Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy

Pilot and Feasibility Studies · 25 authors, 7 centres

AI SUMMARY

FIDELITY 72%

POPULATIONAdults aged 70 years or older taking 5 or more long-term medications in a primary care setting

INTERVENTIONTAPER (Team Approach to Polypharmacy Evaluation and Reduction) clinical pathway, including pharmacist and physician consultations, patient preference integration, and a 'pause and monitor' drug holiday approach supported by the TaperMD web-based system

COMPARISONUsual care (control group offered TAPER after 6-month follow-up)

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TL;DR

This feasibility trial tested TAPER, a structured clinical pathway to reduce polypharmacy in older adults (≥70 years on ≥5 medications) in primary care. All nine pre-specified feasibility criteria were met, including high clinician participation (100%) and low patient withdrawal (5%). The results support proceeding to a larger randomized controlled trial to test TAPER's effectiveness in reducing medication burden and improving health outcomes.

Full summary

4,731 CHARS

**Background:** Polypharmacy, commonly defined as taking five or more long-term medications, is associated with negative health outcomes in older adults, including increased risk of functional decline, falls, hospitalizations, impaired cognition, and reduced quality of life. Factors contributing to this association may include medication adverse effects, interactions, complex regimens, and reduced adherence. While deprescribing tools exist (e.g., Beers list, STOPP), many do not incorporate patient preferences or priorities. TAPER (Team Approach to Polypharmacy Evaluation and Reduction) was developed to address these gaps by integrating patient goals with evidence-based screening and a structured 'pause and monitor' drug holiday approach, supported by a web-based platform (TaperMD). This study aimed to determine the feasibility of implementing TAPER in primary care and to pilot outcome measures for a future larger randomized controlled trial (RCT).

**Methods:** This was a prospective 1:1 single-blinded randomized controlled feasibility trial conducted at the McMaster Family Health Team in Hamilton, Ontario, Canada. Eligible participants were patients aged 70 years or older, taking five or more long-term medications, and willing to try medication discontinuation. Exclusion criteria included recent comprehensive medication review (within 6 months), inadequate English or cognitive skills, or terminal illness. Participants were randomized to intervention (TAPER) or control (usual care, offered TAPER after 6 months) using variable block sizes via REDCap. The intervention involved a clinical pharmacist consultation (comprehensive medication review, machine screen for potentially inappropriate medications, patient preference integration) followed by a family physician consultation (finalization of a 'pause and monitor' plan). The control group received usual care. Feasibility outcomes were assessed across four domains: process (recruitment, refusal, drop-out rates, eligibility challenges, survey understanding, unblinding), resources (time to complete surveys, travel time), management (data entry problems), and scientific (adverse events, outcome variance). Pre-specified success thresholds were set for each domain. Secondary outcomes (e.g., number of medications, quality of life, psychological distress, cognition, fatigue, nutritional status, falls, healthcare utilization) were collected at baseline and 6 months. Statistical analyses used Poisson regression for medication counts and linear regression for continuous outcomes, with multiple imputation for missing data.

**Key Results:** All nine pre-specified feasibility criteria were met. Of 85 patients screened, 39 (46%) were enrolled and randomized; two were excluded post hoc for not meeting age requirements. Withdrawals (2, 5%) and losses to follow-up (3, 8%) were low and evenly distributed. All invited clinicians participated: 3 pharmacists (100%) and 31 physicians (100%). Data collection visits were generally completed within 2 hours (baseline: 1-2.5 hours; 6-month: 1-1.5 hours), with 59% of visits at participants' homes (travel time 10-30 minutes one-way). Six instances of unblinding occurred, all deemed mitigable. No serious adverse events were associated with the intervention. Outcome measures showed no substantive floor or ceiling effects. At 6 months, the intervention group had a mean of 7.00 (SD 1.75) prescribed medications versus 7.65 (SD 2.83) in controls. In the intervention group, 11 of 18 patients (61%) stopped at least one prescribed medication, 5 (28%) had dose reductions, and 6 (33%) had failed tapers. Most outcome measures signaled a direction favoring TAPER over usual care, except for the mental health domain of SF-36, patient enablement, MMSE, and grip strength.

**Clinical Implications:** This feasibility study demonstrates that TAPER is implementable in a primary care team setting and within an RCT framework. The high clinician participation and low patient attrition suggest strong acceptability. The emergent trends toward reduced medication use and improved outcomes (e.g., quality of life, psychological distress) support the hypothesis that polypharmacy's negative associations may be partially reversible. The findings justify proceeding to a large-scale RCT to formally test TAPER's effectiveness. Key modifications for the main trial include refining outcome measures (e.g., replacing lengthy scales), improving data management software, and enhancing blinding procedures. The study underscores the importance of integrating patient preferences into deprescribing pathways and highlights the feasibility of team-based approaches in primary care to address polypharmacy in older adults.

