Hello, deprescribers. Today we have Dr. Katharina Jungo (University of Bern, Switzerland) summarizing key findings from her recent PhD dissertation that explored ways to optimize medication use in older people with multimorbidity and polypharmacy. Take it away, Katharina!
Older adults with multiple chronic conditions, who regularly use different medications, are at high risk of using potentially inappropriate medications. It is therefore recommended that the medication use of such patients is regularly reviewed, and if necessary, the inappropriate medications are deprescribed. Since general practitioners (GPs) often care for patients over a long period of time and often act as the main prescriber, interventions to optimize medication use in the primary care setting are crucial.
As deprescribing researchers, our mission is to identify successful and sustainable strategies to reduce inappropriate medication use. My PhD research explored different aspects related to the optimization of medication use and deprescribing in older patients with multimorbidity and polypharmacy, with a focus in the primary care setting. Below I provide a quick summary of what I found.
High utilization and costs of potentially inappropriate medications in older adults with multimorbidity and polypharmacy
The first study in my thesis was a retrospective cross-sectional study using linked claims and data from electronic health records from a large healthcare system in the Boston metropolitan area for the period from 2007 to 2014 (with 61,500 – 103,000 patients in the dataset depending on the year). In this study I found that more than two thirds of patients aged ≥65 years, with minimum two chronic conditions and polypharmacy, used at least one potentially inappropriate medication (defined by the 2019 version of the Beers criteria). Central nervous system drugs and gastrointestinal drugs were the most used potentially inappropriate medications. More than 10% of medication costs were spent on potentially inappropriate medications. In the context of the potential negative health outcomes associated with the use of potentially inappropriate medications, these results demonstrate the continued need for screening and deprescribing interventions in this patient group.
Factors associated with the new prescribing of potentially inappropriate medications
The second study in my thesis, a retrospective cohort study using linked claims and data from electronic health records from a large healthcare system in the Boston metropolitan area, estimated the association between demographic and clinical characteristics and the probability of being newly prescribed a potentially inappropriate medication (defined by the 2019 version of the Beers criteria). In older multimorbid patients with polypharmacy, who did not use or were prescribed a potentially inappropriate medication during the baseline period (N=17,912), we found that male sex, a higher number of ambulatory visits, a higher number of prescribing orders, and a diagnosis of heart failure were independently associated with a higher risk of being newly prescribed a potentially inappropriate medication. Higher age was independently associated with a lower risk. Overall, these findings suggest that patients with more complex health problems may be at a higher risk of being newly prescribed a potentially inappropriate medication. These study findings should inform the development of interventions designed to optimize medication use in this patient population.
General practitioners’ willingness to make deprescribing decisions
The third study in my thesis was a cross-sectional case vignette study with >1700 GPs from 31 mostly European countries. The results of this study showed that, despite differences across countries and GPs’ characteristics, more than 80% of GPs reported that they would make a deprescribing decision for a minimum of one medication in oldest-old patients (aged ≥80 years) with polypharmacy, which were presented to them in different case vignettes. While presenting the same medication list and patient characteristics, the case vignettes differed in terms of patients’ history of cardiovascular disease and their functional dependency in activities of daily living. We found that likelihood of GPs deprescribing was higher in patients without history of cardiovascular disease and in patients with an increased level of functional dependency in activities of daily living. The medications that were most often selected to be deprescribed in the hypothetical case vignettes were pain medications and proton pump inhibitors. The findings from this study could provide important information that can be used for designing targeted deprescribing interventions for GPs and their patients.
High willingness to have medications deprescribed in older adults with multimorbidity and polypharmacy
In another study I worked on during my PhD, we used the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire in the Swiss context to explore the willingness to have medications deprescribed in older adults with multimorbidity and polypharmacy. We found that 80% of older multimorbid patients with polypharmacy, who participated in the OPTICA trial, reported to be willing to stop ≥1 of their medications if their doctor indicated that this was possible, which is in line with the findings from other studies using this questionnaire. More than 90% of the patients reported to be satisfied with their current medication intake. An additional analysis showed that more than half of the patients in our sample used a potentially inappropriate medication and a higher number of medications was associated with the use of potentially inappropriate medications. We also found, however, that the willingness of older adults to have medications deprescribed was not associated with the use of potentially inappropriate medications. These findings suggest that patients may be unaware on whether they are using potentially inappropriate medications, which shows that there is a need for raising awareness.
Key message: We need targeted deprescribing interventions
As an implication of the findings from my thesis, there is a need for developing tailored interventions targeted at the reducing of the use and prescribing of potentially inappropriate medications and to facilitate deprescribing in older adults with multimorbidity and polypharmacy. This is very much in line with what was written in a previous blog post by Dr. Kristie Weir (@KristieWeir).
Designing interventions that build on and combine both patients and general practitioners’ attitudes and preferences towards deprescribing (e.g. what types of medications GPs and patients feel most comfortable deprescribing, what patient characteristics are associated with making deprescribing decisions, etc.), and consider the most commonly used types of potentially inappropriate medications (e.g. central nervous system drugs, gastrointestinal drugs, etc.) as well as the factors associated with their use (e.g. patient characteristics, etc.), could be an important factor for the implementation and the long-term efficacy of such interventions.
My postdoctoral research will focus on several of these issues. On the one hand, I plan on designing and studying the implementation of health information technology deprescribing interventions, such as tools integrated into electronic health record software or patient portals. On the other hand, I plan on studying the communication related to deprescribing decisions between patients and different healthcare providers (e.g. GPs, pharmacists, home carers, etc.) with the goal of facilitating the implementation of such decisions in clinical outpatient care.