Research ArticleOriginal Research

Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)

Barbara Clyne, Susan M. Smith, Carmel M. Hughes, Fiona Boland, Marie C. Bradley, Janine A. Cooper and Tom Fahey; on behalf of the OPTI-SCRIPT study team
The Annals of Family Medicine November 2015, 13 (6) 545-553; DOI: https://doi.org/10.1370/afm.1838

Article Figures & Data

Figures

Tables

  • Table 1

    Summary of OPTI-SCRIPT Intervention and Control Procedures

    InterventionControl
    Academic detailing with a pharmacist, which entailed one 30-min session in which a pharmacist visited the practice to discuss PIP, a review of medicines, and the web-based pharmaceutical treatment algorithms
    Medicine review with web-based pharmaceutical treatment algorithms. GPs were asked to conduct 1 review per patient using the web-based platform to guide them through the process. The GP was presented with the specific PIP drug(s) for each patient, and for each PIP drug, was offered a treatment algorithm with the following structure:
     1. The individual PIP with reason for concern
     2. Alternative pharmacologic and nonpharmacologic treatment options
     3. Background information (where relevant)
    Patient information leaflets to give to patients during the review. Each leaflet:
     1. Described the PIP and the reasons why it may be inappropriate
     2. Outlined the alternative pharmacologic and nonpharmacologic therapies GPs may offer    		Delivery of usual care, which for public general medical services patients allows GPs to give a prescription on a monthly or 3-month basis
    Receipt of simple, patient-level PIP postal feedback in the form of a list summarizing the medication class to which the individual patient’s potentially inappropriate medication belonged
    No academic detailing visit, and no prompts to carry out a medicine review with the individual patients

    • GP = general practitioner; OPTI-SCRIPT = Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial; PIP = potentially inappropriate prescribing.

  • Table 2

    Baseline Characteristics of Practices and Patients in Intervention and Control Groups

    CharacteristicIntervention GroupControl Group
    Practicesn = 11n = 10
    GMS list size, No. (%)
     ≤5001 (9.1)2 (20.0)
     501–1,5003 (27.3)2 (20.0)
     ≥1,5017 (63.6)6 (60.0)
    Have a manager, No. (%)8 (72.8)7 (70.0)
    Location, No. (%)
     Urbana8 (80.0)8 (72.7)
     Mixed3 (20.0)2 (27.3)
    GPs per practice, mean (SD)4.1 (3.1)4.1 (2.1)
    Patients >70 years old per practice, mean (SD)712.1 (525.3)788.2 (987.2)
    Deprivation score, median (IQR)b0.5 (–0.3 to 1.6)1.4 (0.3 to 2.4)
    Patientsn = 99n = 97
    Male, No. (%)55 (55.6)50 (51.5)
    Marital status, No. (%)
     Married56 (56.6)51 (53.1)
     Widowed26 (26.3)32 (33.3)
     Single14 (14.1)10 (10.4)
    GMS card holder, No. (%)88 (88.9)95 (97.9)
    Age, mean (SD)77.1 (4.9)76.4 (4.8)
    Repeat medications, mean (SD)10.2 (4.5)9.5 (4.1)
    PIP drugsc
     Mean (SD)1.31 (0.6)1.39 (0.6)
     Median (IQR)1 (1–2)1 (1–2)
    Most prevalent PIP drug: proton pump inhibitors, No. (%)53 (53.3)65 (67.7)

    • GMS = general medical services; GP = general practitioner; IQR = interquartile range; PIP = potentially inappropriate prescribing.

    • Note: Figures are numbers (percentages) unless stated otherwise.

    • ↵a Urban area: relatively small center of population, with at least 5,000 residents.37

    • ↵b Population-weighted deprivation score for each practice; higher scores mean practices are situated in more socioeconomically deprived areas.

    • ↵c All patients had at least 1 potentially inappropriate prescription at baseline.

  • Table 3

    Potentially Inappropriate Prescriptions at Baseline in Intervention and Control Groups

    Potentially Inappropriate PrescriptionIntervention Group, No. (%) (n = 99)Control Group, No. (%) (n = 97)
    Proton pump inhibitor at maximum therapeutic dosage for >8 weeks53 (53.3)65 (67.7)
    NSAIDs: long-term use, interactions with certain medications (eg, diuretic)21 (21.2)16 (16.8)
    Therapeutic duplication: any regular duplicate drug class prescription (eg, 2 concurrent opiates, NSAIDs)19 (19.2)13 (13.5)
    Long-term use (>1 month) of long-acting benzodiazepines14 (14.4)8 (8.3)
    Steroid without bisphosphonate9 (9.1)4 (4.2)
    Bladder antimuscarinics: contraindications and interactions with certain medications1 (1.0)9 (9.4)
    Prolonged use (>1 week) of first-generation antihistamines4 (4.0)2 (2.1)
    Tricyclic antidepressants: contraindications and interactions with certain medications (eg, opiate, calcium channel blocker)1 (1.0)5 (5.2)
    Thiazide diuretic in patient with gout3 (3.0)2 (2.1)
    Aspirin: contraindications and interactions with certain medications (eg, warfarin)3 (3.0)1 (1.0)
    Digoxin: inappropriate dose1 (1.0)3 (3.1)
    Calcium channel blocker: contraindications and interactions with certain medications0 (0.0)3 (3.1)

    • NSAID = nonsteroidal anti-inflammatory drug.

