| dc.description.abstract | Introduction
People are living longer but not necessarily in better health. The ageing population coupled with the increasing prevalence of chronic conditions has resulted in many older people being prescribed polypharmacy (four or more concurrent medicines), which may not always be appropriate. An intervention to improve appropriate polypharmacy in older people was developed and tested in Northern Ireland (NI), the PolyPrime intervention. It was developed using theory following guidance from the Medical Research Council on the development of complex interventions. The aim of this research programme was to identify other theoretically derived interventions aimed at improving polypharmacy and their effectiveness, undertake a pilot cluster randomised control trial (cRCT)of the PolyPrime intervention and explore how community pharmacists could enhance their role in the management of older people with polypharmacy, in the Republic of Ireland (RoI).
Methods
A systematic review was conducted to assess the effectiveness of theoretically derived interventions on appropriate polypharmacy in older people. The theories used and the extent to which they informed intervention design was established. The PolyPrime intervention, developed in NI, was refined for use in the RoI by undertaking semi-structured interviews with general practitioners (GPs) in the RoI. A pilot cRCT was conducted with six general practices from a defined area in the RoI (Cavan, Donegal, Leitrim, Louth, Monaghan, Sligo). The GP-led intervention involved four components: i) GPs watch a short online video (designed and scripted by the research team) ii) explicit plans made at weekly staff meetings to ensure that target patients prescribed appropriate polypharmacy, iii) patients are invited to attend the practice for a scheduled medication review, and iv) reception staff prompt the GP that the patient has arrived at the practice for their medication review. GP record data and patient self-reported data was collected at baseline, 6-months post initial medication review (or equivalent for control arm practices) and 9-months post initial medication review (or equivalent for control arm practices). Medication appropriateness, health-related quality of life and healthcare utilisation were measured, the fidelity of intervention delivery was assessed, participants perspectives of the intervention were ascertained and a process evaluation of the pilot RCT was undertaken. A semi-structured interview study, based on the Theoretical Domains Framework (TDF) was undertaken with community pharmacists regarding their role in the management of appropriate polypharmacy in older people. The PolyPrime intervention was presented to community pharmacists to determine if a similar approach would be applicable in that setting.
Results
Only two studies were included in the systematic review, highlighting a lack of theoretically derived interventions aimed at improving appropriate polypharmacy in older people. As a result of the qualitative interviews conducted with GPs minor amendments were made to PolyPrime intervention, notably the addition of guidelines and validated assessment tools. The pilot cRCT demonstrated that it was feasible to collect the desired data, both from GP practice records and patient self-reported, to provide outcome data. Overall, the intervention was well received by GPs, practice staff (as identified in semi-structured interviews), and patients (data collected in feedback questionnaire). The intervention was delivered as intended. The qualitative research with community pharmacists identified three strategies (medication review, communication with prescribers, access to patient records) that could be investigated to enhance their role in managing appropriate polypharmacy. TDF domains addressed in all three strategies included Beliefs about consequences and Environmental context and resources. Barriers to enhancing the role of community pharmacists in managing appropriate polypharmacy in older people included lack of resources such as staff and equipment, issues around General Data Protection Regulations and lack of financial support; facilitators included free up GP time, development of standard operating procedure and making changes public policy. The PolyPrime intervention was well received by community pharmacists.
Discussion/Conclusion
The research presented in this thesis reports that there is a lack of theoretically derived interventions aimed at improving appropriate polypharmacy in older people. The pilot cRCT of the PolyPrime intervention found that such interventions are acceptable to key stakeholders. The effectiveness of the PolyPrime intervention now needs to be established via a definitive trial, considering feedback from the pilot cRCT process evaluation. There is potential to expand the role of the community pharmacist in the RoI in managing appropriate polypharmacy, including developing medication reviews and communicating more with prescribers. It is possible that the PolyPrime intervention could be refined for use in community pharmacy practice. | en |
