The multimorbidity collaborative medication review and decision making (MyComrade) study: a pilot cluster randomised trial in two healthcare systems.

BACKGROUND: While international guidelines recommend medication reviews as part of the management of multimorbidity, evidence on how to implement reviews in practice in primary care is lacking. The MyComrade (MultimorbiditY Collaborative Medication Review And Decision Making) intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care. AIM: The pilot study aimed to assess the feasibility of a definitive trial of the MyComrade intervention across two healthcare systems (Republic of Ireland (ROI) and Northern Ireland (NI)). DESIGN: A pilot cluster-randomised controlled trial was conducted (clustered at general practice level), using specific progression criteria and a process evaluation framework. SETTING: General practices in the ROI and NI. PARTICIPANTS: Eligible practices were those in defined geographical areas who had GP's and Practice Based Pharmacists (PBP's) (in NI) willing to conduct medication reviews. Eligible patients were those aged 18 years and over, with multi morbidity and on ten or more medications. INTERVENTION: The MyComrade intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care, using a planned collaborative approach guided by an agreed checklist, within a specified timeframe. OUTCOME MEASURES: Feasibility outcomes, using pre-determined progression criteria, assessed practice and patient recruitment and retention and intervention acceptability and fidelity. Anonymised patient-related quantitative data, from practice medical records and patient questionnaires were collected at baseline, 4 and 8 months, to inform potential outcome measures for a definitive trial. These included (i) practice outcomes-completion of medication reviews; (ii) patient outcomes-treatment burden and quality of life; (iii) prescribing outcomes-number and changes of prescribed medications and incidents of potentially inappropriate prescribing; and (iv) economic cost analysis. The framework Decision-making after Pilot and feasibility Trials (ADePT) in conjunction with a priori progression criteria and process evaluation was used to guide the collection and analysis of quantitative and qualitative data. RESULTS: The recruitment of practices (n = 15) and patients (n = 121, mean age 73 years and 51% female), representing 94% and 38% of a priori targets respectively, was more complex and took longer than anticipated; impacted by the global COVID-19 pandemic. Retention rates of 100% of practices and 85% of patients were achieved. Both practice staff and patients found the intervention acceptable and reported strong fidelity to the My Comrade intervention components. Some practice staff highlighted concerns such as poor communication of the reviews to patients, dissatisfaction regarding incentivisation and in ROI the sustainability of two GPs collaboratively conducting the medication reviews. Assessing outcomes from the collected data was found feasible and appropriate for a definitive trial. Two progression criteria met the 'Go' criterion (practice and patient retention), two met the 'Amend' criterion (practice recruitment and intervention implementation) and one indicated a 'Stop - unless changes possible' (patient recruitment). CONCLUSION: The MyComrade intervention was found to be feasible to conduct within two different healthcare systems. Recruitment of participants requires significant time and effort given the nature of this population and the pairing of GP and pharmacist may be more sustainable to implement in routine practice. TRIAL REGISTRATION: Registry: ISRCTN, ISRCTN80017020 ; date of confirmation 4/11/2019; retrospectively registered.

The MultimorbiditY COllaborative Medication Review And DEcision Making (MyComrade) study: a protocol for a cross-border pilot cluster randomised controlled trial.

