We have been awarded funding from the National Institute for Health Research (NIHR) Policy Research Programme to learn from the deprescribing experiences of the 25 pharmacist prescribers involved in the CHIPPS Study and to develop a national policy for deprescribing in care homes.
We know that residents in care homes for older people regularly receive large numbers of medicines and are exposed to large numbers of medication errors. One approach is to stop medicines that are either no longer necessary or could possibly cause harm in the future. The NIHR funded Care Homes Independent Pharmacist Prescribing Study (CHIPPS) placed 25 pharmacist independent prescribers in care homes in Norfolk, Yorkshire, Scotland and Northern Ireland. Assuming responsibility for medicines optimisation within the care homes, the study found that some pharmacists were more likely to stop medicines than others. We want to understand why this is more common in some care homes than others so that we can develop a policy to support all care homes to stop medicines that are not beneficial or are possibly harmful.
To develop policy to support effective implementation of proactive deprescribing (discontinuation of inappropriate medicines) within care homes.
- Describe the types of medicines commonly proactively deprescribed in CHIPPS and characterise variation in this behaviour within CHIPPS intervention care homes.
- Identify what helped and what hindered proactive deprescribing within CHIPPS intervention care homes.
- Devise a list of what processes can be introduced to change the behaviour of those responsible for prescribing in care homes.
- Develop a draft policy document to implement proactive deprescribing in care homes.
There will be 4 phases of activity:
Review the CHIPPS data to identify trends and variation in practice in terms of what medicines people were more or less willing to stop and who was more or less likely to stop them. This will help us identify who we want to talk to in Phase 2.
Interview general practitioners, pharmacists and care home staff from CHIPPS to help us understand what happened and why. We will look for common descriptions of what prevents medicines from being stopped and what helps. We will then compile a list of options to see what could make things better.
We will work with a group of experts who work in and with care homes to agree which of the options identified in phase 2 are best.
We will develop a draft policy document and approach to getting our plan into practice and present it to people responsible for implementing policy to obtain their feedback.
Two patient and public members will be fully involved throughout: from research management and design to delivery and presentation.
The potential or actual impact
The target audience for this research is NHS England policymakers regarding medicines optimisation, Clinical Commissioning Groups and local authority service commissioners responsible for medicines optimisation in care homes, Care England (who represent all multiple care homeowners across England) and owners of independent and small chains of care homes. Having worked across Scotland and Northern Ireland within CHIPPS, we will additionally encourage adoption in the two devolved nations.
We anticipate the impact of this study will be the better design of interventions to facilitate proactive deprescribing in the care home setting and ultimately more timely discontinuation of medicines where risks outweigh the benefits. Identifying approaches at all levels that will facilitate more effective deprescribing in this vulnerable patient population will reduce the risk of harm from medicines, reduce medicines administrator time and burden, minimise the opportunity for administrator error, reduce prescribing budget costs and additional unnecessary NHS resource costs such as preventable hospitalisation and GP call-outs.
Millar, A.N., Daffu-O’Reilly, A., Hughes, C.M. et al. Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes. Trials 18, 175 (2017). https://doi.org/10.1186/s13063-017-1915-6
Inch, J., Notman, F., Bond, C.M. et al. The Care Home Independent Prescribing Pharmacist Study (CHIPPS)—a non-randomised feasibility study of independent pharmacist prescribing in care homes. Pilot Feasibility Stud 5, 89 (2019). https://doi.org/10.1186/s40814-019-0465-y
Kate Massey, on behalf of PPIRes and the CHIPPS Research Project Management Team, Not just a ‘tick box exercise’ – meaningful public involvement in research, International Journal of Pharmacy Practice, Volume 26, Issue 3, June 2018, Pages 197–198, https://doi.org/10.1111/ijpp.12450
David John Wright, Vivienne Maskrey, Annie Blyth, Nigel Norris, David P Alldred, Christine M Bond, James Desborough, Carmel M Hughes, Richard Charles Holland, Systematic review and narrative synthesis of pharmacist-provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process, International Journal of Pharmacy Practice, Volume 28, Issue 3, June 2020, Pages 207–219, https://doi.org/10.1111/ijpp.12591
Bond, C.M., Holland, R., Alldred, D.P. et al. Protocol for the process evaluation of a cluster randomised controlled trial to determine the effectiveness and cost-effectiveness of independent pharmacist prescribing in care home: the CHIPPS study. Trials 21, 439 (2020). https://doi.org/10.1186/s13063-020-04264-8
Lane, K, Bond, C, Wright, D, et al. “Everyone needs to understand each other’s systems”: Stakeholder views on the acceptability and viability of a Pharmacist Independent Prescriber role in care homes for older people in the UK. Health Soc Care Community. 2020; 28: 1479– 1487.
Bond, C.M., Holland, R., Alldred, D.P. et al. Protocol for a cluster randomised controlled trial to determine the effectiveness and cost-effectiveness of independent pharmacist prescribing in care homes: the CHIPPS study. Trials 21, 103 (2020). https://doi.org/10.1186/s13063-019-3827-0
Bond, C., Alldred, D., Hughes, C., Holland, R., Poland, F., Wright, D., & Lancaster, G. A. (Ed.). (2020). Lessons learned from chipps: How feasibility studies informed ultimate randomized controlled trial design.In SAGE Research Methods Cases. https://www.doi.org/10.4135/9781529742763
- Secondary analysis of medicines data is underway (Phase 1)
- Ethical approval obtained for interview study (Phase 2)
- PPI representatives briefed in preparation for the commencement of study
This project is funded by the National Institute for Health Research (Policy Research Programme, NIHR202053). This is independent research supported by the National Institute for Health Research (NIHR) Applied Research Collaboration for the East of England and South West Peninsula. The views expressed are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health and Social Care.
CHIPPS NIHR Programme Grant – Care Homes Independent Pharmacist Prescribing Study. Designed to estimate the effectiveness and cost-effectiveness of pharmacist independent prescribers assuming responsibility for medicines optimisation in care homes.
CHARMER NIHR Programme Grant – Comprehensive Geriatrician-led Medication Review. Developing and testing a strategy for implementing proactive deprescribing in the hospital setting.
Who is involved?
Professor David Wright & Dr Sion Scott, UEA
Researchers and institutions
Professor David Alldred, University of Leeds
Professor Christine Bond, University of Aberdeen
Professor Richard Holland, University of Leicester
Professor Carmel Hughes, Queen’s University of Belfast
Dr Linda Birt, Senior Research Associate, UEA
Jeanette Blacklock, Senior Research Associate, UEA
Janet Gray, PPI Representative
Christine Handford, PPI Representative
Mohammed Alharthi, PhD Researcher
David Wright: D.J.Wright@uea.ac.uk
Sion Scott: Sion.Scott@uea.ac.uk