How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

Isabel Del Cura-González, Juan A López-Rodríguez, Francisca Leiva-Fernández, Antonio Gimeno-Miguel, Beatriz Poblador-Plou, Fernando López-Verde, Cristina Lozano-Hernández, Victoria Pico-Soler, Mª Josefa Bujalance-Zafra, Luis A Gimeno-Feliu, Mercedes Aza-Pascual-Salcedo, Marisa Rogero-Blanco, Francisca González-Rubio, Francisca García-de-Blas, Elena Polentinos-Castro, Teresa Sanz-Cuesta, Marcos Castillo-Jimena, Marcos Alonso-García, Amaia Calderón-Larrañaga, José M Valderas, Alessandra Marengoni, Christiane Muth, Juan Daniel Prados-Torres, Alexandra Prados-Torres, Multi-Pap Group, Paula Ara Bardaji, Jesús Martín Fernández, Maria del Pilar Barnestein Fonseca, Miguel Dominguez Santaella, Nuria Garcia Agua Soler, Maria Isabel Marquez Chamizo, Jose María Ruiz San Basilio, Jose María Abad Diez, Marta Alcaraz Borrajo, Gloria Ariza Cardiel, Amaya Azcoaga Lorenzo, Ana Cristina Bandrés Liso, Mercedes Clerencia Sierra, Javier Marta Moreno, Antonio Poncel Falcó, Ana Isabel González González, Virginia Hernandez Santiago, Angel Mataix San Juan, Ricardo Rodriguez Barrientos, Mercedes Rumayor Zarzuelo, Luis Sánchez Perruca, María Eugenia Tello Bernabé, Javier Martin Izquierdo, Macarena Toro Sainz, María José Fernández Jiménez, Esperanza Mora García, José Manuel Navarro Jiménez, Leovigildo Ginel Mendoza, Luz Pilar de la Mota Ybancos, Jaime Sasporte Genafo, María José Alcaide Rodriguez, Elena Barceló Garach, Beatriz Caffarena de Arteaga, María Dolores Gallego Parrilla, Catalina Sánchez Morales, María del Mar Loubet Chasco, Irene Martínez Ríos, Elena Mateo Delgado, Esther Martín Aurioles, Sylvia Hazañas Ruiz, María Auxiliadora Nieves Muñoz Escalante, Enrique Leonés Salido, María Antonia Máximo Torres, María Luisa Moya Rodríguez, María Encarnación Peláez Gálvez, José Manuel Ramírez Torres, Cristóbal Trillo Fernández, María Dolores García Martínez Cañavate, María del Mar Gil Mellado, María Victoria Muñoz Pradilla, María José Clavijo Peña, José Manuel Leiva Fernández, Virginia Castillo Romero, Rubén Vázquez Alarcón, Rafael Ángel Maqueda, Gloria Aycart Valdés, Ana María Fernández Vargas, Irene García Martínez Cañavate, Antonia González Rodríguez, María Carmen Molina Mendaño, Juana Morales Naranjo, Francisco Serrano Guerra, Carmen Sánchez Celaya del Pozo, José Ignacio Torrente Garrido, Concepción García Aranda, Marina Pinilla Lafuente, Mª Teresa Delgado Marroquín, Mª José Gracia Molina, Javier Cuartero Bernal, Mª Victoria Asin Martín, Susana García Domínguez, Carlos Bolea Gorbea, Antonio Luis Oto Negre, Eugenio Galve Royo, Mª Begoña Abadía Taira, José Fernando Tomás Gutiérrez, José Porta Quintana, Valentina Martín Miguel, Esther Mateo de las Heras, Carmen Esteban Algora, María Teresa Martín Nasarre de Letosa, Elena Gascón del Prim, Noelia Sorrinas Delgado, María Rosario Sanjuan Cortés, Teodoro Corrales Sánchez, Eustaquio Dendarieta Lucas, María del Pilar Miguez Sorio, Adolfo Cajal Marzal, Eduardo Díaz García, Juan Carlos García Álvarez, Cristina Guisado Pérez, Alberto López García Franco, María Elisa Viñuela Benitez, Ana Ballarín González, María Isabel Ferrer Zapata, Esther Gómez Suárez, Fernanda Morales Ortiz, Lourdes Carolina Peláez laguno, José Luis Quintana Gómez, Enrique Revilla Pascual, Mª Ángeles Miguel Abanto, Blanca Gutiérrez Teira, Francisco Ramón Abellán López, Carlos Casado Álvaro, Paulino Cubero González, Santiago Manuel Machín Hamalainen, Raquel Mateo Fernández, César Sánchez Arce, Jorge Olmedo Galindo, Claudia López Marcos, Soledad Lorenzo Borda, Juan Carlos Moreno Fernández, Belén Muñoz Gómez, Enrique Rodríguez De Mingo, Juan Pedro Calvo Pascual, Margarita Gómez Barroso, Beatriz López Serrano, María Paloma Morso Peláez, Julio Sánchez Salvador, Jeannet Dolores Sánchez Yépez, Ana Sosa Alonso, María del Mar Álvarez Villalba, Purificación Magán Tapia, María Angélica Fajardo Alcántara, María Canto De Hoyos Alonso, María Aránzazu Murciano Antón, Manuel Antonio Alonso Pérez, Ricardo De Felipe medina, Amaya Nuria López Laguna, Eva Martínez Cid de Rivera, Iliana Serrano Flores, María Jesús Sousa Rodríguez, María Soledad Núñez Isabel, Jesús Mª Redondo Sánchez, Pedro Sánchez Llanos, Lourdes Visedo Campillo, Isabel Del Cura-González, Juan A López-Rodríguez, Francisca Leiva-Fernández, Antonio Gimeno-Miguel, Beatriz Poblador-Plou, Fernando López-Verde, Cristina Lozano-Hernández, Victoria Pico-Soler, Mª Josefa Bujalance-Zafra, Luis A Gimeno-Feliu, Mercedes