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Background Polypharmacy is common and deleterious for elders. We devised a QI-research collaboration, Structured Process Informed by Data, Evidence and Research (SPIDER) aimed at improving medication appropriateness for complex older patients. Methods Single-arm mixed methods feasibility study followed by a 2-arm (Intervention vs Usual Care) pragmatic cluster randomized controlled trial. Setting: seven Practice-Based Research Networks across Canada. Participants: Seven practices (each with two physicians) per arm per region will be recruited. patients 65+ years taking 10+ different medications identified by participating physicians' EMR. Intervention: three key elements: 1) Practice teams participating in QI Learning Collaboratives; 2) Support of coaching/practice facilitation; and 3) validated EMR data for feedback. Main Outcome Measures: Reduction of potentially inappropriate prescriptions (PIPs) measured using EMR data. Results Thirty-three physicians from ten family health teams/practices and one nurse practitioner and three family physicians from a community health centre in Toronto were recruited. All teams have accessed coaching support, reflecting high engagement. Teams were given flexibility in developing deprescription strategies and action plans that fit for the local context. Review and validation of patient cohort identified by the EMR were time-consuming for some, depending on the size of the cohort and the patterns practices have been using to capture medication information in their EMR. Engaging pharmacists in the medication review and deprescription process greatly alleviated the burdens on the physicians. Conclusions SPIDER appeared to be feasible and has the potential to enhance safer prescription for complex older patients. A flexible and contextually adaptable design helped with increased uptake. Having access to embedded QI and data support and working with collaborating pharmacists may enhance the sustainability of the approach. Key messages A QI-Research collaboration to improve care for complex elders is feasible. If the RCT shows improvement, this may provide an argument for QI support in primary care.

Safer prescribing for older patients: Preliminary findings from a large project in Canada