1. Impetus
A cluster RCT to achieve medication appropriateness in the setting of a geriatric palliative care approach
C.A.M. Pouw, M. Smalbrugge, J.G. Hugtenberg, R.J. van der Marum, C.M.P.M. Hertogh
Background
Nursing home (NH) residents often have a limited life expectancy ( years). Many suffer the combined burden of advanced disease, functional impairment and severe dependency. These older patients often use a large number of drugs. Consequently, they often suffer from adverse effects.
It is increasingly recognized that prescribing in this patient group is better guided by a geriatric palliative care (GPC) approach, with focus on quality of life, comfort and medication safety rather than on disease-specific outcomes and life extension.
Objective
This study aims to align medication prescription with GPC goals (quality of life, comfort and medication safety) in nursing home residents, by means of an Advance Care Planning (ACP+) intervention. This intervention consists of a structured multidisciplinary medication review (SMMR) and ACP discussion, for which participating physicians will receive training.
Strategy
1. Delphi study to develop a list of medication appropriateness indicators for the target group
2. Identify patients by using SPICT
3. The intervention group will receive a structured multidisciplinary medication review (SMMR) followed by an ACP discussion. (fig. 1)
4. Repeat after 6, 12, 18 months
Outcomes
Medication appropriateness in the setting of a GPC approach
Secondary: Quality of life, mortality, pain, social wellbeing, patients attitude towards prescribing
At the end of the study, the training programme will be adjusted on the basis of study findings, and also offered to the control group.
Fig. 1: Study Strategy
NH residents identified by SPICT
Intervention group
20 wards, ±240pts
Control group
ACP+
(SMMR + ACP discussion)
Assessment by
expert panel
Repeat after 6, 12, 18 months
Analysis
Usual care
Adjusted ACP+ training programme
Research Question
1. What is the effect of the ACP+ intervention on medication appropriateness
2. What is the effect of the ACP+ intervention on
- Quality of life
- Falls
- Mortality
- Hospital admissions / acute care referrals
- Pain
- Patient satisfaction and involvement in decision making
3. What are facilitators and barriers for implementing ACP+
Design, study and research population
Expected first inclusion: September 2017
The cluster RCT is conducted in 2x20 long term care wards of university affiliated NHs.
Patients: NH residents with indication for a GPC care goal based on the Supportive and Palliative Indicators Tool (SPICT) or with a clear wish for a GPC-approach.
Contact: