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Can a consumer-targeted, pharmacist-led educational intervention reduce prescriptions for inappropriate medication among community-dwelling older adults?
In this cluster randomized trial that included 489 older adults, the percentage achieving discontinuation of a targeted inappropriate prescription at 6 months was 43% among patients receiving the intervention vs 12% receiving usual care, which represents a significant difference.
A pharmacist-led intervention has the potential to reduce prescriptions for inappropriate medication in older adults.
High rates of inappropriate prescribing persist among older adults in many outpatient settings, increasing the risk of adverse drug events and drug-related hospitalizations.
To compare the effectiveness of a consumer-targeted, pharmacist-led educational intervention vs usual care on discontinuation of inappropriate medication among community-dwelling older adults.
Design, Setting, and Participants
A cluster randomized trial (D-PRESCRIBE [Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly]) that recruited community pharmacies in Quebec, Canada, from February 2014 to September 2017, with follow-up until February 2018, and randomly allocated them to intervention or control groups. Patients included were adults aged 65 years and older who were prescribed 1 of 4 Beers Criteria medications (sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs), recruited from 69 community pharmacies. Patients were screened and enrolled before randomization.
Pharmacists in the intervention group were encouraged to send patients an educational deprescribing brochure in parallel to sending their physicians an evidence-based pharmaceutical opinion to recommend deprescribing. The pharmacists in the control group provided usual care. Randomization occurred at the pharmacy level, with 34 pharmacies randomized to the intervention group (248 patients) and 35 to the control group (241 patients). Patients, physicians, pharmacists, and evaluators were blinded to outcome assessment.
Main Outcomes and Measures
Discontinuation of prescriptions for inappropriate medication at 6 months, ascertained by pharmacy medication renewal profiles.
Among 489 patients (mean age, 75 years; 66% women), 437 (89%) completed the trial (219 [88%] in the intervention group vs 218 [91%] in the control group). At 6 months, 106 of 248 patients (43%) in the intervention group no longer filled prescriptions for inappropriate medication compared with 29 of 241 (12%) in the control group (risk difference, 31% [95% CI, 23% to 38%]). In the intervention vs control group, discontinuation of inappropriate medication occurred among 63 of 146 sedative-hypnotic drug users (43.2%) vs 14 of 155 (9.0%), respectively (risk difference, 34% [95% CI, 25% to 43%]); 19 of 62 glyburide users (30.6%) vs 8 of 58 (13.8%), respectively (risk difference, 17% [95% CI, 2% to 31%]); and 19 of 33 nonsteroidal anti-inflammatory drug users (57.6%) vs 5 of 23 (21.7%), respectively (risk difference, 35% [95% CI, 10% to 55%]) (P for interaction = .09). Analysis of the antihistamine drug class was not possible because of the small sample size (n = 12). No adverse events requiring hospitalization were reported, although 29 of 77 patients (38%) who attempted to taper sedative-hypnotics reported withdrawal symptoms.
Conclusions and Relevance
Among older adults in Quebec, a pharmacist-led educational intervention compared with usual care resulted in greater discontinuation of prescriptions for inappropriate medication after 6 months. The generalizability of these findings to other settings requires further research.
ClinicalTrials.gov Identifier: NCT02053194
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Accepted for Publication: September 25, 2018.
Corresponding Author: Cara Tannenbaum, MD, MSc, Centre de Recherche de l’Institut universitaire de gériatrie de Montréal, 4545 Queen Mary Rd, Montreal, QC, Canada H3W 1W5 (firstname.lastname@example.org).
Author Contributions: Dr Martin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Martin, Ahmed, Tannenbaum.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Martin, Tannenbaum.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Martin, Benedetti, Ahmed.
Obtained funding: Martin, Tannenbaum.
Administrative, technical, or material support: Martin.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Martin received a bursary from the Michel Saucier Endowed Chair in Pharmacology, Health and Aging of the Faculty of Pharmacy of the Université de Montréal. Drs Ahmed and Tannenbaum are clinician-scientists funded by the Fonds de Recherche en Santé de Quebec. No other disclosures were reported.
Funding/Support: This study was funded by Canadian Institutes of Health Research Grant CIHR 201303MOP-299872-KTR.
Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We wish to acknowledge Isabelle Reid, MSc, who coordinated and conducted the in-home interviews, enrolled patients in the study, and helped with database management. We also thank Danielle Clément,BA; Liliane Cefaloni, BA; Marie-Ève Lavoie, PhD; and Céline Morisette, PhD, who aided with recruitment and follow-up. Isabelle Reid, MSc; Danielle Clément, BA; Liliane Cefaloni, BA; Marie-Ève Lavoie, PhD; and Céline Morisette, PhD, were all affiliated with the Centre de recherche de l'Institut universitaire de gériatrie de Montréal. Nancy Zhang (PharmD student) provided assistance with the pharmaceutical profiles and is affiliated with the Université de Montréal. All of the above-mentioned individuals received financial compensation for their contribution to this work. Alex Halme, MD, PharmD, of McGill University provided assistance without compensation for the multivariable imputation modeling. We express gratitude to all the patients and pharmacists who took part in this trial. Telus, the Pharmaprix, Uniprix, and Brunet pharmacy chains were instrumental as collaborators.
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