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. 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. We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. Clinicaltrials.gov NCT03689049 ; registered September 28, 2018

中文翻译：

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改善对多种药物治疗的老年患者的护理：加拿大社区初级保健实践中的实用整群随机试验方案


长期服用多种药物的老年人可能正在服用对他们无益的药物。多重用药可能会导致健康状况不佳的风险增加、生活质量下降、护理成本高昂以及护理需求持续复杂。虽然许多药物可能存在问题，但该项目针对的是大多数老年人应取消处方的药物，并且可以使用这些指南和基于证据的取消处方工具。这些被称为潜在不适当处方 (PIP)，如下所示：质子泵抑制剂、苯二氮卓类药物、抗精神病药物和磺酰脲类药物。需要制定在复杂的老年患者群体中取消 PIP 处方的实施策略。这将是加拿大各地基于社区的初级保健实践的一项务实的整群随机对照试验。符合条件的诊所提供全面的初级保健，并且至少有一名医生同意参与。过去一年中拥有 10 种或以上独特药物处方的 65 岁及以上社区居民患者将被纳入其中。目的是评估与常规护理相比，干预措施是否会减少这些患者的目标 PIP。这项名为“数据、证据和研究结构化流程”(SPIDER) 的干预措施是质量改进 (QI) 和研究项目之间的合作。初级保健团队将组建跨专业学习协作机构，并与 QI 教练合作，审查其区域基于实践的研究网络 (PBRN) 提供的电子病历数据，确定需要改进的领域，并制定和实施变革。该研究将使用前瞻性单臂混合方法在三个 PBRN（多伦多、蒙特利尔和埃德蒙顿）进行可行性测试。 研究结果将指导在五个 PBRN（卡尔加里、温尼伯、渥太华、蒙特利尔和哈利法克斯）进行的实用整群随机对照试验。每个 PBRN 将为每个部门招募 7 名执业人员。分析将按意向进行治疗。基线时至少有 1 次 PIP 的患者中，有 10% 将被随机选择参与患者体验和自我报告结果的评估。定性方法将用于探索患者和医生的经验并评估 SPIDER 的流程。我们正在具有复杂护理需求的初级保健人群中测试 SPIDER。这可以为改善护理提供广泛适用的模型。临床试验。政府 NCT03689049 ； 2018年9月28日注册