PolypharmacyNCT03445767
Structured Polypharmacy Management Before Elective Non-cardiac Surgery in Frail and Elderly People
A study testing MedSafer in people with Polypharmacy, run by Ottawa Hospital Research Institute.
Trial summary
The older segment of the population is growing faster than any other segment. Older people have surgery more often than any other age group, and these older patients often take multiple medications, including medications that may result in more side effects (and risk) than benefit. Read more about this study
- Who is it for?
- Ages 65 years and olderHealthy volunteers can take part
- Conditions the study is for
- Polypharmacy
- What is being tested?
- MedSafer
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 0 participants
- Where
- No sites listed yet
- Study dates
- Feb 2018to Jul 2019
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 65 years and older
- All sexes
- Healthy volunteers accepted
- Older adult
Who may be able to join
- English or French-speaking people aged 65 years or older seen in the Pre-Admission Unit prior to elective, inpatient non-cardiac surgery
Who cannot join
- Patients who cannot be reached by telephone for follow up, or are not covered by the Ontario Health Insurance
About this study
Official title: Structured Polypharmacy Management Before Elective Non-cardiac Surgery in Frail and Elderly People: a Pilot for a Randomized Control Trial
The older segment of the population is growing faster than any other segment. Older people have surgery more often than any other age group, and these older patients often take multiple medications, including medications that may result in more side effects (and risk) than benefit. Older patients who take multiple medications, and especially high risk medication, are more likely to die after surgery, and in those who survive, levels of disability are higher. For these reasons, testing a program that reviews the medications of older patients before surgery to decrease the use of dangerous medicines is very important.
Most older patients in Ontario are seen in a preoperative anesthesiology clinic. Previous research has shown that this clinic visit is a "teachable moment", where patients are more motivated to change their health-related behaviors. Therefore, the investigators propose to compare a structured medication review in the preoperative clinic to the usual care that people receive with the goal of decreasing the number and potential danger of the medications taken by older surgical patients. Recent systematic reviews have shown that no such programs have been tested to date in patients having surgery, so our findings will be unique. In addition, the investigators will also measure the impact of this program on people's health status, disability status, and use of healthcare resources (such as days in hospital) after surgery. If the investigators find that this single-center pilot randomized controlled designed study positively impacts these patient health outcomes, the investigators will perform a future multi-center cluster randomized trial of our intervention.
MedSafer is a CIHR-funded Canadian software product that aids patients and physicians in deprescribing. It contains rules that identify potentially inappropriate medications (PIMs), prioritizes them in terms of risk of harm, and provides deprescribing opportunities for safely stopping medications using the current evidence as well as incorporating patient comorbidities in the analyses.
Read the detailed description
The population is aging rapidly, and elderly people have surgery at a higher rate than any other age group. Advanced age is independently associated with a 2- to 4-fold increase in adverse event rates after surgery, as well as increased rates of postoperative healthcare resource use such as costs and prolonged hospital length of stay. Polypharmacy (defined by the World Health Organization as taking >5 medications concurrently), and potentially inappropriate medications (PIM; i.e., taking medications that are likely to produce more harm than benefit given an individual's risk profile) are increasingly common in older people.
In the perioperative setting, the epidemiology of polypharmacy and inappropriate prescribing is poorly described. Single center studies of general surgery patients suggest that inappropriate prescriptions are independently associated with a 3- to 4- fold increase in the odds of serious complications, while hip fracture patients with polypharmacy have an increased risk of readmission and are often discharged on the same PIMs which may have caused the fracture.
Strategies to address polypharmacy and medication appropriateness have been synthesized in two recent systematic reviews. In general, interventions resulted in decreases in the number of medications taken, and overall medication appropriateness. However, substantial gaps in this knowledge base were also identified. First, no perioperative interventions were identified. Second, overall methodological quality of identified studies was low to very low, with significant issues identified related to study design and inadequate power, poor allocation concealment, and lack of appropriate analytic techniques. Finally, although decreasing the number and inappropriateness of medications are worthwhile outcomes, most studies did not report the impact of these interventions on patient-centered or system-level outcomes.
The preoperative anesthesiology clinic encounter may represent an optimal time to initiate polypharmacy management strategies, as the surgical encounter with the healthcare team is a teachable moment where patients demonstrate extra motivation to make positive changes in their health behaviors. Therefore, the hypothesized positive impact of preoperative polypharmacy management could extend not only into the postoperative period, but also on a longitudinal basis beyond the transition from acute postoperative care.
