Older patients with polypharmacy have become the norm rather than the exception in general practice. Treating these patients is very complex and often many specialties are involved. Keeping an overview of all drugs becomes difficult, especially in countries like Germany where the GP does not act as a gatekeeper and is not necessarily informed of prescriptions made by specialist colleagues. We all know of cases where some patients are taking up to 20 different drugs regularly and we often ask ourselves if they are all really necessary. We know that this kind of polypragmatic medicine is not good for the patient. Numerous studies have shown that polypharmacy is associated with increased adverse event rates, hospitalizations, and even premature death. So there is a strong need to address the topic.
All the approaches and tools that we know of to reduce polypharmacy are either extremely time-consuming or address only single or few aspects of drugs, interactions, or adverse events. We need something bigger: a tool that detects all sorts of drug-problems, interactions, and adverse-event-risks within a few seconds, is based on sound evidence from studies wherever possible, and is easy to handle in everyday practice. Quite an ambitious undertaking!
To tackle this challenging task, we—an international consortium of researchers with expertise in evidence-based medicine, clinical decision support, general practice and pharmacotherapy—set out to develop the “PRIMA-eDS tool” (Polypharmacy: Reduction of Inappropriate Medication and Adverse drug events in an older population by electronic Decision Support), a comprehensive electronic decision support tool to support GPs in treating their older patients with polypharmacy. The PRIMA-eDS tool consists of two parts: a data entry form to fill in up-to-date patient data and a comprehensive medication review to support physicians and patients in reducing potentially inappropriate and non-evidence-based polypharmacy in a shared decision-making process.
This kind of medication review is a novel approach to assessing a patient’s medication: it is not limited to any specific drug or drug classes, but rather uses an all-inclusive approach based on best available evidence derived from systematic reviews that our group undertook and national guidelines. [1-7] It also included information on a number of reliable databases (e.g. on indication, dosing, drug-drug-interactions and renal dosing adjustment). Most importantly, the results of this comprehensive medication review are available to the GP within a second, provided that patient data are submitted electronically.
We evaluated this tool in a large European randomized-controlled trial and published the findings in The BMJ. [8]
After a follow-up of two years, in the intention-to-treat analysis, we found no difference in mortality and hospitalisation between the group using the PRIMA-eDS tool and the control group providing usual care. However, when restricting the analysis to only those that followed the instructions of our protocol, we saw a pronounced difference, suggesting that use of the PRIMA- eDS tool enabled GPs to reduce the number of drugs the patient was taking without causing harm—in fact the results suggest that reducing polypharmacy decreased the chance of hospital admission and death. The differences between the intention to treat analysis and the per protocol analysis can probably be explained by the way that different GPs used the form—something that we feel could be improved if the PRIMA-eDS tool was integrated into the electronic medical record. This would save time and increase the use of the tool. We believe that this is something the IT companies who develop the different electronic medical records used throughout Europe should consider, because of the benefit that reducing polypharmacy will have for many older patients.
Most of all it appears to be safe to withdraw drugs, which is a positive result in itself. It helps to reduce the treatment burden and prescribing costs.
There has been a lot of discussion about overtreatment, which led to concepts like “less is more” or the “choosing wisely” initiative. PRIMA-eDS adds an important piece to the big picture of combatting medical overtreatment. It shows clearly that “less” is not only possible, but helps to provide better care and most likely better outcomes.
Our process evaluation revealed that GPs appreciate having such a tool. They often feel overwhelmed by the polypharmacy of their patients, being unable to judge appropriateness due to a lack of knowledge and a lack of time [9, 10].
So what’s the next step? The PRIMA-eDS-tool needs to be implemented in the electronic health record and become a routine medication check for all patients taking several drugs. We need further research to identify how to integrate this into the consultation between doctor and patient. Even though the comprehensive medication review is provided within seconds, the GP still needs time to discuss the results with the patient and come to a shared deprescribing decision. This can only be achieved in collaboration with stakeholders (health departments who are responsible for funding primary care) providing resources and structures fostering this new approach—to improve healthcare and drug treatment for many patients in the future.
Anja Rieckert, Institute of General Practice and Family Medicine, Witten/Herdecke University.
David Reeves, professor, National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, UK.
Aneez Esmail, professor, National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, UK.
Andreas Sönnichsen, professor, National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, UK and Department of General Practice and Family Medicine, Center of Public Health, Medical University of Vienna, Vienna, Austria.
Competing interests: Please see full declaration on research paper.
References:
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10 Rieckert A, Teichmann A-L, Drewelow E, et al. Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS project): a survey of general practitioners’ experiences. J Am Med Inform Assoc. https://academic.oup.com/jamia/advance-article-pdf/doi/10.1093/jamia/ocz104/29521023/ocz104.pdf.