Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial

• Published in: BMJ (Online) 2023-02, Vol.380, p.e071883-e071883
• Main Authors: Holland, Richard, Bond, Christine, Alldred, David P, Arthur, Antony, Barton, Garry, Birt, Linda, Blacklock, Jeanette, Blyth, Annie, Cheilari, Stamatina, Daffu-O'Reilly, Amrit, Dalgarno, Lindsay, Desborough, James, Ford, Joanna, Grant, Kelly, Harry, Bronwen, Hill, Helen, Hughes, Carmel, Inch, Jacqueline, Maskrey, Vivienne, Myint, Phyo, Norris, Nigel, Poland, Fiona, Shepstone, Lee, Spargo, Maureen, Turner, David, Watts, Laura, Zermansky, Arnold, Wright, David
• Format: Article
• Language: English
• Subjects: Aged, 80 and over; Consent; Drug stores; Feasibility studies; Female; Humans; Intervention; Male; Northern Ireland; Pharmaceutical Services; Pharmaceuticals; Pharmacists; Quality of Life; Safety; Scotland; Stakeholders; Systematic review
• ISSN: 1756-1833; 1756-1833
• DOI: 10.1136/bmj-2022-071883

AbstractObjectiveTo estimate the effectiveness, cost effectiveness (to be reported elsewhere), and safety of pharmacy independent prescribers in care homes.DesignCluster randomised controlled trial, with clusters based on triads of a pharmacist independent prescriber, a general practice, and one to three associated care homes.SettingCare homes across England, Scotland, and Northern Ireland, their associated general practices, and pharmacy independent prescribers, formed into triads.Participants49 triads and 882 residents were randomised. Participants were care home residents, aged ≥65 years, taking at least one prescribed drug, recruited to 20 residents/triad.InterventionEach pharmacy independent prescriber provided pharmaceutical care to approximately 20 residents across one to three care homes, with weekly visits over six months. Pharmacy independent prescribers developed a pharmaceutical care plan for each resident, did medicines reviews/reconciliation, trained staff, and supported with medicines related procedures, deprescribing, and authorisation of prescriptions. Participants in the control group received usual care.Main outcomes measuresThe primary outcome was fall rate/person at six months analysed by intention to treat, adjusted for prognostic variables. Secondary outcomes included quality of life (EQ-5D by proxy), Barthel score, Drug Burden Index, hospital admissions, and mortality. Assuming a 21% reduction in falls, 880 residents were needed, allowing for 20% attrition.ResultsThe average age of participants at study entry was 85 years; 70% were female. 697 falls (1.55 per resident) were recorded in the intervention group and 538 falls (1.26 per resident) in the control group at six months. The fall rate risk ratio for the intervention group compared with the control group was not significant (0.91, 95% confidence interval 0.66 to 1.26) after adjustment for all model covariates. Secondary outcomes were not significantly different between groups, with exception of the Drug Burden Index, which significantly favoured the intervention. A third (185/566; 32.7%) of pharmacy independent prescriber interventions involved medicines associated with falls. No adverse events or safety concerns were identified.ConclusionsChange in the primary outcome of falls was not significant. Limiting follow-up to six months combined with a small proportion of interventions predicted to affect falls may explain this. A significant reduction in the Drug Burden Index was re