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Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies

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Abstract

Background

Polypharmacy, common in elderly multimorbid adults, leads to increased iatrogenic health risks. Yet, no consistent approach to stopping medicines exists in primary healthcare.

Objectives

Our objective was to synthesize qualitative studies exploring the perspectives and experiences of general practitioners (GPs) and older patients in reducing polypharmacy and to discover approaches already being practiced.

Methods

We conducted a search in the PubMed, Cochrane Library, Web of Science Core Collection, and Scopus databases to identify qualitative studies in the primary care setting addressing multimorbid older patients and polypharmacy reduction. The seven-step model of meta-ethnography allowed for cross-interpretation between studies considering their original context and developing theories.

Results

A total of 14 studies from the perspectives of patients (n = 6) and providers (n = 8) were included, although discontinuing medicines only occurred as a sub-theme in patient studies. Emerging key concepts for patients were experimenting with medicines, attitudes and experiences towards medicines, necessity of prioritizing treatments, relationship to GP, and system-related contributors. For GPs, they covered assumptions about elderly patients, interface prescribing problems, evidence-based guidelines, failure to meet the challenge of complex decision-making, and solutions.

Discussion

Complex medication regimens and uncertainties in decision making are challenges for both GPs and patients. For patients, symptom experiences with medicines, relationship with their prescriber, and fragmented care are at the forefront; for GPs, it is the decision-making responsibility in the context of unsuitable guidelines, time constraints, and deficient multidisciplinary co-operation. Heuristics such as prioritizing and individualizing treatments and relaxation of guidelines emerged. These strategies require professional awareness of the problem and establishing a trusting, patient-centered consultation style and supportive work conditions.

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References

  1. Haefeli WE. Polypharmazie. Swiss Med Forum. 2011;47:847–52.

    Google Scholar 

  2. Neuner-Jehle S. Weniger ist mehr–wie Polypharmazie vermeiden? Praxis. 2013;102:21–7.

    Article  PubMed  Google Scholar 

  3. Viniol A, Bösner S, Baum E, et al. Forgotten drugs: long-term prescriptions of thyroid hormones – a cross sectional study. Int J Gen Med. 2013;6:329–34.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Keller H, Hirsch O, Kaufmann-Kolle P, et al. Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis. BMC Public Health. 2013;13:623.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Deveugele M, Derese A, van den Brink-Muinen A, et al. Consulting length in general practice: cross sectional study in six European countries. BMJ. 2002;325:472.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Burkhardt H, Wehling M. Probleme bei der Pharmakotherapie älterer Menschen. Der Internist. 2010;51:737–48.

    Article  CAS  PubMed  Google Scholar 

  7. Moynihan R, Henry D. The fight against disease mongering: Generating knowledge for action. PLoS Med. 2006;3:e191.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Gnjidic D, Le Couteur DG, Kouladjian L, et al. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med. 2012;28:237–53.

    Article  PubMed  Google Scholar 

  9. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5:345–51.

    Article  PubMed  Google Scholar 

  10. Rottenkolber D, Schmiedl S, Rottenkolber M, et al. Adverse drug reactions in Germany: direct costs of internal medicine hospitalizations. Pharmacoepidemiol Drug Saf. 2011;20:626–34.

    Article  PubMed  Google Scholar 

  11. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. JAGS. 2006;54:1516–23.

    Article  Google Scholar 

  12. Junius-Walker U, Theile G, Hummers-Pradier E. Prevalence and predictors of polypharmacy among older primary care patients in Germany. Fam Pract. 2007;24:14–9.

    Article  CAS  PubMed  Google Scholar 

  13. Frazier SC. Health outcomes and polypharmacy in elderly individuals: an integrated literature review. J Gerontol Nurs. 2005;31:4–11.

    Article  PubMed  Google Scholar 

  14. Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002–12.

