AN INTRODUCTION TO THE CHARMER RESEARCH PROGRAMME

The issue

As we get older, our bodies are less able to handle some medicines. Medicines that were once effective and safe, can become less beneficial, with increased risk of harm. Half of older people in hospital are prescribed a medicine with a safety risk, but these medicines are rarely stopped. Nine out of ten patients and carers believe that risky medicines should be stopped in hospital and that doctors should start the discussion.

To make this happen, we need to change doctor and pharmacist behaviour so that the idea of stopping medicines is more likely to be discussed with patients. Our research with 54 doctors and pharmacists working with older people, found one thing that helps (drawing attention to prescribers who successfully stop risky medicines) and four things that hinder (wrong belief that patients don't want to stop, pharmacists being unavailable when stopping decisions could be made, thinking that doing nothing is safer than stopping and medicine stopping is not a hospital priority).  

Aims

In older people's wards we aim to:

  • develop our approach to increasing discussions with patients about stopping medicines by using what helps and removing what hinders

  • develop a list of things that people think are important to measure when stopping medicines in hospital

  • design and carry out a study testing whether our approach works and is value for money

  • make discussions about medicines stopping in hospital important

  • develop a way for getting our approach to be used in all hospitals  

Plan  

We will work with patients, carers, and staff from the hospital and community to develop a way to change pharmacist and doctor behaviour so that risky medicines are more likely to be stopped. They will also help us to design a study comparing hospitals using our approach, with hospitals carrying on as usual. After small-scale testing, we will test our approach in 22 hospitals and see if more medicines are stopped compared to 22 hospitals without our approach.

We will also see whether our approach has benefits to patients, such as preventing hospital readmissions or improving quality of life. We will also calculate the cost of our approach in such a way that the government can compare it with other services. Four patient and public members will be fully involved throughout: from research management and design, to delivery and presentation.  

We have designed the study so our approach can be easily taken up in different hospitals and will make the information on how to do this freely available. Throughout the research, we will plan how and with whom to share our findings; this will be led by a public member experienced in changing national practice. 

WP1 - Selecting patient outcomes and exploring trial design features for collecting outcomes

 

WP1 - Months 1-6

Selecting patient outcomes and exploring trial design features for collecting outcomes

DEBI BHATTACHARYA  DEBI BHATTACHARYA

  Co-Chief Investigator

  Professor of Behavioural Medicine - University of East Anglia

  https://people.uea.ac.uk/d_bhattacharya

JO TAYLOR       JO TAYLOR

       Study Qualitative Researcher

        Lecturer in Applied Health Research - University of York

        https://www.york.ac.uk/healthsciences/our-staff/jo-taylor/

SION SCOTT

Programme Manager

Lecturer in Behavioural Medicine - University of East Anglia

https://people.uea.ac.uk/sion_scott

We will use modified Delphi (n=120-150) to develop a core outcome set for hospital deprescribing trials and to identify a suitable primary outcome measure for this trial.

WP2 - Developing the intervention package

 

WP2 - Months 1-10

Developing the intervention package

JO TAYLOR        JO TAYLOR

        Study Qualitative Researcher

        Lecturer in Applied Health Research - University of York

        https://www.york.ac.uk/healthsciences/our-staff/jo-taylor/ 

SION SCOTT

Programme Manager

Lecturer in Behavioural Medicine - University of East Anglia

https://people.uea.ac.uk/sion_scott

  DEBI BHATTACHARYADEBI BHATTACHARYA

  Co-Chief Investigator

  Professor of Behavioural Medicine - University of East Anglia

  https://people.uea.ac.uk/d_bhattacharya

We will characterise the six BCTs and operationalise them into an intervention package using two rounds of co-design workshops with stakeholders (n=8-10). We will also develop a questionnaire investigating the mechanism of action of the intervention BCTs.

WP3 - Feasibility Testing

 

WP3 - Months 11-24

Feasibility Testing

DEBI BHATTACHARYADEBI BHATTACHARYA

Co-Chief Investigator

Professor of Behavioural Medicine - University of East Anglia

https://people.uea.ac.uk/d_bhattacharya

SION SCOTTSION SCOTT

Programme Manager

Lecturer in Behavioural Medicine - University of East Anglia

https://people.uea.ac.uk/sion_scott

We will use modified Delphi (n=120-150) to develop a core outcome set for hospital deprescribing trials and to identify a suitable primary outcome measure for this trial.

 

WP4 - Internal pilot and definitive cluster randomised control trial

 

WP4 - Months 22-49

Internal pilot and definitive cluster randomised control trial

DAVID WRIGHTDAVID WRIGHT

Co-Chief Investigator

Professor of Pharmacy Practice - University of East Anglia

https://people.uea.ac.uk/d_j_wright

DAVID ALLDREDDAVID ALLDRED

Expert on trials with older people

Professor of Medicines Use and Safety - University of Leeds

https://medicinehealth.leeds.ac.uk/healthcare/staff/77/professor-david-alldred

We will phase recruitment of 44 hospitals (each recruiting 110 patients) over 14 months and randomise each to intervention or control. This will provide 90% power at 5% significance for detecting a 20% difference in proactive deprescribing between intervention and control hospitals.

 

WP5 - Dissemination

 

WP5 - Months 1-58

Dissemination

DEBI BHATTACHARYADEBI BHATTACHARYA

Co-Chief Investigator

Professor of Behavioural Medicine - University of East Anglia

https://people.uea.ac.uk/d_bhattacharya

KATHERINE MURPHYKATHERINE MURPHY

Patient and Public Involvement and Media Relations lead

https://uk.linkedin.com/in/katherine-murphy-43044b30

 

We will undertake dissemination activities and refine the strategy throughout the programme and convene a strategy workshop with key stakeholders (n=8-10), to prepare a detailed plan for the intervention to be more widely implemented and adopted.

 

Studies relating to CHARMER and the teams wider work:

Wright D, Scott S, Buck J, Bhattacharya D. Roles of nurses in supporting proactive deprescribing. Nursing Standard. 2019 Jan 14.

Wright D, Bhattacharya D, Scott S. Deprescribing: routine pharmacy practice or an exciting research opportunity?. International Journal of Pharmacy Practice. 2019; 27(5):406-7.

Scott S, Wright DJ, Bhattacharya D. The role of behavioural science in changing deprescribing practice. British Journal of Clinical Pharmacology. 2020 Sep 25.

Research studies that underpin the CHARMER programme:

Scott S, Clark A, Farrow C, May H, Patel M, Twigg MJ, Wright DJ, Bhattacharya D. Deprescribing admission medication at a UK teaching hospital; a report on quantity and nature of activity. International Journal of Clinical Pharmacy. 2018 Oct 1;40(5):991-6.

Scott S, Clark A, Farrow C, May H, Patel M, Twigg MJ, Wright DJ, Bhattacharya D. Attitudinal predictors of older peoples’ and caregivers’ desire to deprescribe in hospital. BMC geriatrics. 2019 Dec 1;19(1):108.

Scott S, Twigg MJ, Clark A, Farrow C, May H, Patel M, Taylor J, Wright DJ, Bhattacharya D. Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists. Age and ageing. 2020 Jan 1;49(1):102-10.

Sion Scott, Helen May, Martyn Patel, David J Wright, Debi Bhattacharya, A practitioner behaviour change intervention for deprescribing in the hospital setting, Age and Ageing, afaa169, https://doi.org/10.1093/ageing/afaa169