Implementation of inter-departmental Collaborative Medication Review to reduce potentially inappropriate medication use in hospitalized elderly patients: A mixed methods study protocol

doi:10.21203/rs.3.rs-5223887/v1

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Study protocol

Implementation of inter-departmental Collaborative Medication Review to reduce potentially inappropriate medication use in hospitalized elderly patients: A mixed methods study protocol

https://doi.org/10.21203/rs.3.rs-5223887/v1

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Background: The inappropriate use of multiple medications, known as polypharmacy, is a growing concern for the elderly population in India, who are often prescribed multiple medications due to comorbid conditions. This can lead to serious adverse health outcomes, increased healthcare costs, and reduced quality of life. Screening tools, such as the Medication Appropriateness Index (MAI) and the STOPP/START criteria, can help identify potentially inappropriate medications (PIMs), and interventions, such as medication review clinics and prescribing audits, can help improve appropriateness. Collaborative medication review (CMR) involving a team approach is important to ensure that patients receive the best possible care. However, the cost of these interventions remains a concern, especially in countries where healthcare spending is high for the elderly population.

Methods: This study will be conducted in 5 phases, where phase 1 involves developing a scoping review on CMR practices, followed by phase 2, which involves the drafting of SOPs to formulate the CMR team in the Indian context, defining their individual roles and responsibilities, the constitution of the CMR team, and training of the CMR team; phase 3 will assess the efficacy of CMR via standardized tools such as the MAI and STOPP/START criteria; and phase 4 will assess the challenges and barriers in the implementation of collaborative medication review (CMR) in the Indian health care setting. The final phase, phase 5, will evaluate the costs incurred in the implementation of CMR from a health system perspective. The study design will be a multicentred mixed-method study, where the qualitative component will assess the feasibility of collaborative medication review via in-depth interviews and focused group discussion to explore the challenges in the implementation of interdepartmental collaborative medication review to reduce PIM use in hospitalized elderly patients. The quantitative component of the study will be a quasi-experimental pre- and postinterventional study involving 280 hospitalized elderly participants' prescriptions from the admission day until 30 days post discharge by the CMR team members to estimate the costs incurred for the implementation of CMR in healthcare settings from the health care provider perspective and a reduction in the percentage of potentially inappropriate medications using the STOPP/START criteria, the medication appropriateness index (MAI) and post discharge adverse events. The assessment tool for hospital admissions related to medications-10 (AT-HARM10) will be used to identify hospital admissions related to medications.

Discussion: The findings of this study provide valuable insights into the implementation and effectiveness of CMR in the Indian healthcare setting. This study helps to understand the facilitators of and barriers to implementing interdepartmental collaborative medication review (CMR) and the cost incurred in its implementation from a healthcare provider perspective in an Indian healthcare setting. Healthcare professionals from different departments or disciplines work together to review the medication needs of elderly patients, who more commonly suffer from multiple chronic conditions. This approach addresses the challenges of managing multimorbidity in India, such as professional isolation, inadequate guidelines and evidence-based medicine, and barriers pertaining to shared decision-making by treating clinicians. The collaborative medication review process allows for a more comprehensive and coordinated approach to medication management, potentially improving patient outcomes and reducing healthcare costs.

Trial registration: The study has been registered with the Clinical Trials Registry–India (CTRI/2024/06/069220) registered on 19/06/2024.

Collaborative medication review

potentially inappropriate medications

medication-related hospital admissions

elderly prescriptions

facilitators

barriers

Inappropriate polypharmacy refers to the use of multiple medications in a way that is not consistent with established treatment guidelines or that can increase the risk of adverse drug reactions, drug interactions, or other health problems. High-risk populations, such as older adults and individuals with multiple chronic conditions, are particularly vulnerable to inappropriate polypharmacy. In India, inappropriate polypharmacy in elderly individuals is a growing concern due to the lack of awareness and regulations surrounding medication use. The prevalence of potentially inappropriate medicine use among the older Indian adult population is 28%.¹ The elderly population in India above 60 years of age represents 8.6% (104 million) of the total population.² These patients often have multiple comorbidities, leading to the prescription of multiple medications. The consequences of inappropriate polypharmacy in high-risk populations can be serious and can include increased risk of falls, hospitalizations, and other adverse health outcomes. In addition, inappropriate polypharmacy can lead to increased healthcare costs and reduced quality of life for patients.³

