Optimizing Prescribing in Older Adults with Multimorbidity and Polypharmacy in Primary Care: A Cluster Randomized Clinical Trial (OPTICA Trial)

ImportanceInappropriate prescribing and prescribing omissions are major drivers of healthcare-related harm. Medication review may help improve pharmacotherapy. ObjectiveTo study the effects of a primary care medication review intervention centered around an electronic clinical decision support system (eCDSS) on medication appropriateness and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared to usual care. Design and SettingThe "Optimising PharmacoTherapy In the multimorbid elderly in primary Care" (OPTICA) trial is a cluster randomized clinical trial conducted with general practitioners (GPs) and older multimorbid patients with polypharmacy in Swiss primary care settings, between January 2019 and February 2020. The 12-month follow-up was completed in February 2021. ParticipantsEligible patients had to be [≥]65 years of age with [≥]3 chronic conditions and [≥]5 long-term medications. InterventionThe intervention to optimize pharmacotherapy centered around an eCDSS compared to usual care. Main Outcomes and MeasuresThe two primary outcomes were the improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilization (AOU) at 12 months. Secondary outcomes included the number of medications, number of falls and fractures and quality of life. ResultsIn 43 GP clusters, 323 patients were recruited (median age: 77 years (IQR: 73-83), 45% were female). 21 GPs with 160 patients were assigned to the intervention group and 22 GPs with 163 patients to the control group. On average, 1 recommendation to stop or start a medication were reported to be implemented per patient. At 12 months, there were no group differences in the improvement of medication appropriateness (Odds ratio (OR): 1.05; 95% confidence interval (CI): 0.59 to 1.87) nor the number of prescribing omissions (OR: 0.90; 95% CI: 0.41 to 1.96) in the intention-to-treat analysis. The per-protocol analysis showed no statistically significant group difference and there were no group differences in the secondary outcomes either. Conclusions and RelevanceIn this randomized trial of GPs and older adults, medication reviews based on the eCDSS reduced inappropriate prescriptions but did not lead to higher appropriateness of patients medications. The intervention could be safely delivered to patients without causing any detriment to their health. FundingSwiss National Science Foundation (407440_167465) Key points QuestionWhat is the effect of a GP administered medication review intervention supported by an electronic clinical decision support system on medication appropriateness in older patients with multimorbidity and polypharmacy? FindingsThis cluster randomized controlled trial included 43 general practitioners and 323 patients. At the end of the 12-month follow-up period, medication appropriateness and the number of prescribing omissions did not differ between patients who received the intervention and those who received usual care. MeaningThe intervention to optimize pharmacotherapy was feasible and safe to implement in primary care but did not improve overall medication appropriateness nor reduce the number of prescribing omissions.