care deprescribing to understand the benefits of this practice in geriatric setting and to explore the factors affecting deprescribing practice.

Methods and analysis: This multicentre prospective study consists of a prestudy interview questionnaire, and a preintervention and postintervention study to be conducted in the nursing home setting on residents at least 65 years old and on five or more medications. We will employ a cluster randomised stepped-wedge interventional design, based on a five-step (reviewing, checking, discussion, communication and documentation) team-care deprescribing practice coupled with the use of a deprescribing guide (consisting of Beers and STOPP criteria, as well as drug interaction checking), to assess the health and pharmacoeconomic outcome in nursing homes' practice. Primary outcome measures of the intervention will consist of fall risks using a fall risk assessment tool. Other outcomes assessed include fall rates, pill burden including number of pills per day, number of doses per day and number of medications prescribed. Cost-related measures will include the use of cost-benefit analysis, which is calculated from the medication cost savings from deprescribing. For the prestudy interview questionnaire, findings will be analysed qualitatively using thematic analysis.

Ethics and dissemination: This study is approved by the Domain Specific Review Board of National Healthcare Group, Singapore (2016/00422) and Monash University Human Research Ethics Committee (2016-1430-7791). The study findings shall be disseminated in international conferences and peer-reviewed publications. The study is registered with ClinicalTrials.gov (NCT02863341), Pre-results.

Keywords: Deprescribing; Elderly; Falls; Multidisciplinary; Nursing home; Polypharmacy.

Figure 1

The stepped-wedge design for the current study. Baseline population of each home is subclassified into two groups (groups A and B). Group As are non-naive (participants whose attending doctor or pharmacist has recently deprescribed their medications within 6 months before the study starts), while the group Bs are intervention naive. Intervention will be implemented to first half of the participants in 3 months. Each home thus has four clusters, and all clusters will be assessed for sustainability of outcomes after 6 months.

Figure 2

Five-step team-based deprescribing practice.