Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada.

BACKGROUND: Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. METHODS: This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes. CONCLUSION: We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.

Discussion of lifestyle-related issues in family practice during visits with general medical examination as the main reason for encounter: an exploratory study of content and determinants.

The aim of this study was to describe the frequency and content of discussions on lifestyle issues during an annual examination and to identify characteristics of patients, physicians, and visits associated with lifestyle discussions. Audio-recordings of the visits of 35 family physicians with 148 of their patients were analyzed. Bivariate descriptive and multivariate analyses were used. On average, the visits contained discussions of 3.6 different issues for a total time of 2.9 min. Of the 11 topics of interest, weight, diet and nutrition, physical activity, and tobacco use were the most frequently discussed. Consultation with a female physician and perception by the physician of a poorer patient mental health status were associated with the number of themes discussed and the duration of exchanges. Results suggest that although, discussions on lifestyle issues are frequently observed during these visits, they remain limited in scope. Physicians appear to concentrate their energy on targeted patients, and female doctors are more active in this domain.

Lessons for clinicians from physician-patient communication literature.

Research about the communication between physicians and patients contains information that can help clinicians be better diagnosticians and achieve greater compliance and can lead to improved patient health and satisfaction. We present research results that can be useful for the physician in daily clinical practice.