To address this issue, many screening tools can be classified as either implicit (judgment-based) or explicit (criterion-based) tools to identify inappropriate polypharmacy.⁴ Implicit tools such as the Medication Appropriateness Index (MAI) and Assessment of Underutilization of Medicine (AOU) assess the prescribing quality of a physician’s prescription for an elderly patient. Explicit tools such as Beer’s criteria and the Screening Tool of Older Person’s Prescriptions (STOPP)/Screening Tool are used to alert doctors to the right treatment. START criteria are developed from the literature reviews, expert opinions, and consensus exercises, typically comprising a list of drugs to be avoided or added to elderly people.⁵ However, along with identifying inappropriateness, choosing the best intervention to improve appropriate polypharmacy is a priority goal.

Improvements in inappropriate polypharmacy can be achieved by a wide range of interventions to address the complexity of clinical situations and the individuality of prescribers. In India, interventions to improve appropriate polypharmacy are needed to address specific problems related to multimorbidity, which need to be integrated into existing healthcare systems and embedded with interprofessional collaboration. Some of the interventions include education programs for prescribers or consumers; medication review clinics and specific prescribing audits; and prescribing incentive schemes and regulatory interventions.⁶

Effective polypharmacy interventions involving drug reviews require the consideration of several factors, including the hospital setting, health care professional, purpose and scope of review, criteria to guide review, tool to base drug review and, finally, method (manual of the clinical decision support system) used for drug review. The current literature distinguishes three types of drug reviews, namely, prescription reviews (performed without the patient) and concordance and complication reviews and clinical medication reviews (performed in the presence of the patients). However, in India, it is feasible to conduct only a prescription review on the basis of its convenience and feasibility.⁷

Furthermore, drug reviews are usually formalized and driven either by implicit or explicit criteria. Owing to their usefulness, explicit or criteria-based screening tools are used most often to help systematic assessment of medication appropriateness. Varas-Doval et al. conducted the ConSIGUE Program, which assessed the impact and implementation of medication review with follow-up (MRF) for aged polypharmacy patients. This finding suggested that the provision of an MRF in collaboration with general medical practitioners and patients contributes to the improvement of aged polypharmacy patients’ health status and reduces their problems related to the use of medicines.⁸ Medication reviews have been shown to be a cost-effective strategy through a cost‒utility analysis.⁹ However, policy makers look for other economic evidence other than the cost‒utility analysis in the process of considering a change in health policy and a payment for the service.

Malet-Larrea et al.¹⁰ conducted a cluster randomized trial of medication review with follow-up (MRF) to ascertain its economic impact from a national health system (NHS) perspective over six months. The cost‒benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained. In fact, other studies presented even greater cost‒benefit ratios, such as those included in a series of systematic reviews (1:34.61, 1:17.0, 1:25.95, and 1:75.84).

In India, physicians follow the theme of professional isolation in the management of multimorbid patients. This practice emanated from the interplay between four aspects of patient management, namely, disorganization and fragmentation of health care, inadequacy of guidelines and evidence-based medicine for multimorbidity, challenges in delivering patient-centered rather than disease-focused care and barriers to shared decision making.

Interdepartmental collaborative review may overcome all these barriers, allowing for a more comprehensive review of the patient's medication needs, considering factors such as the patient's medical history, current symptoms, and medication side effects. This study will evaluate the challenges in the implementation of interdepartmental CMR and the cost analysis of the Collaborative Medication Review planned to prevent potentially inappropriate medications in the hospitalized elderly population.

Study settings

This study is planned to be conducted over a period of 2 years in five phases chronologically (Fig. 1). The study will be conducted at the Pondicherry Institute of Medical Sciences and Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India, in collaboration with ICMR-National Institute of Epidemiology, Chennai, India, and ICMR Head- quarters, New Delhi.

Study phases:

Phase 1: Scoping review on collaborative medication review

We will conduct a comprehensive search, including the PubMed, Cochrane Library, Clinicaltrials.gov, Global Index Medicus, Lens.org and WHO-ICTRP registries, using the following search terms: medication review, collaborative review, prescriptions, prescription drugs and aged people. We included only English language articles. Two review authors independently extracted data from each included study via a predesigned data extraction form. We will attempt to contact the trial authors to request incompletely reported data. We will extract the following information: general information (study ID, date of extraction, title, authors, and source of study if not published); study characteristics (study settings, study design, participants, and inclusion/exclusion criteria used in the study); details of interventions; outcomes as described in the types of outcome measures above; and details necessary for risk of bias assessment. Disagreements between review authors were resolved by discussion or by consultation with a third review author.