  • Table 4

    Intention-to-Treat Analysis of Primary Outcomes

    OutcomeIntervention Group, No. (%)Control Group, No. (%)Adjusteda Odds Ratio (95% CI)Adjusteda Incidence Rate Ratio (95% CI)Mean Differencea,b (95% CI)P Value
    Primary outcome: proportion with PIP
     Baseline99 (100)97 (100)––––
     Intervention completion52 (52.5)75 (77.3)0.32 (0.15–0.70)––.02
    Primary outcome: mean (SD) PIP
     Baseline1.31 (0.6)1.39 (0.6)––––
     Intervention completion0.70 (0.1)1.18 (0.1)––−0.48 (–0.80 to –0.17).02
    Additional outcome: median (IQR) PIP per patient
     Baseline1 (1–2)1 (1–2)––––
     Intervention completion1 (0–1)1 (1–2)––––
    Additional outcome: Poisson regression
     Baseline99 (100)97 (100)––––
     Intervention completion52 (52.5)75 (77.3)–0.71 (0.50–1.02)c–.49

    • IQR = interquartile range; PIP = potentially inappropriate prescribing.

    • Note: Values are numbers (percentages) unless stated otherwise. We used the Bonferroni method to account for multiple comparisons.

    • ↵a Adjusted for age, sex, baseline number of PIP drugs, baseline number of repeat medications, number of general practitioners, and practice location.

    • ↵b Results from modeling the number of PIP drugs per patient with Poisson regression analysis adjusted for age, sex, baseline number of PIP drugs, baseline number of repeat medications, number of general practitioners, and practice location.

    • ↵c Results from unadjusted cluster-level t test.

  • Table 5

    Intention-to-Treat Analysis of Secondary Outcomes

    OutcomeIntervention GroupControl GroupAdjusteda Odds Ratio or Mean Difference (95% CI)P Value
    Drug-specific outcomes
    Proton pump inhibitor, No. (%)
     Baseline53 (53.5)65 (67.7)
     Intervention completion23 (23.2)46 (47.4)0.30 (0.14–0.68).04
    Duplicate, No. (%)
     Baseline19 (19.2)13 (13.5)
     Intervention completion11 (11.1)11 (11.3)0.83 (0.32–2.13).99
    Long-term benzodiazepines,
     No. (%)
     Baseline14 (14.1)8 (8.1)
     Intervention completion9 (9.1)9 (9.1)1.31 (0.47–3.68).99
    Patient-reported outcomes
    WBQ-12 score: mean well-beingb
     Baseline24.324.4
     Intervention completion23.624.0–0.41 (−0.80 to 1.07).99
    BMQ score: median necessity-concern differentialc
     Baseline7.05.8
     Intervention completion6.06.00.16 (−1.85 to 1.07).99

    • BMQ = Beliefs About Medicine Questionnaire; WBQ-12 = 12-item Well-Being Questionnaire.

    • Note: Figures are numbers (percentages) unless stated otherwise. The Bonferroni method was used to account for multiple comparisons.

    • ↵a Adjusted for age, sex, baseline number of PIP drugs, baseline number of repeat medications, number of general practitioners, and practice location.

    • ↵b Well-being score ranges from 0 to 36 (1–12 low, 13–24 medium, 25–36 high).

    • ↵c Scale from −20 to 20, where positive scores indicate benefits outweigh risks.

  • Table 6

    Comparison of PIP in the OPTI-SCRIPT Study Population With the PCRS National Comparator

    PIP OutcomeOPTI-SCRIPT Intervention GroupOPTI-SCRIPT Control GroupPCRS National Comparator
    Presence of PIP
     PIP at baseline99 (100)97 (100)103,261 (100)
     PIP at intervention completion52 (52.5)75 (77.3)75,401 (73.1)
     No PIP at intervention completion47 (47.5)22 (22.7)27,860 (26.9)
     Crude odds ratio (95% CI)0.4 (0.3–0.6)–1.0 (ref)
    Decrease in PIP
     PIP at baseline99 (100)97 (100)103,261 (100)
     PIP same or increased at intervention completion42 (42.4)65 (67.0)67,188 (65.1)
     PIP decreased at intervention completion57 (57.6)32 (32.9)36,073 (34.9)
     Crude odds ratio (95% CI)2.5 (1.8–4.0)–1.0 (ref)

    • OPTI-SCRIPT = Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial; PCRS = Primary Care Reimbursement Services; PIP = potentially inappropriate prescribing; ref = reference group.

    • Note: Numbers (percentages) of participants are presented, unless otherwise stated.

Additional Files

  • Supplemental Appendixes

    Supplemental Appendix 1. Selected prescribing criteria/prescribing indicator; Supplemental Appendix 2. OPTI-SCRIPT website materials

    Files in this Data Supplement:

  • The Article in Brief

    Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)

    Barbara Clyne , and colleagues

    Background Potentially inappropriate prescribing of medications is a common and growing public health concern that can result in increased death, adverse drug reactions, hospitalizations, and costs. Previous research in Ireland showed that 36 percent of those aged 70 years or older received at least one potentially inappropriate prescription in 2007 with an associated cost of more than 45 million euros. In this study, researchers in Ireland test the effectiveness of an intensive multifaceted intervention for reducing potentially inappropriate prescribing (PIP) in primary care.

    What This Study Found The year-long intervention was effective in reducing PIP. It included face-to-face academic detailing with a pharmacist, medicine review with web-based pharmaceutical treatment algorithms that provided alternative treatment options, and tailored patient information leaflets. At the completion of the intervention, the percentage of patients having PIP was 52 percent in the intervention group compared with 77 percent in the control group. The average number of PIP drugs per patient in the intervention group was 0.70 compared with 1.18 in the control group. Potentially inappropriate prescribing of proton pump inhibitors, which was highly prevalent at baseline (60 percent) was greatly improved through the intervention.

    Implications

    • The authors suggest that face-to-face, patient-specific detailing encouraged immediate action rather than simply providing educational support or information. They call for future research to examine tailoring of this intervention to influence different cases of PIP.
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