Family Conferences to facilitate shared prioritisation and deprescribing in frail elderlies with polypharmacy cared for at home. Results from of a pragmatic cluster randomized trial in primary care

Achim Mortsiefer, Stefan Wilm, Susanne Löscher, Anja Wollny, Manuela Ritzke, Eva Drewelow, Petra Thürmann, Veronika Bencheva, Jens Abraham, Gabriele Meyer, Birgitt Wiese, Andrea Icks, Joseph Montalbo, Attila Altiner

Keywords: polypharmacy, shared decisionmaking, frailty, family conferences, cluster randomised trail

Background:

For patients with geriatric frailty syndrome, the reduction of polypharmacy is a promising therapeutic option. Deprescribing is above all a challenge for communication between the different parties involved, such as patients, relatives, nursing staff and general practitioners.

Research questions:

The aim of this study was to investigate what effects family conferences on joint prioritisation and deprescribing can achieve in frail outpatients with polypharmacy.

Method:

Cluster-randomised, controlled intervention study with 114 GPs and 623 non-hospitalised patients with frailty and polypharmacy. Study physicians in the intervention group received three trainings on the application of a deprescribing guideline, including communication training. Three family conferences were conducted over a period of six months with the involvement of family caregivers and/or nursing services. Primary endpoint was the hospitalisation rate after 12 months. Secondary endpoints included the number of medications and parameters of geriatric assessments. Analysis using descriptive statistics and multilevel regression models.

Results:

Intention-to-treat analysis (n=510) showed no statistically significant difference in the adjusted mean number of hospitalisations between intervention group (0.98 (SD1.72)) and control group (0.99 (1.53)). In the per-protocol population (n=385), the number of medications taken evolved from 8.98 (3.56) to 8.11 (3.21) at six months and to 8.49 (3.63) at 12 months in the intervention group and from 9.24 (3.44) to 9.32 (3.59) at six months and to 9.16 (3.42) at 12 months in the control group, with a statistically significant difference at six months in the mixed-effect Poisson regression model (p=0.001).

Conclusions:

The mean number of hospitalisations did not differ between intervention and control group. After six months, the number of medicines taken per patient decreased by 0.87 in the intervention group, while it remained about the same in the control group. This is a quite powerful effect compared to other pragmatic deprescribing studies. However, this intervention effect was no longer significantly detectable after 12 months.

Points for discussion:

How to manage the process of deprescribing in the frail elderly?

What are the benefits of family conferences in primary care?

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