Aza-Pascual-Salcedo, Marisa Rogero-Blanco, Francisca González-Rubio, Francisca García-de-Blas, Elena Polentinos-Castro, Teresa Sanz-Cuesta, Marcos Castillo-Jimena, Marcos Alonso-García, Amaia Calderón-Larrañaga, José M Valderas, Alessandra Marengoni, Christiane Muth, Juan Daniel Prados-Torres, Alexandra Prados-Torres, Multi-Pap Group, Paula Ara Bardaji, Jesús Martín Fernández, Maria del Pilar Barnestein Fonseca, Miguel Dominguez Santaella, Nuria Garcia Agua Soler, Maria Isabel Marquez Chamizo, Jose María Ruiz San Basilio, Jose María Abad Diez, Marta Alcaraz Borrajo, Gloria Ariza Cardiel, Amaya Azcoaga Lorenzo, Ana Cristina Bandrés Liso, Mercedes Clerencia Sierra, Javier Marta Moreno, Antonio Poncel Falcó, Ana Isabel González González, Virginia Hernandez Santiago, Angel Mataix San Juan, Ricardo Rodriguez Barrientos, Mercedes Rumayor Zarzuelo, Luis Sánchez Perruca, María Eugenia Tello Bernabé, Javier Martin Izquierdo, Macarena Toro Sainz, María José Fernández Jiménez, Esperanza Mora García, José Manuel Navarro Jiménez, Leovigildo Ginel Mendoza, Luz Pilar de la Mota Ybancos, Jaime Sasporte Genafo, María José Alcaide Rodriguez, Elena Barceló Garach, Beatriz Caffarena de Arteaga, María Dolores Gallego Parrilla, Catalina Sánchez Morales, María del Mar Loubet Chasco, Irene Martínez Ríos, Elena Mateo Delgado, Esther Martín Aurioles, Sylvia Hazañas Ruiz, María Auxiliadora Nieves Muñoz Escalante, Enrique Leonés Salido, María Antonia Máximo Torres, María Luisa Moya Rodríguez, María Encarnación Peláez Gálvez, José Manuel Ramírez Torres, Cristóbal Trillo Fernández, María Dolores García Martínez Cañavate, María del Mar Gil Mellado, María Victoria Muñoz Pradilla, María José Clavijo Peña, José Manuel Leiva Fernández, Virginia Castillo Romero, Rubén Vázquez Alarcón, Rafael Ángel Maqueda, Gloria Aycart Valdés, Ana María Fernández Vargas, Irene García Martínez Cañavate, Antonia González Rodríguez, María Carmen Molina Mendaño, Juana Morales Naranjo, Francisco Serrano Guerra, Carmen Sánchez Celaya del Pozo, José Ignacio Torrente Garrido, Concepción García Aranda, Marina Pinilla Lafuente, Mª Teresa Delgado Marroquín, Mª José Gracia Molina, Javier Cuartero Bernal, Mª Victoria Asin Martín, Susana García Domínguez, Carlos Bolea Gorbea, Antonio Luis Oto Negre, Eugenio Galve Royo, Mª Begoña Abadía Taira, José Fernando Tomás Gutiérrez, José Porta Quintana, Valentina Martín Miguel, Esther Mateo de las Heras, Carmen Esteban Algora, María Teresa Martín Nasarre de Letosa, Elena Gascón del Prim, Noelia Sorrinas Delgado, María Rosario Sanjuan Cortés, Teodoro Corrales Sánchez, Eustaquio Dendarieta Lucas, María del Pilar Miguez Sorio, Adolfo Cajal Marzal, Eduardo Díaz García, Juan Carlos García Álvarez, Cristina Guisado Pérez, Alberto López García Franco, María Elisa Viñuela Benitez, Ana Ballarín González, María Isabel Ferrer Zapata, Esther Gómez Suárez, Fernanda Morales Ortiz, Lourdes Carolina Peláez laguno, José Luis Quintana Gómez, Enrique Revilla Pascual, Mª Ángeles Miguel Abanto, Blanca Gutiérrez Teira, Francisco Ramón Abellán López, Carlos Casado Álvaro, Paulino Cubero González, Santiago Manuel Machín Hamalainen, Raquel Mateo Fernández, César Sánchez Arce, Jorge Olmedo Galindo, Claudia López Marcos, Soledad Lorenzo Borda, Juan Carlos Moreno Fernández, Belén Muñoz Gómez, Enrique Rodríguez De Mingo, Juan Pedro Calvo Pascual, Margarita Gómez Barroso, Beatriz López Serrano, María Paloma Morso Peláez, Julio Sánchez Salvador, Jeannet Dolores Sánchez Yépez, Ana Sosa Alonso, María del Mar Álvarez Villalba, Purificación Magán Tapia, María Angélica Fajardo Alcántara, María Canto De Hoyos Alonso, María Aránzazu Murciano Antón, Manuel Antonio Alonso Pérez, Ricardo De Felipe medina, Amaya Nuria López Laguna, Eva Martínez Cid de Rivera, Iliana Serrano Flores, María Jesús Sousa Rodríguez, María Soledad Núñez Isabel, Jesús Mª Redondo Sánchez, Pedro Sánchez Llanos, Lourdes Visedo Campillo

Abstract

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65-74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was -2.42 (95% CI from -4.27 to -0.59) and, between baseline and a 12-month follow-up was -3.40 (95% CI from -5.45 to -1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Keywords: Ariadne principles; multimorbidity; polypharmacy.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Study flow diagram.

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Source: PubMed

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