Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

Abstract

Background: Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.

Methods: The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.

Discussion: So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.

Trial registration: ISRCTN, ISRCTN18427377 . Registered 11 January 2018.

Keywords: Cluster-randomised controlled trial; Deprescribing; Hospital discharge; Medication review; Multimorbidity; Patient priorities; Polypharmacy; Potentially inappropriate medication.

Fig. 1

Study flow chart with accompanying process and impact evaluation. Coloured rectangles provide data for the impact evaluation (IE), and rounded edges indicate stages of the process evaluation (PE1-10). Numbers refer to the items in Additional file 1. SC, study centre; HD, hospital director; HP, hospital physician; GP, general practitioner

Fig. 2

Framework model for process (dark grey) and impact evaluation (light grey), adapted from Grant et al. [32]. Bold frames indicate extensions to the original framework; asterisks mark thematic focus. cRCT, cluster RCT; HP, hospital physician; GP, general practitioner

Fig. 3

Study schedule (SPIRIT diagram of trial stages of enrolment, intervention, outcome assessment and evaluation). R, Recruitment; T, Training; A, Admission; D, Discharge; T1/3/6, follow-ups at 1/3/6 months after discharge; HP, hospital physician; ED, emergency department; GP, general practitioner