Phase 2: Drafting SOP to formulate CMR teams in the Indian context, defining their individual roles and responsibilities, constructing CMR teams, and training CMR teams.

On the basis of the results of the scoping review, the SOPs will be developed by the team of investigators. The scope of the SOPs will include the composition (members) of the CMR team, training of the CMR team, frequency of the CMR - team review meetings, details regarding the intervention, which includes assessment of drug charts and conveyance of the information regarding any medication inappropriateness to the treating clinicians as well as follow-up of the subjects, and the documentation process. All the developed SOPs were reviewed and approved by the Principal Investigator and the Head of the Institution.

Phase 3: Assess the efficacy of CMR via standardized tools such as the MAI, the START/STOPP criteria and AT-HARM10:

&

Phase 4: Assessing the challenges and barriers in implementing collaborative medication review (CMR) in the Indian health care setting.

Study design

Mixed-method study design

Qualitative component

In-depth interviews and focus group discussions were conducted to explore the facilitators of and barriers to the implementation of interdepartmental CMR to reduce potentially inappropriate medications in hospitalized elderly patients.

Quantitative component – Quasi-experimental pre- and postinterventional study design

Costs incurred for the implementation of CMR in Indian healthcare settings
Medication appropriateness index, reduction in the percentage of inappropriate medications, post discharge adverse events and medication-related admissions.

Study period and duration

Each subject’s participation will last from admission until 30 days after discharge from the hospital.

Study participants

Health care providers at the two sites will be involved in the study to assess the facilitators and barriers in the implementation of interdepartmental collaborative medication review (CMR) from their perspective.

The prescriptions of both male and female elderly patients (aged 60 years and above) admitted to any medical or surgical ward at both study sites will be assessed to determine whether the participants meet the eligibility criteria after the medical records are reviewed.

Study eligibility criteria:

Inclusion criteria:

● Male and female patients aged 60 years and above with multiple morbidities admitted to all the medical and/or surgical specialty/subspecialty wards at the study sites.

● Patients coming to the study sites from places (villages/towns) within a 50 km radius (for ease of carrying out the study and to reduce attrition).

Exclusion criteria

● Patients who are discharged against medical advice before the completion of treatment.

● Patients who are referred to other hospitals for various reasons.

● Patients or patients whose kin refused to give consent to participate in the study.

● Readmission and emergency department visits other than drug-related problems (DRPs).

Sample size estimation and analysis:

The sample size calculation for assessment of CMR efficacy was based on a previous study conducted by Bhagavathula et al. (2018), who reported that the prevalence of potentially inappropriate medications in the elderly population was 28% in India. We assume that the effect size of the interdepartmental collaborative medication review is 10%, the power is 80%, and the significance level is 5%. The sample size calculation was estimated to be 280 participants. Given that this study will be conducted at two different sites, PIMS and JIPMER, 140 participants will be recruited from each site. Universal sampling techniques will be used to enrol participants in this phase of the study.

For qualitative component of study to assess implementation challenges of CMR, Preferably, 2 focus group discussions will be conducted among CMR team members at each study site. Approximately 10–16 in-depth interviews will be conducted per site until the data saturation point is reached.

Description of CMR Interventions during the phase III study:

Screening phase

Prescriptions of both male and female elderly patients (aged 60 years and above) admitted to any medical or surgical ward at both study sites will be assessed to determine whether participants meet the eligibility criteria after the medical records are reviewed.

Study enrolment phase

Once potential participants are deemed eligible, we will proceed with the enrolment process. The collection of baseline data on participants' medication profiles, medical history, and other relevant information will be performed. The participants' demographic details and contact information for follow-up will also be documented. Using tools such as the MAI and START STOPP criteria, the incidence of inappropriate medications will be evaluated after 24 hrs of admission at baseline and during hospitalization every 3rd day.