The preoperative polypharmacy management intervention will be based on a pragmatic, evidence-based, CIHR-funded tool developed by our coinvestigators from McGill for use in elderly inpatients. It has recently been field tested in a 600-patient inpatient study at the Universities of Ottawa, Toronto, and McGill. The tool is a web-based platform developed by experts in internal and geriatric medicine and is based on best-practice guidelines, Choosing Wisely Canada's declarative statements, and evolving issues (such as narcotic and benzodiazepine co-administration). It contains rules that identify PIMs, prioritizes them in terms of risk of harm, and provides deprescribing opportunities for safely stopping medications using the current evidence as well as incorporating patient comorbidities in the analyses.
The investigators will address a clear knowledge gap in the literature by conducting a single center pilot randomized trial to evaluate the efficacy of a structured polypharmacy management program in preparation for a future multicenter randomized trial. The primary objectives of this pilot study are to: (1) provide evidence of efficacy of the intervention in reducing PIMs, (2) estimate characteristics of secondary outcomes, specifically patient-centered and system-level measures, including baseline prevalence and measures of variation, to inform sample size calculations for a future multi-site randomized trial powered to meaningfully impact these outcomes, and (3) demonstrate acceptability of the intervention to patients and providers along with potential barriers and facilitators to implementation.
- Conditions
- Polypharmacy
- Being tested
- MedSafer
- Keywords
- Peri-operative care, Medication management
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
MedSaferOther
An electronic deprescribing intervention that identifies potentially inappropriate medications (PIMs) and generates instructions for safe discontinuation. These recommendations are presented to the treating physicians for their consideration.
| Study group | Role | What they receive |
|---|---|---|
| Standard Care | No intervention | All patients will receive perioperative care per the standards of TOH. Standard care relevant to our study consists of a history by a nurse or physician; a best possible medication history performed by a pharmacy technician; and standardized perioperative-specific medication recommendations (e.g., anticoagulant, diabetes agent, and ACE-inhibitor management) based on medical directives. Medication recommendations beyond these medical directives do not occur as standard care in our clinics. Participants will be informed that their medical care will proceed as usual and that they are being recruited for a study to evaluate medication recommendations before surgery |
| Intervention | Experimental | In addition to standard care, the intervention will include a structured preoperative polypharmacy management strategy that consists of: a) input of best possible medication history and comorbidities into our polypharmacy management tool (MedSafer); b) communication of the prioritized deprescribing plan (if indicated) to the patient's active treating physicians (automatically via fax), to the perioperative team (surgeon, anesthesiologist), and to the electronic medical record. During the pre-operative visit, the patient will receive a generalized information flyer about deprescribing. As in the usual care phase, patients will continue to receive usual recommendations from the perioperative team based on medical directives relevant to the perioperative period. Receives: Other: MedSafer |
What is being measured
The primary outcome is the main question the study is designed to answer.
Average number of PIMs
Average number of Potentially Inappropriate Medications based on patient report
Measured: 90-days post-surgery
Secondary outcomes (8)
Patient-reported health outcomes: Health related quality of life
Standardized instrument (5 level version) developed by the EuroQol Group as a measure of health-related quality of life (patient-reported). The EQ-5D assesses domains of self-perceived mobility, self-care, usual activity participation, pain/discomfort, and anxiety depression which is captured as a overall health state score. The EQ-5D also uses a self-report 0-100 point scale relating the person's current health status to their best imaginable status.
Measured: Before surgery, 30-day post-surgery, and 90-day post-surgery
Patient-reported health outcomes: Sleep Quality
Sleep quality measured using the PROMIS (Patient-Reported Outcomes Measurement Information System) short form 4a questions.
Measured: Before surgery, 30-days post-surgery, and 90-days post-surgery
Patient-reported health outcomes: Disability
Disability measured using the World Health Organization Disability Assessment Schedule version 2.0, a 30-day look-back multidimensional disability scale that is validated in a variety of disease states, including postoperatively.
