Randomized Controlled Trial

. 2019 Jun 6;14(1):55.

doi: 10.1186/s13012-019-0904-4.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

M Greiver^{1

2}, S Dahrouge^{3

4}, P O'Brien⁵, D Manca⁶, M T Lussier⁷, J Wang⁸, F Burge⁹, M Grandy⁹, A Singer¹⁰, M Twohig⁸, R Moineddin^{5

11

12}, S Kalia⁵, B Aliarzadeh⁵, N Ivers¹³, S Garies¹⁴, J P Turner^{15

16}, B Farrell^{3

4

17}

Affiliations

¹ North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada. michelle.greiver@nygh.on.ca.
² Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada. michelle.greiver@nygh.on.ca.
³ Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario, K1R 6M1, Canada.
⁴ Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, K1N 5C8, Canada.
⁵ Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.
⁶ Department of Family Medicine, University of Alberta, 8303 - 112 Street NW, 610 University Terrace, Edmonton, Alberta, T6G 2T4, Canada.
⁷ Department of Family Medicine and Emergency Medicine, University of Montreal, 1755 René Laennec, Bureau DS-079, Laval, Québec, H7M3L9, Canada.
⁸ North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.
⁹ Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans' Memorial Lane, Halifax, Nova Scotia, B3H 2E2, Canada.
¹⁰ Department of Family Medicine, University of Manitoba, D009 - 780 Bannatyne Ave, Winnipeg, Manitoba, R3T 2N2, Canada.
¹¹ ICES, Toronto, Canada.
¹² Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada.
¹³ Family Practice Health Centre and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5S 1B2, Canada.
¹⁴ Department of family Medicine, Cumming School of Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.
¹⁵ Faculty of Pharmacy, University of Montreal, 2900 Edouard Montpetit Boulevard, Montreal, Quebec, H3T 1J4, Canada.
¹⁶ Centre de Recherche, Institut Universitaire de Geriatrie de Montreal, Montreal, Canada.
¹⁷ School of Pharmacy, University of Waterloo, Waterloo, Canada.

PMID: 31171011
PMCID: PMC6551894
DOI: 10.1186/s13012-019-0904-4

Randomized Controlled Trial

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

M Greiver et al. Implement Sci. 2019.

. 2019 Jun 6;14(1):55.

doi: 10.1186/s13012-019-0904-4.

Authors

Affiliations

¹ North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada. michelle.greiver@nygh.on.ca.
² Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada. michelle.greiver@nygh.on.ca.
³ Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario, K1R 6M1, Canada.
⁴ Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, K1N 5C8, Canada.
⁵ Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.
⁶ Department of Family Medicine, University of Alberta, 8303 - 112 Street NW, 610 University Terrace, Edmonton, Alberta, T6G 2T4, Canada.
⁷ Department of Family Medicine and Emergency Medicine, University of Montreal, 1755 René Laennec, Bureau DS-079, Laval, Québec, H7M3L9, Canada.
⁸ North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.
⁹ Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans' Memorial Lane, Halifax, Nova Scotia, B3H 2E2, Canada.
¹⁰ Department of Family Medicine, University of Manitoba, D009 - 780 Bannatyne Ave, Winnipeg, Manitoba, R3T 2N2, Canada.
¹¹ ICES, Toronto, Canada.
¹² Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada.
¹³ Family Practice Health Centre and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5S 1B2, Canada.
¹⁴ Department of family Medicine, Cumming School of Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.
¹⁵ Faculty of Pharmacy, University of Montreal, 2900 Edouard Montpetit Boulevard, Montreal, Quebec, H3T 1J4, Canada.
¹⁶ Centre de Recherche, Institut Universitaire de Geriatrie de Montreal, Montreal, Canada.
¹⁷ School of Pharmacy, University of Waterloo, Waterloo, Canada.

PMID: 31171011
PMCID: PMC6551894
DOI: 10.1186/s13012-019-0904-4

Abstract

Background: Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed.

Methods: This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes.

Conclusion: We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement.

Trial registration: Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.

Keywords: Aged; Clinical trials, randomized; Electronic health records; Inappropriate prescribing; Polypharmacy; Primary health care; Quality improvement; Social facilitation.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

**Fig. 1**
Plan-Do-Study-Act cycle supported by SPIDER. OPEN Ottawa Practice Enhancement Network, one of the seven Practice Based Research Networks participating in SPIDER. QI quality improvement, EMR electronic medical record

**Fig. 2**
Schedule of enrolment, intervention, and outcome measurements for RCT

See this image and copyright information in PMC

References

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Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

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Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

Authors

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Conflict of interest statement

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