    Article  CAS  PubMed  Google Scholar 

  15. Alldred DP. Deprescribing: a brave new word? Int J Pharm Pract. 2014;22:2–3.

    Article  PubMed  Google Scholar 

  16. de Vries ThP, Henning RH, Hogerzeil HV, et al. Guide to good prescribing. Geneva: World Health Organization; 1995.

    Google Scholar 

  17. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33:323–8.

    Article  Google Scholar 

  18. Scott IA, Gray LD, Martin JH, et al. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med. 2013;18:121–4.

    Article  PubMed  Google Scholar 

  19. Scott IA, Gray LD, Martin JH, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125:529–37.

    Article  PubMed  Google Scholar 

  20. Scott IA, Anderson K, Freeman CR, et al. First do no harm: a real need to describe in older patients. Med J Aust. 2014;201:390–2.

    Article  PubMed  Google Scholar 

  21. Scott IA, Le Couteur DG. Physicians need to take the lead in deprescribing. Int Med J. 2015;45:352–6.

    Article  CAS  Google Scholar 

  22. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy. The process of deprescribing. JAMA. Intern Med. 2015;175:827–34.

    Google Scholar 

  23. Campanelli CM. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616–31.

    Article  PubMed Central  Google Scholar 

  24. Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int. 2010;107:543–51.

    PubMed  PubMed Central  Google Scholar 

  25. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Wehling M. Drug therapy in the elderly: too much or too little, what to do? A new assessment system: fit for the aged (FORTA). Dtsch Med Wochenschr. 2008;133:2289–91.

    Article  CAS  PubMed  Google Scholar 

  27. Leitliniengruppe Hessen. Hausärztliche Leitlinie Multimedikation. Empfehlung zum Umgang mit Multimedikation bei Erwachsenen und geriatrischen Patienten. http://www.pmvforschungsgruppe.de/pdf/03_publikationen/multimedikation_II.pdf. Accessed 10 Feb 2014.

  28. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med. 2010;170:1648–54.

    Article  PubMed  Google Scholar 

  29. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.

    Article  CAS  PubMed  Google Scholar 

  30. Hausärztliche Leitlinie: Multimedikation als “iatrogene” Erkrankung—und wie man ihr begegnet. http://deutsch.medscape.com/artikelansicht/4904080#vp_2. Accessed 15 Dec 2015.

  31. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitative studies. Newbury Park: Sage; 1988.

    Google Scholar 

  32. Britten N, Campbell R, Pope C, et al. Using meta-ethnography to synthesise qualitative research: a worked example. J Health Serv Res Policy. 2002;7:209–15.

    Article  PubMed  Google Scholar 

  33. Campbell R, Pound P, Morgan M, et al. Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research. Health Technol Assess. 2011;15:1–164.

    Article  CAS  PubMed  Google Scholar 

  34. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;9:349–57.

    Article  Google Scholar 

  35. Campbell R, Pound P, Pope C, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med. 2003;56:671–84.

    Article  PubMed  Google Scholar 

  36. Tordoff J, Simonsen K, Thomson WM, et al. „It’s just routine”. A qualitative study of medicine taking amongst older adults in New Zealand. Pharm World Sci. 2010;32:154–61.

    Article  PubMed  Google Scholar 

  37. Torrible SJ, Hogan DB. Medication use and rural seniors. Who really knows what they are taking? Can Fam Physician. 1997;43:893–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Gröber-Grätz D, Waldmann UM, Metzinger U, et al. Reasons of changes in drug therapy after hospital discharge: a qualitative study of perception by general practitioners and patients. Gesundheitswesen. 2014;76:639–44.

    Article  PubMed  Google Scholar 

  39. Krska J, Morecroft CW, Poole H, et al. Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study. Int J Clin Pharm. 2013;35:1161–9.

    Article  PubMed  Google Scholar 

  40. Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns. 2015;98:220–5.

    Article  PubMed  Google Scholar 

  41. Post SG, Stuckey JC, Whitehouse PJ, et al. A focus group on cognition-enhancing medications in Alzheimer disease: disparities between professionals and consumers. Alzheimer Dis Assoc Disord. 2001;15:80–8.