PICO

PPOPULATION

Adults aged 70 years or older taking 5 or more long-term medications in a primary care setting

IINTERVENTION

TAPER (Team Approach to Polypharmacy Evaluation and Reduction) clinical pathway, including pharmacist and physician consultations, patient preference integration, and a 'pause and monitor' drug holiday approach supported by the TaperMD web-based system

OOUTCOME

Feasibility outcomes (process, resource, management, scientific) and emergent evidence of effectiveness (number of prescribed/prescribable medications, quality of life, psychological distress, cognition, fatigue, nutritional status, falls, adverse events, healthcare utilization)

STUDY TYPE

RCT

SPECIALTY

geriatrics

SUMMARISED BY

AI pipeline

FIDELITY CHECK

72% · C

ORIGINAL PAPER

PMC10193598

Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy

Pilot and Feasibility Studies

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ABSTRACT

Abstract Background Polypharmacy is associated with poorer health outcomes in older adults. Other than the associated multimorbidity, factors contributing to this association could include medication adverse effects and interactions, difficulties in managing complicated medication regimes, and reduced medication adherence. It is unknown how reversible these negative associations may be if polypharmacy is reduced. The purpose of this study was to determine the feasibility of implementing an operationalized clinical pathway aimed to reduce polypharmacy in primary care and to pilot measurement tools suitable for assessing change in health outcomes in a larger randomized controlled trial (RCT). Methods We randomized consenting patients ≥ 70 years old on ≥ 5 long-term medications into intervention or control groups. We collected baseline demographic information and research outcome measures at baseline and 6 months. We assessed four categories of feasibility outcomes: process, resource, management, and scientific. The intervention group received TAPER (team approach to polypharmacy evaluation and reduction), a clinical pathway for reducing polypharmacy using “pause and monitor” drug holiday approach. TAPER integrates patients’ goals, priorities, and preferences with an evidence-based “machine screen” to identify potentially problematic medications and support a tapering and monitoring process, all supported by a web-based system, TaperMD. Patients met with a clinical pharmacist and then with their family physician to finalize a plan for optimization of medications using TaperMD. The control group received usual care and were offered TAPER after follow-up at 6 months. Results All 9 criteria for feasibility were met across the 4 feasibility outcome domains. Of 85 patients screened for eligibility, 39 eligible patients were recruited and randomized; two were excluded post hoc for not meeting the age requirement. Withdrawals (2) and losses to follow-up (3) were small and evenly distributed between arms. Areas for intervention and research process improvement were identified. In general, outcome measures performed well and appeared suitable for assessing change in a larger RCT. Conclusions Results from this feasibility study indicate that TAPER as a clinical pathway is feasible to implement in a primary care team setting and in an RCT research framework. Outcome trends suggest effectiveness. A large-scale RCT will be conducted to investigate the effectiveness of TAPER on reducing polypharmacy and improving health outcomes. Trial registration clinicaltrials.gov NCT02562352 , Registered September 29, 2015. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-023-01315-0. Keywords: Polypharmacy, Deprescribing, Multi-morbidity, Patient safety, Primary care

CITATION EXPORT

Dee Mangin, Larkin Lamarche, Gina Agarwal et al.. Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy. Pilot and Feasibility Studies. (2023). https://doi.org/10.1186/s40814-023-01315-0

AUTHORS

25 · 7 CENTRES

Dee Mangin, Larkin Lamarche, Gina Agarwal, Abbas Ali, Alan Cassels, Kiska Colwill, Lisa Dolovich, Naomi Dore Brown, Barbara Farrell, Karla Freeman, Kristina Frizzle, Scott R Garrison, James Gillett, Anne Holbrook, Jane Jurcic-Vrataric, James McCormack, Jenna Parascandalo, Julie Richardson, Cathy Risdon, Diana Sherifali, Henry Siu, Sayem Borhan, Jeffery A Templeton, Lehana Thabane, Johanna Trimble

1Department of Family Medicine, David Braley Health Sciences Centre, McMaster University, 100 Main Street West, 5th Floor, Hamilton, ON L8P 1H6 Canada
2Dept. of General Practice, University of Otago, Christchurch, New Zealand
3University of Victoria, 3800 Finnerty Rd, Victoria, BC Canada
4University of Toronto, 144 College Street, Toronto, ON Canada
5Bruyère Research Institute, 43 Bruyère Street, Ottawa, ON Canada
6University of Alberta, 6-60 University Terrace, Edmonton, AB Canada
7University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC Canada