Background

For older populations with multimorbidity, polypharmacy (use of multiple medications) is standard practice. PolyPrime is a theory-based intervention developed to improve appropriate polypharmacy in older people in primary care. The intervention consists of a video demonstrating how general practitioners (GPs) can prescribe appropriate polypharmacy during a typical consultation with an older patient, a patient recall process, GPs making explicit plans to ensure patients are prescribed appropriate polypharmacy and receiving prompts to do so.

 

Supported by the HSC R&D Division Cross-border Healthcare Intervention Trials in Ireland Network (CHITIN) programme, funded by the European Union’s INTERREG VA Programme, managed by the Special EU Programmes Body (SEUPB), this study aimed to assess the feasibility of the PolyPrime intervention in primary care in two jurisdictions, Northern Ireland (NI) and the Republic of Ireland (ROI).

 

Methods

The study consisted of three phases.  Phase 1 was an intervention refinement phase, Phase 2 was a randomised pilot study, and Phase 3 (running in parallel with Phase 2) was an embedded process evaluation.

 

Phase 1: Because the original intervention had been developed in NI, a refinement phase was carried out in the ROI.  Interviews were conducted with 13 GPs in 12 practices from five border counties in the ROI.  The nature of the intervention was explained, GPs were shown the video and asked for their views. 

 

Phase 2: The external pilot cluster randomised controlled trial (cRCT) aimed to recruit 12 GP practices (six in NI; six in the ROI counties that border NI) and 10 older patients receiving polypharmacy (defined as ≥4 medications in this study) per GP practice (n=120). Practices allocated to the intervention arm watched the video (available via an online platform) and scheduled medication reviews with patients on two occasions. We assessed the feasibility of collecting GP record (medication appropriateness, health service use) and patient self-reported data [health-related quality of life (HRQoL), health service use)] at baseline, 6 and 9 months. HRQoL was measured using the EuroQol-5 dimension-5 level questionnaire (EQ-5D-5L) and medication-related burden quality of life (MRB-QoL) tool.  A health economics analysis was also undertaken using relevant data to assess the cost of the intervention. Pre-specified progression criteria (recruitment and retention of practices and patients and collection of outcome data, assessed against targets which were pre-specified as ‘Go’, ‘Amend’ or ‘Stop’) were used to determine whether to proceed to a definitive cRCT.

 

Phase 3: An embedded process evaluation was undertaken to examine the implementation of the PolyPrime intervention, focusing on acceptability, fidelity and mechanism of action.

 

Results

Phase 1: GPs were largely supportive, suggesting minor changes to the content of the video.  They also recommended providing study information for staff and a patient recruitment poster that could be displayed in practices over the course of the pilot trial.

 

Phase 2: 12 GP practices were recruited and randomised in the pilot trial. Three GP practices withdrew from the study due to COVID-related factors. Sixty-eight patients were recruited, with 47 (69.1%) being retained until the end of the study. GP record data were available for 47 patients for medication appropriateness analysis at nine months. EQ-5D-5L and MRB-QoL data were available for 46 and 41 patients, respectively at nine months. GP record and patient self-reported health service use data were available for 47 patients at nine months. Health service use was comparable in terms of overall cost estimated from GP record versus patient self-reported data, and the cost of the intervention was estimated to be just under £300 per intervention patient.

 

Phase 3: The intervention was successfully delivered as intended, it was acceptable to GPs, practice staff and patients and potential mechanisms of action were identified. All five progression criteria were met (two ‘Go’, three ‘Amend’).

 

Conclusion: Despite challenges faced during the COVID-19 pandemic, this study has demonstrated that it may be feasible to conduct an intervention to improve appropriate polypharmacy in older people in primary care across two healthcare jurisdictions.  In order to take this intervention forward into a full trial, consideration needs to be given to changes in policy and the primary care workforce across the two jurisdictions which may affect the implementation of the PolyPrime intervention.