title: A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial.
abstract: BACKGROUND
  Medication safety for older persons represents an ongoing challenge. Inappropriate prescriptions--those with a high risk of evidence-based harm--persist in up to 25% of seniors, and account for a significant proportion of avoidable emergency department visits. This project is the sequel to the EMPOWER study, in which a novel consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of benzodiazepine de-prescription resulted in a 27% reduction of inappropriate benzodiazepine use at 6-month follow-up (number needed to treat (NNT) = 4). Failure to discontinue in the EMPOWER study was attributable to re-emerging symptoms among participants, prescribing inertia, and lack of knowledge and skills for substituting alternate therapy among physicians and pharmacists. To maximize de-prescription of inappropriate therapy, educational medication-risk reduction initiatives should be tested that simultaneously include patients, physicians and pharmacists. The objective of this trial is to: 1) test the beneficial effect of a new de-prescribing paradigm enlisting pharmacists to transfer knowledge to both patients and prescribers in a 2-pronged approach to reduce inappropriate prescriptions, compared to usual care and 2) evaluate the transferability of the EMPOWER study concept to other classes of inappropriate prescriptions.
  
  
  METHODS
  We intend to conduct a 3-year pragmatic cluster randomized parallel-group controlled trial to test the effect of the new de-prescribing intervention compared to usual care for reducing 4 classes of inappropriate prescriptions from the 2012 Beers criteria among 450 community-dwelling older adults with polypharmacy. Inappropriate prescriptions will include benzodiazepines, sulfonylurea hypoglycemic agents, first generation antihistamines and non-steroidal anti-inflammatory drugs. The study population is community-dwelling older adults recruited from community pharmacies in Quebec, Canada. The intervention was developed based on a systematic review of the evidence for each medication. Participants in the experimental group will receive the written educational program following randomization and have their pharmacist send their physicians an evidence-based pharmaceutical opinion to recommend de-prescription and be followed for a year. The control group will be wait-listed for 6 months.
  
  
  CONCLUSIONS
  System change to effectively reduce medication risk among community-dwelling seniors requires a coordinated approach targeting physicians, pharmacists and patients. This trial will test the feasibility and effectiveness of a tripartite approach to de-prescribing.
  
  
  BACKGROUND
  Registered via ClinicalTrials.gov on 31 January 2014, identifier: NCT02053194.
authors.affiliation: Institut Universitaire de Gériatrie de Montréal, Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada. philippe.martin@umontreal.ca.
authors.forename: Philippe
authors.initials: P
authors.lastname: Martin
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. robyn.tamblyn@mcgill.ca.
authors.forename: Robyn
authors.initials: R
authors.lastname: Tamblyn
authors.affiliation: School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada. Sara.ahmed@mcgill.ca.
authors.forename: Sara
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. Andrea.benedetti@mcgill.ca.
authors.forename: Andrea
authors.initials: A
authors.lastname: Benedetti
authors.affiliation: Institut Universitaire de Gériatrie de Montréal, Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada. cara.tannenbaum@umontreal.ca.
authors.forename: Cara
authors.initials: C
authors.lastname: Tannenbaum
mesh_terms: D000368:Aged; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control*; D008297:Male; D010353:Patient Education as Topic; D010595:Pharmacists; D018401:Sample Size