Measured: Before surgery, 30-days post-surgery, and 90-days post-surgery
Adverse Events
Including falls, and surgical complications using the Post-Operative Morbidity Survey which looks at several categories of complications (pulmonary, cardiovascular, neurological, gastro-intestinal, infectious, renal, wound, hematological, and pain)
Measured: Through study completion, an average of 7 days
Hospital length of stay
Number of days in hospital post-operatively- based on validated administrative data
Measured: Within 365 days after surgery
Proportion of patients discharged to an institution, readmissions within 30 days of discharge
Number of patients discharged to an institution and/or re-admitted post-operatively
Measured: Within 365 days after surgery
Patient safety indicators
A health system outcome- based on validated administrative data
Measured: Within 365 days after surgery
Costs of hospitalization
Amount of healthcare dollars spent will be generated using a validated algorithm in our administrative data
Measured: Within 365 days after surgery
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted26 Feb 2018
- Study startFeb 2018 (estimated)
- Primary completionJul 2019 (estimated)
- Study completionJul 2019 (estimated)
Why it stopped: Did not receive full funding to proceed
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for PolypharmacyStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Other
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Double blind
- Who is masked
- Participant, Outcomes assessor
- Enrolment
- 0 participants (actual)
Sponsor and investigators
- Lead sponsor
- Ottawa Hospital Research Institute
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03445767
- Sponsor's protocol ID
- 20170663
- Status last verified
- Jun 2020
- First submitted
- 30 Jan 2018
- Last updated
- 9 Jun 2020
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 9 Jun 2020. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Structured Polypharmacy Management Before Elective Non-cardiac Surgery in Frail and Elderly People: a Pilot for a Randomized Control Trial
- ClinicalTrials.gov ID
- NCT03445767
- Acronym / sponsor ID
- 20170663
- Conditions
- Polypharmacy
- Keywords
- Peri-operative care, Medication management
- Study type
- Interventional
- Recruitment status
- WithdrawnReason stopped: Did not receive full funding to proceed
- Enrolment
- 0 participants (actual)
- Lead sponsor
- Ottawa Hospital Research InstituteUniversity, hospital or other
- Study start
- Feb 2018 (estimated)
- Primary completion
- Jul 2019 (estimated)
- Study completion
- Jul 2019 (estimated)
- First posted
- 26 Feb 2018 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The older segment of the population is growing faster than any other segment. Older people have surgery more often than any other age group, and these older patients often take multiple medications, including medications that may result in more side effects (and risk) than benefit. Older patients who take multiple medications, and especially high risk medication, are more likely to die after surgery, and in those who survive, levels of disability are higher. For these reasons, testing a program that reviews the medications of older patients before surgery to decrease the use of dangerous medicines is very important.
Most older patients in Ontario are seen in a preoperative anesthesiology clinic. Previous research has shown that this clinic visit is a "teachable moment", where patients are more motivated to change their health-related behaviors. Therefore, the investigators propose to compare a structured medication review in the preoperative clinic to the usual care that people receive with the goal of decreasing the number and potential danger of the medications taken by older surgical patients. Recent systematic reviews have shown that no such programs have been tested to date in patients having surgery, so our findings will be unique. In addition, the investigators will also measure the impact of this program on people's health status, disability status, and use of healthcare resources (such as days in hospital) after surgery. If the investigators find that this single-center pilot randomized controlled designed study positively impacts these patient health outcomes, the investigators will perform a future multi-center cluster randomized trial of our intervention.
MedSafer is a CIHR-funded Canadian software product that aids patients and physicians in deprescribing. It contains rules that identify potentially inappropriate medications (PIMs), prioritizes them in terms of risk of harm, and provides deprescribing opportunities for safely stopping medications using the current evidence as well as incorporating patient comorbidities in the analyses.
Detailed description
The population is aging rapidly, and elderly people have surgery at a higher rate than any other age group. Advanced age is independently associated with a 2- to 4-fold increase in adverse event rates after surgery, as well as increased rates of postoperative healthcare resource use such as costs and prolonged hospital length of stay. Polypharmacy (defined by the World Health Organization as taking >5 medications concurrently), and potentially inappropriate medications (PIM; i.e., taking medications that are likely to produce more harm than benefit given an individual's risk profile) are increasingly common in older people.
In the perioperative setting, the epidemiology of polypharmacy and inappropriate prescribing is poorly described. Single center studies of general surgery patients suggest that inappropriate prescriptions are independently associated with a 3- to 4- fold increase in the odds of serious complications, while hip fracture patients with polypharmacy have an increased risk of readmission and are often discharged on the same PIMs which may have caused the fracture.
Strategies to address polypharmacy and medication appropriateness have been synthesized in two recent systematic reviews. In general, interventions resulted in decreases in the number of medications taken, and overall medication appropriateness. However, substantial gaps in this knowledge base were also identified. First, no perioperative interventions were identified. Second, overall methodological quality of identified studies was low to very low, with significant issues identified related to study design and inadequate power, poor allocation concealment, and lack of appropriate analytic techniques. Finally, although decreasing the number and inappropriateness of medications are worthwhile outcomes, most studies did not report the impact of these interventions on patient-centered or system-level outcomes.
The preoperative anesthesiology clinic encounter may represent an optimal time to initiate polypharmacy management strategies, as the surgical encounter with the healthcare team is a teachable moment where patients demonstrate extra motivation to make positive changes in their health behaviors. Therefore, the hypothesized positive impact of preoperative polypharmacy management could extend not only into the postoperative period, but also on a longitudinal basis beyond the transition from acute postoperative care.
