In the large, 6-month Care Homes Independent Pharmacist Prescriber Study (CHIPPS), weekly visits to care homes by pharmacist independent prescribers (PIPs) significantly reduced the Drug Burden Index and was safe and well received. The primary outcome of fall rate/person was not significantly different in the intervention group than in the control group.
Triads were formed involving care homes, their associated general practices, and pharmacy independent prescribers across England, Scotland, and Northern Ireland. A total of 49 triads and 882 residents (in groups of approximately 20 residents in 1 to 3 facilities) were randomized by clusters. All participants were care home residents, 65 years of age or older, and taking at least 1 prescribed drug. Over the 6-month period, PIPs developed a pharmaceutical care plan for each resident, performed medication reviews and reconciliation, trained staff, and supported medication-related procedures, deprescribing, and authorization of prescriptions. Participants in the control group received usual care.
Based on a primary outcome of the fall rate/person at 6 months analyzed by intention to treat, the study found: “The average age of participants at study entry was 85 years; 70% were female. 697 falls (1.55 per resident) were recorded in the intervention group and 538 falls (1.26 per resident) in the control group at six months. The fall rate risk ratio for the intervention group compared with the control group was not significant (0.91, 95% confidence interval 0.66 to 1.26) after adjustment for all model covariates. Secondary outcomes were not significantly different between groups, with exception of the Drug Burden Index, which significantly favoured the intervention. A third (185/566; 32.7%) of pharmacy independent prescriber interventions involved medicines associated with falls. No adverse events or safety concerns were identified.”
Editorial: “Ideally, service innovation should be based on evidence of improved clinical outcomes,” write 3 authors on behalf of the CHIPPS team. “Yet it is challenging to choose a primary outcome that is relevant to a clinically heterogeneous population and which happens with sufficient frequency (or affects enough residents) to allow a statistically robust trial finding to emerge. After extensive preliminary work, we agreed that falls was the most suitable primary outcome. Our study’s failure to demonstrate any improvement in falls may be explained by the lack of direct proximity to the intervention (improved prescribing and medicines management more widely), our relatively short follow-up time, and the lower than anticipated fall rate in participating homes. The reduction in anticholinergic and sedative prescribing by the PIPs would be expected to lead to a reduction in future adverse drug reactions or events.
“CHIPPS does, however, provide evidence to support implementing this model of care. At a time when [general practitioner] time is paramount and care homes require substantial support, integrating PIPs into care homes can make a notable contribution to both agendas, while improving the care of residents. It should be noted, however, that the PIPs were not visiting once every three to six months, which is a commonly reported model, but weekly for half a day. This would represent a considerable shift in costs related to care provision, but it enables the pharmacist to effectively become responsible for all elements of medicines management in care homes and responds to the original recommendations in the research that provided the rationale for CHIPPS.”