Intervention phase

CMR intervention as per the SOP will be applied, and all the relevant details mentioned in the CMR activities checklist will be executed. The clinical pharmacists will perform the activities and discuss them with the CMR team, and their suggestions will be presented to the treating physician in written format.

Follow-up phase

At discharge, the clinical pharmacist will assess the discharge prescription for the MAI score and PIMs. The percentage of acceptance of the suggestions given (by the CMR team during the admission) by the clinicians will also be recorded from the patient records. After discharge, the patients will be telephonically followed up by a trained field investigator for a period of 30 days to inquire about any hospital admissions, visits to the emergency department, drug-related complications, episodes of dizziness and falls. The AT-HARM10 tool will be used to identify medication-related hospital admissions (MRAs) after discharge after obtaining necessary permission from the authors. The detailed description of study evaluations/measurements/assessments at various time points after CMR intervention is shown in Table 1.

A comparison of MAI scores and the incidence of potentially inappropriate medications before and after CMR intervention at admission and at discharge will predict the efficacy of CMR.

Process indicators of intervention

The following methods have been used to assess the feasibility of implementing interdepartmental collaborative medication review (CMR).

Number of inter-Departmental CMR meetings.
Number of CMR consultations per patient.
Percentage of medication discrepancies/medication-related adverse events identified, prevented or resolved.
Percentage of suggestions given by the CMR team

Study endpoints:

Primary endpoint

Facilitators and barriers in implementing interdepartmental CMR to reduce PIMs.

Secondary endpoints:

1. Costs involved in the implementation of CMR in Indian healthcare settings (tertiary health care settings perspective)

2. Change in the number of potentially inappropriate medications from hospital admission to discharge due to CMR.

3. Change in the MAI score from hospital admission to discharge due to CMR.

4. Number of medication-related hospital admissions from the day of discharge to 30 days post discharge.

Table 1

Description of study evaluations/measurements/assessments after CMR intervention
EVENT	Hospital admission	During hospitalization	Hospital discharge
TIME POINTS	Day 1	Every 3rd day until discharge	Day X	Days X + 30
ENROLLMENT
Eligibility screen	X
Informed Consent	X
SCREENING PRESCRIPTIONS
START/STOPP Criteria	X	X	X
MAI score	X	X	X
INTERVENTION (CMR)
Medication history	X	X	X
Medication Reconciliation	X	X	X
Medication review	X	X	X
Collaborative team meeting	X	X	X
ASSESSMENTS
CMR team time	X	X	X
Cost analysis	X	X	X
Drug related problem	X	X	X	X
Hospital admissions				X

Description of assessment of challenges and barriers in implementing collaborative medication review (CMR) in the Indian health care setting

Focus group discussions (FGDs) will be conducted among the CMR team members, and in-depth interviews will be conducted with the prescribers whose patients will be admitted to the wards. This would help in understanding prescribers' and CMR team members' perceptions and attitudes towards the Collaborative Medication Review.

Focus group discussion (FGD) via the nominal group technique (NGT) is a structured variation of a small-group discussion to reach consensus. It gathers information by asking individuals to respond to questions posed by a moderator and then asking participants to prioritize the ideas or suggestions of all group members.

The participants for focus group discussion (FGD) will be chosen via a purposive sampling method, i.e., team members of the Collaborative Medication Review Board (CMR). Preferably, 2 focus group discussions will be conducted among CMR team members at each study site. The total number of participants per FGD will be between 8 and 10 members, and it will be a heterogeneous group depending upon the operational feasibility. Each focus group discussion will be conducted for approximately 40–60 mins until the data saturation point is reached.

In-depth interviews (IDIs) will be conducted among prescribers, including physicians, intensivist and senior grade staff nurses, via semi structured interview guides, with topics covering the working process, resources, competences, DRPs, intervention effects and collaboration. Approximately 10–16 in-depth interviews will be conducted per site until the data saturation point is reached. Each in-depth interview will be conducted for a minimum of 20–30 mins. The participants for the IDIs will be selected via a purposive sampling method. The selection of participants should ensure representativeness across all professional domains.

Phase 5: Calculating the costs incurred in the implementation of CMR from a health system perspective (opportunity costs)

The costs incurred in implementing CMR in the Indian healthcare setting from the health system perspective are evaluated. The parameters to assess the direct costs include the following:

The infrastructure provided by the healthcare setting for patients (as per the National Health System Cost database for India)¹¹
Salary for the Employment of Clinical Pharmacists
Time spent by the CMR team for review, analysis and recommendations on the basis of the input of the clinical pharmacist. Costs will be expressed in rupees at 2024 prices.