The preoperative polypharmacy management intervention will be based on a pragmatic, evidence-based, CIHR-funded tool developed by our coinvestigators from McGill for use in elderly inpatients. It has recently been field tested in a 600-patient inpatient study at the Universities of Ottawa, Toronto, and McGill. The tool is a web-based platform developed by experts in internal and geriatric medicine and is based on best-practice guidelines, Choosing Wisely Canada's declarative statements, and evolving issues (such as narcotic and benzodiazepine co-administration). It contains rules that identify PIMs, prioritizes them in terms of risk of harm, and provides deprescribing opportunities for safely stopping medications using the current evidence as well as incorporating patient comorbidities in the analyses.
The investigators will address a clear knowledge gap in the literature by conducting a single center pilot randomized trial to evaluate the efficacy of a structured polypharmacy management program in preparation for a future multicenter randomized trial. The primary objectives of this pilot study are to: (1) provide evidence of efficacy of the intervention in reducing PIMs, (2) estimate characteristics of secondary outcomes, specifically patient-centered and system-level measures, including baseline prevalence and measures of variation, to inform sample size calculations for a future multi-site randomized trial powered to meaningfully impact these outcomes, and (3) demonstrate acceptability of the intervention to patients and providers along with potential barriers and facilitators to implementation.
Study design
- Primary purpose
- Other
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Double blind (participant, outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Standard Care | No intervention | –All patients will receive perioperative care per the standards of TOH. Standard care relevant to our study consists of a history by a nurse or physician; a best possible medication history performed by a pharmacy technician; and standardized perioperative-specific medication recommendations (e.g., anticoagulant, diabetes agent, and ACE-inhibitor management) based on medical directives. Medication recommendations beyond these medical directives do not occur as standard care in our clinics. Participants will be informed that their medical care will proceed as usual and that they are being recruited for a study to evaluate medication recommendations before surgery |
| Intervention | Experimental | Other: MedSaferIn addition to standard care, the intervention will include a structured preoperative polypharmacy management strategy that consists of: a) input of best possible medication history and comorbidities into our polypharmacy management tool (MedSafer); b) communication of the prioritized deprescribing plan (if indicated) to the patient's active treating physicians (automatically via fax), to the perioperative team (surgeon, anesthesiologist), and to the electronic medical record. During the pre-operative visit, the patient will receive a generalized information flyer about deprescribing. As in the usual care phase, patients will continue to receive usual recommendations from the perioperative team based on medical directives relevant to the perioperative period. |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Older adult
Key inclusion criteria (1 listed)
- English or French-speaking people aged 65 years or older seen in the Pre-Admission Unit prior to elective, inpatient non-cardiac surgery
Key exclusion criteria (1 listed)
- Patients who cannot be reached by telephone for follow up, or are not covered by the Ontario Health Insurance
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| MedSaferAn electronic deprescribing intervention that identifies potentially inappropriate medications (PIMs) and generates instructions for safe discontinuation. These recommendations are presented to the treating physicians for their consideration. | Other | Intervention |
Primary outcome
Average number of PIMs
Time frame: 90-days post-surgery
Average number of Potentially Inappropriate Medications based on patient report
8 secondary outcomes
Patient-reported health outcomes: Health related quality of life
Time frame: Before surgery, 30-day post-surgery, and 90-day post-surgery
Patient-reported health outcomes: Sleep Quality
Time frame: Before surgery, 30-days post-surgery, and 90-days post-surgery
Patient-reported health outcomes: Disability
Time frame: Before surgery, 30-days post-surgery, and 90-days post-surgery
Adverse Events
Time frame: Through study completion, an average of 7 days
Hospital length of stay
Time frame: Within 365 days after surgery
Proportion of patients discharged to an institution, readmissions within 30 days of discharge
Time frame: Within 365 days after surgery
Patient safety indicators
Time frame: Within 365 days after surgery
Costs of hospitalization
Time frame: Within 365 days after surgery
Results and safety
The study was withdrawn before enrolling participants, so there are no results.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 9 Jun 2020.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
The record lists no contact. Use the official record to reach the sponsor.
Questions about this trial
What is this clinical trial studying?
A study testing MedSafer in people with Polypharmacy, run by Ottawa Hospital Research Institute.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 1 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: withdrawn, as of the sponsor's last update on 9 Jun 2020. Status can change between updates, so confirm with the study contact before making plans.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study was withdrawn before enrolling participants, so there are no results.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Average number of PIMs (time frame: 90-days post-surgery). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 9 Jun 2020; AzTrials last refreshed its copy on 31 Oct 2026.