BACKGROUND: While international guidelines recommend medication reviews as part of the management of multimorbidity, evidence on how to implement reviews in practice in primary care is lacking. The MultimorbiditY Collaborative Medication Review And Decision Making (MyComrade) intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care. Our aim in this pilot study is to evaluate the feasibility of a trial of the intervention with unique modifications accounting for contextual variations in two neighbouring health systems (Republic of Ireland (ROI) and Northern Ireland (NI)). METHODS: A pilot cluster randomised controlled trial will be conducted, using a mixed-methods process evaluation to investigate the feasibility of a trial of the MyComrade intervention based on pre-defined progression criteria. A total of 16 practices will be recruited (eight in ROI; eight in NI), and four practices in each jurisdiction will be randomly allocated to intervention or control. Twenty people living with multimorbidity and prescribed ≥ 10 repeat medications will be recruited from each practice prior to practice randomisation. In intervention practices, the MyComrade intervention will be delivered by pairs of general practitioners (GPs) in ROI, and a GP and practice-based pharmacist (PBP) in NI. The GPs/GP and PBP will schedule the time to review the medications together using a checklist. Usual care will proceed in practices in the control arm. Data will be collected via electronic health records and postal questionnaires at recruitment and 4 and 8 months after randomisation. Qualitative interviews to assess the feasibility and acceptability of the intervention and explore experiences related to multimorbidity management will be conducted with a purposive sample of GPs, PBPs, practice administration staff and patients in intervention and control practices. The feasibility of conducting a health economic evaluation as part of a future definitive trial will be assessed. DISCUSSION: The findings of this pilot study will assess the feasibility of a trial of the MyComrade intervention in two different health systems. Evaluation of the progression criteria will guide the decision to progress to a definitive trial and inform trial design. The findings will also contribute to the growing evidence-base related to intervention development and feasibility studies. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN80017020 . Date of confirmation is 4/11/2019.

The 'general check-up' in the asymptomatic adult­a study of GPs in the North West of Ireland.

BACKGROUND: The asymptomatic general check-up (AGCU) is a common consultation in primary care. Detractors of the AGCU cite a lack of evidence and the harm of over-investigation. Proponents cite the opportunity for the GP to engage in health promotion and explore hidden concerns of the patient. OBJECTIVES: To research Irish GP experiences with the AGCU, including their approach to the consultation and to assess their attitudes towards the AGCU. METHODS: In 2013, a cross-sectional postal-survey of 136 GPs in the Northwest of Ireland was performed. This was a mixed-method study which underwent both quantitative and qualitative analysis. RESULTS: The response rate was 79/136 (57%). Over 6% of reported consultations were for an AGCU. Large differences existed amongst GPs in their approach to the AGCU. Cardiovascular risk assessment and blood investigations were deemed the most important. GPs had concerns about the AGCU relating to patients being falsely reassured, about the workload and over-diagnosis. Still, 63% of responding GPs felt that the AGCU was clinically useful. Seventy per cent did not agree with private companies offering an AGCU. CONCLUSION: Despite the lack of evidence for its use and frustrations expressed by GPs, the AGCU is a frequent consultation. GPs took very different approaches to the consultation when a patient presented for a check-up. Most responding GPs think it can have some clinical benefit. There is a need for GPs to appropriately challenge mistaken health beliefs pertaining to the AGCU.

Termination of pregnancy: attitudes and clinical experiences of Irish GPs and GPs-in-training.

BACKGROUND: Termination of pregnancy (ToP) is currently illegal in Ireland. In 2010, more than 4000 women travelled from Ireland to the UK for a ToP. OBJECTIVES: The aims of this study were to assess the attitudes and clinical experiences of Irish General Practitioners (GPs) and GPs-in-training (GPRs) towards ToP. METHODS: A postal survey was sent to 500 GPs in Ireland. An internet-based survey was sent to 244 GPRs. Quantitative and qualitative analysis was performed. RESULTS: Overall response was 44%. Four groups of doctor's opinions could be identified: (A) abortion can never be allowed (10%); (B) abortion can be allowed in limited circumstances (25%); (C) abortion should be available to all women (51%); and (D) no definite opinion (14%). Doctors in groups (A) and (B) were older and more often Catholic. Of doctors in group (C), 66% indicated an upper gestational limit of maximum 16 weeks. More than 40% of all respondents had at least one consultation specifically dealing with ToP within the past six months and 43% agreed with the statement that women's health suffers due to the travel related to ToP. CONCLUSION: Most responding GPs and GPRs (75%) support the provision of ToP in Ireland in certain circumstances. The qualitative analysis of this survey showed that the terms pro-life and pro-choice inappropriately describe the spectrum of opinions. This study highlights clinical situations in which women's health may be adversely affected due to the requirement to travel for ToP.