Deprescribing is an essential component of safe prescribing, especially for people with higher levels of polypharmacy. Identifying individuals prepared to consider medicine changes may facilitate deprescribing-orientated reviews. We aimed to explore the relationship between revised patient attitudes towards deprescribing (rPATD) scores and medication changes in older people prescribed ≥15 medicines. A secondary analysis of rPATD scores and prescription data from a cluster randomised controlled trial of a GP-delivered, deprescribing-orientated medication review was conducted. The association between number of medicines stopped, started and changed and baseline rPATD scores was assessed using Poisson regression adjusting for patient age, gender, study group allocation, baseline number of medicines and effects of clustering. Participants (n=404) had a mean age of 76.4 years and were prescribed a mean of 17.1 medicines at baseline. Willingness to stop a medicine was associated with higher rates of both deprescribing (IRR: 1.40; 95%CI: 1.06-1.84) and initiating medicines (IRR: 1.43; 95%CI: 1.09-1.88). Satisfaction with current medicines was associated with a lower rate of deprescribing (IRR: 0.69; 95%CI: 0.57-0.85). The rPATD questionnaire could be used as part of a deprescribing intervention to identify participants who may be prepared to engage in deprescribing, enabling more efficient use of clinician time during complex consultations.

BackgroundNumber of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions. The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines during the SPPiRE trial.MethodsWe retrospectively analysed trial prescription data from 51 general practices with 404 participants aged ≥65 years and prescribed ≥15 repeat medicines. Repeat medications at baseline and follow-up (~1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up.Results There were 7,051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n=6,777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up.ConclusionThe number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety.Key words: Multimorbidity, polypharmacy, cluster randomised controlled trial, deprescribing, potentially inappropriate prescribingThe SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).

Background: The SPPiRE cluster randomised controlled trial (RCT) found that a GP delivered medication review that incorporated screening potentially inappropriate prescriptions (PIP), a brown bag review and a patient priority assessment, resulted in a significant but small reduction in the number of medicines and no significant reduction in PIP. Objective: To explore the experiences of GPs and patients engaged in the SPPiRE intervention and the potential for system wide implementation.Design: Mixed methods process evaluation; quantitative data was collected from the SPPiRE intervention website and qualitative data via semi-structured interviews.Setting and participants: 51 general practices throughout Ireland, and 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines participated in the RCT. Qualitative data was collected with purposive samples of intervention GPs (18/26) and patients (27/208).   Methods: Quantitative data was analysed descriptively, qualitative data thematically and both were integrated using a triangulation protocol.Results: The analysis generated three themes, intervention implementation, mechanisms of action, and both were underpinned by the theme of context. One fifth of patients had no review, primarily due to insufficient GP time. The brown bag review component resulted in the most medication changes, particularly stopping a medicine. GPs felt it easier to change medicines if the patient was well known to them, and patients were generally receptive to change. GPs identified lack of integration into practice software systems and resources as barriers to future implementation.Conclusion: Consideration of implementation of successful interventions is key to informing policy and integration into clinical practice. GPs and patients viewed the intervention positively, but implementation will depend on resourcing and integration into practice software systems.Trial registration number: ISRCTN12752680