Falls are a leading cause of injury among older adults, with medication often contributing to the risk. As ageing populations face increasing medication use, the challenge of safely managing prescriptions becomes more urgent. General practitioners (GPs) frequently lack the tools to identify patients at risk and to consolidate complex, fragmented guidelines into actionable plans. Patients, especially older individuals, may also feel unprepared or lack confidence to engage in meaningful consultation. The SNOWDROP intervention addresses these issues by combining a clinical decision support system (CDSS) with a patient portal, designed to enhance shared decision-making (SDM) in the context of fall prevention. By integrating predictive modelling into electronic medical records and preparing patients ahead of consultations, SNOWDROP aims to improve communication, decision-making quality and prescribing practices. A cluster randomised controlled trial evaluated the impact of this multicomponent approach on communication outcomes, patient satisfaction, decisional conflict and medication changes.
Shared Decision-Making and Communication Gains
SDM is a collaborative process where medical professionals and patients jointly make treatment decisions, taking into account clinical evidence and personal preferences. Although SDM is promoted by legal and professional frameworks, such as the Dutch Medical Treatment Contracts Act, its practical implementation remains inconsistent. Technology has the potential to bridge this gap, especially when interventions are tailored to the specific needs of older adults.
The SNOWDROP intervention includes a CDSS that generates personalised deprescribing recommendations using a fall-risk prediction model. This tool is embedded in the GP’s electronic medical record, providing timely, evidence-based advice without additional input or complexity. The second component, the patient portal, offers educational content and a question prompt list to help older patients prepare for consultations. Together, these tools aim to empower patients and structure GP communication around fall risk and medication.
Results showed that GPs using SNOWDROP achieved significantly higher SDM scores than those in the control group. Patients also scored higher on SDM when supported by the intervention. The inter-observer agreement for scoring was high for both patient and GP measures, reinforcing the reliability of the findings. Notably, consultations in the intervention group were not longer than those in the control group, indicating that the improved communication quality did not come at the cost of efficiency.
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Patient satisfaction with the communication was also higher in the intervention group. Structured discussions and clearer communication contributed to this improvement. Patients reported feeling more involved, likely due to the preparatory role of the portal and the organised flow of the consultation supported by the CDSS. The intervention facilitated the completion of essential SDM steps, including discussing options, weighing pros and cons, and incorporating patient priorities into decision-making.
Reduced Decisional Conflict and Stable Medication Beliefs
Patients in the intervention group experienced significantly lower levels of decisional conflict. Decisional conflict reflects the extent to which individuals feel uncertain or distressed about medical decisions. Lower levels of conflict are associated with better adherence and satisfaction. While the scores in the intervention group remained slightly above the clinical relevance threshold, the reduction represents a meaningful improvement. The structured communication process likely contributed to greater clarity, reduced anxiety and a stronger sense of support during decision-making.
However, beliefs about medication remained stable across both groups. The intervention did not significantly alter patients’ necessity-concerns differential (NCD), nor were there notable changes between the initial and follow-up assessments. This may be attributed to the framing of the belief measurement, which addressed general medication attitudes rather than specific treatments. Additionally, changing long-held beliefs about medicines may require repeated interactions, as a single consultation might not suffice. Given the general nature of the medication review topic, similar discussions occurred in both groups, possibly limiting the intervention’s influence on this outcome.
Medication Changes and Observed Limitations
The effect of the intervention on actual medication changes was less conclusive. When including all GPs, no significant difference was observed between the intervention and control groups in the number or quality of deprescribing decisions. However, further analysis revealed that one GP in the control group made an unusually high number of changes, acting as an outlier. After removing this GP’s data, the intervention group showed significantly more patients with medication changes and a higher total number of adjustments.
The categories most affected were cardiovascular and other medications, rather than psychotropics. These results suggest that the personalised advice offered by the CDSS can support deprescribing decisions that align more closely with established guidelines, particularly in medication categories where change is typically more challenging. Nevertheless, the small sample size and the impact of the outlier mean that results should be interpreted cautiously. A larger sample would provide greater statistical power to detect consistent patterns.
While the SNOWDROP intervention effectively improved communication outcomes and supported SDM, its multicomponent nature makes it difficult to isolate the specific effects of each element. Both the CDSS and the patient portal contributed to the overall improvements, but further research is needed to understand their individual roles. Additionally, the study’s implementation in real-world general practices introduced some limitations, including incomplete tracking of patient recruitment and a potential bias towards more motivated GPs.
The SNOWDROP intervention demonstrates the value of integrating digital tools into primary care consultations focused on fall prevention. By supporting GPs with embedded predictive advice and empowering patients through a tailored portal, it significantly enhanced shared decision-making and communication satisfaction while reducing decisional conflict. Although the impact on medication changes was less clear, the intervention shows promise in promoting safer and more structured prescribing practices for older adults. Future evaluations with larger cohorts could offer deeper insight into its potential for wider adoption in clinical practice.
Source: npj digital medicine
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