CompreHensive geriAtRician-led MEdication Review (CHARMER)

Background: Ageing affects the body s drug handling processes resulting in the risk of harm from medicines potentially outweighing the benefits. Patients, carers and GPs expect medicines to be reviewed in hospital, and any medicines with a greater risk of harm than benefit to be stopped before harm occurs (proactive deprescribing). 50% of patients are prescribed at least one medicine where the harms outweigh the benefits, however, only 6% of these patients have an inappropriate medicine proactively deprescribed in hospital. The research team have established the barriers and enablers (determinants) to geriatricians and hospital pharmacists increasing the number of older patients in hospital for they proactively deprescribe. We have also identified six behaviour change techniques (BCTs) that are suitable for addressing these determinants. Aims: Over 58 months, to develop and test an intervention to target the determinants of geriatrician and hospital pharmacist proactive deprescribing in order to enable estimation of effectiveness and cost-effectiveness. Methods: WP1 (9 months): With no current standardisation of outcome measures for use within hospital deprescribing trials, resulting in disparate practice with limited underpinning evidence, we will develop a core outcome set drawing on COMET recommendations. We will use modified Delphi (n=120-150) to identify a suitable primary outcome measure for this trial. WP2 (10 months): We will develop the intervention using two rounds of co-design workshops with stakeholders (n=8-10) to characterise the six BCTs and operationalise them into an intervention package. We will also develop a questionnaire investigating the mechanism of action of the intervention BCTs. WP3 (16 months): We will test intervention and trial procedures over three months in four hospitals, each recruiting two geriatricians and two pharmacists. To supplement quantitative data, we will observe intervention delivery in all four hospitals to test the fidelity framework and identify enhancements to the intervention and trial procedures. We will additionally interview hospital staff responsible for intervention delivery and all recipients of the intervention (geriatricians and pharmacists). We will use these data together with data from a, to undertake pre-trial modelling of the intervention. We will purposively sample (n=24) patients and carers for telephone interviews to explore experiences of trial participation and service delivery by geriatrician and pharmacist participants. WP4 (34 months): We will phase recruitment of 44 hospitals over 14 months, randomise each to intervention or control and allow six months for each site to recruit 110 patients. This will provide 90% power at 5% significance for detecting a 20% difference in proactive deprescribing between intervention and control hospitals. WP5 (58 months): We will undertake dissemination activities and refine the strategy throughout the programme and convene a strategy workshop with key stakeholders (n=8-10), to prepare a detailed plan for the intervention to be more widely implemented and adopted.