Study variables and tools

The study variables, namely, patient demographics (name, age, contact information) and medical history, including current and past medical conditions, allergies and adverse drug reactions, will be collected with the help of a predesigned case record form that includes tools such as the MAI tool, the STOPP/START tool and the AT-HARM10 tool, which will be used for data analysis. The direct costs incurred in the implementation of CMR will be captured via a predesigned structured case record form. The collected information in case record forms will also be entered electronically into Research Electronic Data capture (REDCap) software, improving the data quality and enabling central access to data (since this is a multicentric study).

Data management and statistical analyses

The investigators will ensure completeness, accuracy, and timely data collection. The study sites will enter data in RED-Cap software (Vanderbilt, USA), and case record forms will be scanned in REDCap. The data were checked for a normal distribution (Kolmogorov‒Smirnov test). Student’s paired t test will be used to analyse the differences between MAI scores at admission and discharge to determine the effectiveness of CMR, and the chi-square test or Fisher’s exact test will be used to assess the differences in frequency distribution. All analyses will be conducted via the Statistical Package for the Social Sciences (SPSS v. 22.0 for Windows 11, Microsoft, USA), Microsoft Excel 2019 and STATA version 12 (StataCorp LP, College Station, TX, USA).

For analysis of the qualitative component of the study, the audio-recorded FGDs and in-depth interviews (IDIs) will be transcribed by the investigator. The transcripts were read thoroughly and exported to N-Vivo software. Thematic analysis based on a framework approach will be used to analyse the transcripts. Inductive coding of the transcripts will be performed independently by two investigators trained in qualitative research. A third independent investigator then reviewed the transcribed data to increase the study's internal validity. The codes obtained from the transcripts were merged to form categories, subthemes and themes, which were further categorized as either facilitators or barriers.

Data monitoring. The data monitoring will be performed by designated officials appointed by ICMR Headquarters, New Delhi.

Ethics

The study was approved by the PIMS Institutional Ethics Committee of Pondicherry Institute of Medical Sciences, Puducherry, India (IEC:RC/2023/83 dated 10.11.2023), and the Institutional Ethics Committee Interventional Studies of Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India (JIP/IEC/2024/03/30 dated 20.03.2024). All participants will be recruited after written informed consent is obtained from themselves or their legally authorized representatives. The study conforms to the requirements of the Declaration of Helsinki, 1964; the Indian Good Clinical Practice guidelines; and the ICMR-National Ethical Guidelines for Biomedical and Health Research Involving Human Participants, 2017. Personal information about the screened and enrolled participants will be collected, shared, and maintained to protect confidentiality before, during, and after the trial. All data source documents, including clinical reports and records necessary for the evaluation and reconstruction of the clinical trial, will be stored securely for five years, with a focus on ensuring the patient’s confidentiality.

Protocol registration

The study has been registered with the Clinical Trials Registry–India (CTRI/2024/06/069220) registered on 19/06/2024.

This study aims to assess the feasibility of implementing collaborative medication review as well as the costs involved in the implementation of the interdepartmental collaborative medication review process in the Indian healthcare setting. Healthcare professionals from different departments or disciplines work together to review the medication needs of elderly patients, who more commonly suffer from multiple chronic conditions. This approach addresses the challenges of managing multimorbidity in India, such as professional isolation, inadequate guidelines and evidence-based medicine, and barriers pertaining to shared decision-making (by treating clinicians). The collaborative medication review process allows for a more comprehensive and coordinated approach to medication management, potentially improving patient outcomes and reducing healthcare costs. This study is the first of its kind to assess the feasibility and costs involved in the implementation of this approach to prevent inappropriate polypharmacy in the elderly population in the Indian setting. Although this concept has been proven in Western and European health care settings, it has not been implemented in Indian health care settings until now. This study explores the feasibility of implementing CMR in Indian healthcare settings through a qualitative research component. The likely outcomes of this study are the identification of facilitators and barriers in implementing CMR in different types of Indian healthcare settings, a clear understanding of the costs involved in the implementation of CMR and a reduction in the incidence of potentially inappropriate medications (PIMs) and medication-related admissions.

