The Australian Team Approach to Polypharmacy Evaluation and Reduction (AusTAPER) study for older hospital inpatients

INTERVENTION: Feasibility of implementing a practical guidance that fosters teamwork and integration in hospital care between hospital pharmacists and the treating multi‐disciplinary team to address polypharmacy in older inpatients. Intervention (TAPER) The AusTAPER is a web based software application (available at eg https://meds.tapermd.org) which can be used as a generic tool for a collaborative medication review between the participant, hospital team, study pharmacist and GP. At an initial consultation with the pharmacist (approximately 30 mins), data will be entered on the participant’s medications, dosages and indications; any reported side effects; the patient’s priorities and preferences for treatment; and medication‐related data such as blood pressure and creatinine (if known). Using the medication history, participant’s preferences for care and perceived medical problems, the TAPER App tool performs a ‘machine screen’ comprising i) interaction checker; and ii) listing of potentially inappropriate medicines (including the Screening Tool of Older Person's potentially inappropriate Prescriptions, the Beers List, anticholinergic & serotonergic burden, and QT prolonging drugs). This screen is also supported by existing evidence based resources providing Numbers Needed to Treat/Harm, and decision aids for deprescribing where available, and tapering guidelines. The focus is on maintaining essential medicines while supporting reduction in medicines known to be associated with adverse reactions causing emergency presentation and/or unplanned admission to hospital, and those in which risk frequently outweighs benefit (eg anticholinergics, sedatives, opiates, proton pump inhibitors). The research staff and study pharmacist records notes in the web‐based AusTAPER App. We will liaise with GPs for follow‐up post‐discharge, and the GP will also record notes in the AusTAPER App, which is intuitive to use for GPs familiar with practice software. All notes can be easily downloaded into the electronic records of clinicians. Decisions will be informed by the individual participant’s priorities, including functional and symptom treatment goals. A preliminary plan is produced by TAPER, based on information collected at baseline, and after this initial consultation between the study pharmacist and patient. This plan is then further refined after a consultation between the hospital team and patient. In this step, the hospital doctor may use the TAPER tool to enter new information or modify information already in TAPER. A prioritised medication plan is created at this stage. The emphasis is on ‘pausing and monitoring’ medications with planned follow‐up and agreed criteria for restarting medications if necessary. The TAPER medication withdrawal plan is then used to record the planned monitoring parameters and track progress during subsequent follow‐up consultations, as a seamless clinical and decision support pathway. The key steps (in detail) for TAPER are: 2) Hospital and usual doctor consultation (same day when feasible): The study pharmacist will liaise with both the inpatient multi‐disciplinary team and the participant’s usual GP (who will both be provided the pharmacist generated accurate medicine list with flagged recommendations, evidence and tools to support deprescribing linked to the AusTAPER Software App). A prioritized plan for appropriate discontinuations and a template for monitoring frequency, duration and criteria for medicine recommencement will then be confirmed with agreement of the hospital mu CONDITION: Polypharmacy PRIMARY OUTCOME: Total number of current regular medicines (assessed by direct interview of the patient reconciled with pharmacy and prescribing records) including ; a. Prescribed medicines 1) Study pharmacist consultation (approximately 30 mins): The participant will be engaged in a face‐to‐face medication‐focused interview with a study pharmacist after admission has been completed. If the patient wishes to have a support person present, a relative/person responsible/carer or advocate can be present at this interview. Information will be collected about medications taken, indications for medications and other mediation‐related information if available (such as blood pressure creatinine, falls history). The aim is to gather patient data including prioritised functional and symptom goals for medical treatment, overall preferences for care (using a tool covering 4 domains developed from our systematic review and patient focus group feasibility work) and perceived medicine problems or side‐effects. The medication data and this information will be entered into the TAPER app. Through application of automated filters within the TAPER App, potentially inappropriate medications, medication interactions and warnings will be identified and flag medications which are candidates for discontinuation or dose reduction. Based on these data, the study pharmacist will generate preliminary recommendations for medicines optimisation. Medications, medication interactions and warnings will be identified and flag medications which are candidates for discontinuation or dose reduction. ; b. Over the counter and complementary and alternative medicines ; c. Herbal and mineral supplements ; ; SECONDARY OUTCOME: Adverse Drug Withdrawal Events (measured by self [or proxy] report, participant's and audit of health records). ; ; Change in number of current regular medicines (assessed by direct interview of the patient reconciled with pharmacy and prescribing records) Cognition via the Standardised Mini Mental Status Examination SMMSE Emergency presentation and/or unplanned admission to hospital (measured through self [or proxy] report and audit of health records) Falls: Number of falls (defined as falls resulting in medical consultation or treatment at a GP or hospital) (measured through self [or proxy] report and audit of health records) Medicine related emergency presentation and/ or unplanned admission to hospital (measured through self [or proxy] report and audit of health records) ; Quality of life measured using EQ‐5D‐5L ; Serious (eg requiring hospital readmission) adverse drug withdrawal events (measured by self [or proxy] report, participant's and audit of health records). ; ; Use of potentially inappropriate medicines (assessed by direct interview of the patient reconciled with pharmacy and prescribing records) ; ; ; INCLUSION CRITERIA: • hospital inpatient aged 70 years or more • Taking 5 or more regular medicines (these might be medicines prescribed by the GP , bought over‐the‐counter, or herbal/alternative remedies) • A regular patient at their GP practice • Living in the community