Standardized Patient-Centered Medication Review in Home Hospice

Not Applicable

Completed

Conditions: Deprescriptions
Hospices
Palliative Care
Prescription Drug Overuse
Interdisciplinary Communication
Poly Pharmacy
Caregivers

Interventions: Behavioral: STOPPFrail (Screening Tool of Older Persons Prescriptions)
Behavioral: NIA Medication Management - Active Comparator
Behavioral: "Discontinuing Medication Appropriately" and "Understanding the Art of Communication about Deprescribing"
Behavioral: "Key Approaches to Support Informal Family Caregivers in Managing Medications"

Registration Number: NCT03972163

Lead Sponsor: University of Massachusetts, Worcester

Brief Summary: This is a pilot cluster randomized trial that tests the effect of a novel intervention that trains hospice staff to 1. regularly review, simplify, and align patients' prescribed medications with their goals of care as their illness progresses, and 2. support family caregivers with education that empowers them to understand each medication's use, develop skills for safe administration, and 3. understand when stopping medications may be beneficial.

Detailed Description: A tremendous challenge in home hospice care is ensuring that medication prescribing is appropriately aligned to patients' goals of care and that medications are appropriately managed by family caregivers. Therefore, the Investigators propose a novel intervention that trains hospice staff to 1. regularly review, simplify, and align patients' prescribed medications with their goals of care as their illness progresses, and 2. support family caregivers with education that empowers them to understand each medication's use, develop skills for safe administration, and understand when stopping medications may be beneficial. This program is called Standardized PatiEnt-CenTered medicatiOn Review (SPECTORx) in Home Hospice, and is based on a combination of 3 existing, complementary, educational programs that, together, train hospice staff to create a comprehensive, patient-centered, medication management care plan. The program also creates an online learning community that promotes ongoing education and practice change for hospice clinicians. This pilot study aims to demonstrate the feasibility of conducting a clinical trial to evaluate the efficacy of SPECTORx. The long-term objective is to test the hypothesis that SPECTORx reduces inappropriate medication prescribing and improves family caregiver reported quality of care. However, to accomplish this, the Investigators must first address challenging questions regarding the design, feasibility, and execution of trials in home hospice. The Investigators will accomplish this using a stakeholder engagement process to refine the SPECTORx intervention and trial protocol. The Investigators will then conduct a pilot cluster randomized trial and compare outcomes within and across 2 large, multi-office, hospice agencies from Utah and Massachusetts. Within each hospice agency, the Investigators will randomize 1 office to intervention and 1 office to attention control. Target enrollment is n=60 family caregiver-patient dyads of patients aged ≥65 years with advanced, life-limiting illness. Primary outcomes are acceptability and feasibility of the SPECTORx intervention by hospice stakeholders, and acceptability, burden and completion of family caregiver assessments (Family Caregiver Medication Administration Hassle Scale at baseline, 2 weeks, 4 weeks, 12 weeks, and quarterly). The overarching goal of this research is to align patient's prescribed medications with their goals of care at each stage of their advanced illness and to support family caregivers' medication management challenges. Ultimately, the Investigators want to improve the quality of medication prescribing, reduce treatment complexity and medication-related harm, and improve family caregiver outcomes for the almost 600,000 elderly Americans who receive home hospice services annually.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 23

Inclusion Criteria

Patient - Newly admitted home hospice enrollees, aged ≥65 years old with:

1. advanced life-limiting illness;
1. an estimated life expectancy of >1 month;
1. recent functional status decline (defined as change in Karnofsky Performance Status [KPS] to < 80% in prior 3 months);
1. polypharmacy (defined as ≥ 5 regularly scheduled medications [excluding antimicrobials]);
1. cognitive ability to provide informed consent based on a Short Portable Mental Status Questionnaire (SPMSQ) score ≥6 OR, with a legally authorized representative who is willing and able to provide proxy consent.

Family ("any relative, partner, friend or neighbor who has a significant personal relationship with, and provides a broad range of assistance) Caregiver -

self-identification as "usually" or "always" providing care to the eligible patient;
English-speaking;
telephone access; and
cognitive ability to participate.

Exclusion Criteria

Patient:

Imminent death;
pain crisis;
no family caregiver or health care proxy

Family Caregiver:

no telephone access;
cognitive impairment.

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
SPECTORx Educational Intervention	"Key Approaches to Support Informal Family Caregivers in Managing Medications"	The program intervention is based on a combination of 3 existing, complementary, educational programs that, together, equip hospice staff to create a comprehensive, patient-centered, medication management care plan.
SPECTORx Educational Intervention	STOPPFrail (Screening Tool of Older Persons Prescriptions)	The program intervention is based on a combination of 3 existing, complementary, educational programs that, together, equip hospice staff to create a comprehensive, patient-centered, medication management care plan.
Attention Control	NIA Medication Management - Active Comparator	As the attention control, we will refer staff in control offices to the National Institute of Aging (NIA)'s website on "Medicines and Medication Management" to review content and materials for use in Family Care Giver (FCG) support.
SPECTORx Educational Intervention	"Discontinuing Medication Appropriately" and "Understanding the Art of Communication about Deprescribing"	The program intervention is based on a combination of 3 existing, complementary, educational programs that, together, equip hospice staff to create a comprehensive, patient-centered, medication management care plan.

Primary Outcome Measures

Name	Time	Method
Intervention Training Completion by Hospice Staff	Baseline	Number of Completed Intervention Trainings
Patient and Family Caregiver Eligibility Screens	2 weeks prior to enrollment	Number of Eligible Dyad Participants (i.e. participant = 1 dyad) screened for potential eligibility to inform subsequent eligibility criteria to obtain a sufficient study population.
Completion of Primary Patient Outcome--Retention	Baseline	Number of Dyads who completed the Medication Regimen Complexity Score at Baseline
Patient and Family Caregiver Enrollment	Baseline	Number of Patients and Family Caregivers who enrolled

Secondary Outcome Measures

Name	Time	Method
Family Caregiver Medication Administration Hassle Scale	Baseline, 2, 4, 6, 8 12, 16, 20, 24 weeks(or death)	The 24-item Family Caregiver Medication Administration Hassle Scale has four subscales: Information Seeking/Sharing, Safety Issues, Scheduling Logistics, and Polypharmacy. The theoretical range of the scores across 4 subscales is 0 to 120. Higher scores indicate greater burden. Overall scale reliability is .95.
Medication Regimen Complexity Index	Baseline, 2, 4, 6, 8, 12, 16, 20, 24 weeks(or death)	Medication Regimen Complexity Index (MCRI) will characterize patients' chronic disease and preventive medication regimens (i.e. drugs initiated prior to hospice admission, not End of Life (EOL) symptom medications \[e.g. haloperidol\] because these increase over time). MRCI score weights dosage form, dosing frequency and administration instructions. Minimum MRCI is 1.5 \[a single tablet once a day\] and maximum score increases with medication number. Higher scores indicate greater complexity. MRCI score of 0 indicates no medication use. There is no established maximum score.
Potential Adverse Event	Week 2, 4, 6, 8, 12, 16, 20, 24	Hospitalizations and Emergency Department (ED) visits will be abstracted from the hospice record. Potential Adverse Drug Event (ADE)s and Adverse Drug Withdrawal Events (ADWEs) will be determined from medical record review