CMR Collaborative medication review

PIMs Potentially inappropriate medications

FGD Focused Group Discussion

IDI In-depth Interview

DRPs Drug-Related Problems

STOPP Screening Tool for Older Persons' Prescriptions

START Screening Tool to Alert to Right Treatment

MAI Medication Appropriateness Index

MRA Medication-related hospital admissions

MRF Medication Review and Follow-up

Availability of data and materials

This is a study protocol and does not contain any study data.

Competing interests

I have read the journal’s policy, and the authors of this manuscript have the following competing interests: This study is funded by ICMR, New Delhi, India (https://www.icmr.gov. in/) through the ICMR-National Taskforce on Safe and Rational Use of Medicines (extramural fund). The fund was awarded to SD (File No. ICMR/EM/SRUM/2023/RajeshKonduru). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Funding:

This study is funded by ICMR, New Delhi, India, through the ICMR-National Taskforce on Safe and Rational Use of Medicines (extramural fund). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors' contributions

Conceptualization: Aravinda Kumar, Rajesh Kumar Konduru, Jerin Jose Cherian, Melvin Gorge, Bhavani Shankara Bagepally, Anusha N, Saranya R, Nayyar Iqbal, Dineshbabu S, Sudharsanan S, Manjunatha CH, Isabella Topno

Funding acquisition: Rajesh Kumar Konduru, Anil J Purty

Methodology: Rajesh Kumar Konduru, Aravinda Kumar, Jerin Jose Cherian, Melvin Gorge, Bhavani Shankara Bagepally

Resources: Rajesh Kumar Konduru, Anil J Purty, Saranya R

Software: Rajesh Kumar Konduru, Manikandan M

Writing-original draft: Aravinda Kumar, Saranya R

Writing - review & editing: Rajesh Kumar Konduru, Jerin Jose Cherian

Acknowledgements:

The authors gratefully acknowledge the feedback received in the protocol from Dr. Jerin Jose Cherian, Scientist E (Medical), ICMR-HQ, New Delhi, India; Dr. Melvin Gorge, Professor of Clinical Pharmacology, SRM Medical College, Chennai, India; Dr. Bhavani Shankara Bagepally, Scientist E, ICMR-National Institute of Epidemiology, Chennai, India; Dr. Tarun Bhatnagar, Scientist F and Mr. Sabari, ICMR-National Institute of Epidemiology, Chennai, India for providing REDCap support; Dr. Nabendu Sekhar Chatterjee, Head, Discovery Research Division (Extra mural Projects), ICMR, New Delhi, India through a protocol development workshop conducted by the ICMR, New Delhi, India. The authors also acknowledge the scientific input received by the Technical Advisory Group, ICMR-National Taskforce on Safe and Rational Use of Medicines.

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Varas-Doval R, Gastelurrutia MA, Benrimoj SI, García-Cárdenas V, Sáez-Benito L, Martinez-Martínez F. Clinical impact of a pharmacist-led medication review with follow up for aged polypharmacy patients: A cluster randomized controlled trial. Pharm Pract. 2020;18(4):2133.
Jódar-Sánchez F, Malet-Larrea A, Martín JJ, García-Mochón L, López D, Amo MP, Martínez-Martínez F, et al. Cost-utility analysis of a medication review with follow-up service for older adults with polypharmacy in community pharmacies in Spain: the conSIGUE program. PharmacoEconomics. 2015;33(6):599–610.
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Competing interest reported. I have read the journal’s policy, and the authors of this manuscript have the following competing interests: This study is funded by ICMR, New Delhi, India (https://www.icmr.gov. in/) through the ICMR-National Taskforce on Safe and Rational Use of Medicines (extramural fund). The fund was awarded to SD (File No. ICMR/EM/SRUM/2023/RajeshKonduru). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Implementation of inter-departmental Collaborative Medication Review to reduce potentially inappropriate medication use in hospitalized elderly patients: A mixed methods study protocol

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Version 1

Abstract

Figures

Background

Methods

Study phases:

Phase 1: Scoping review on collaborative medication review

&

Study eligibility criteria:

Inclusion criteria:

Exclusion criteria

Sample size estimation and analysis:

Description of CMR Interventions during the phase III study:

Study endpoints:

Data management and statistical analyses

Ethics

Protocol registration

Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1