    Article  CAS  PubMed  Google Scholar 

  42. Unson CG, Siccion E, Gaztambide J, et al. Nonadherence and osteoporosis treatment preferences of older women: a qualitative study. J Womens Health (Larchmt). 2003;12:1037–45.

    Article  CAS  Google Scholar 

  43. Givens JL, Datto CJ, Ruckdeschel K, et al. Older patients’ aversion to antidepressants: a qualitative study. J Gen Intern Med. 2006;21:146–51.

    PubMed  PubMed Central  Google Scholar 

  44. Harrold LR, Mazor KM, Veltens S, et al. Patients and providers view gout differently: a qualitative study. Chronic Illn. 2010;6:263–71.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Spinewine A, Swine C, Dhillon S, et al. Appropriateness of use of medicines in elderly inpatients: qualitative study. BMJ. 2005;3331:935.

    Article  Google Scholar 

  46. Yegenoglu S, Baydar T. Information and observation of community pharmacists on geriatric patients: a qualitative study in Ankara City. Turk J Geriatr. 2011;14:344–51.

    Google Scholar 

  47. Farrell B, Tsang C, Raman-Wilms L, et al. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified Delphi process. PLoS One. 2015;10:e0122246.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Schuling J, Gebben H, Veehof LJ, et al. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56.

    Article  PubMed  Google Scholar 

  49. Herrmann ML, von Waldegg GH, Kip M, et al. GP Medication prioritisation in older patients with multiple comorbidities recently discharged from hospital: a case-based bottom-up approach. Gesundheitswesen. 2015;77:16–23.

    CAS  PubMed  Google Scholar 

  50. Elliott RA, Ross-Degnan D, Adams AS, et al. Strategies for coping in a complex world: adherence behavior among older adults with chronic illness. J Gen Intern Med. 2007;22:805–10.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Bagge M, Tordoff J, Norris P, et al. Older people’s attitudes towards their regular medicines. J Prim Health Care. 2013;5:234–42.

    PubMed  Google Scholar 

  52. Meranius MS, Hammar LM. How does the healthcare system affect medication self-management among older adults with multimorbidity? Scand J Caring Sci. 2015. doi:10.1111/scs.12225.

    PubMed  Google Scholar 

  53. Moen J, Bohma A, Tillenius T, et al. ‘‘I don’t know how many of these [medicines] are necessary’: a focus group study among elderly users of multiple medicines. Patient Educ Couns. 2009;74:135–41.

    Article  PubMed  Google Scholar 

  54. Marx G, Püsche K, Ahrens D, et al. Polypharmacy: a dilemma in primary care? Results of group discussions with general practitioners. Gesundheitswesen. 2009;71:339–48.

    Article  CAS  PubMed  Google Scholar 

  55. Moen J, Norrgård S, Antonov K, et al. GPs’ perceptions of multiple-medicine use in older patients. J Eval Clin Pract. 2010;16:69–75.

    Article  PubMed  Google Scholar 

  56. Anthierens S, Tansens A, Petrovic M, et al. Qualitative insights into general practitioners views on polypharmacy. BMC Fam Pract. 2010;11:65.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Sinnott C, McHugh SM, Boyce MB, et al. What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care. Br J Gen Pract. 2015;65:e184–91.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Smith SM, O’Kelly S, O’Dowd T. GPs’ and pharmacists’ experiences of managing multimorbidity: a ‘Pandora’s box’. Br J Gen Pract. 2010;60:285–94.

    Article  PubMed  Google Scholar 

  59. Fried TR, McGraw S, Agostini JV, et al. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008;56:1839–44.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Berne E. Principles of transactional analysis. Indian J Psychiat. 1996;38:154–9.

    CAS  Google Scholar 

  61. Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimizing potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4:e006544.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Cullinan S, O’Mahony D, Fleming A, et al. A meta-synthesis of potentially inappropriate prescribing in older patients. Drugs Aging. 2014;31:631–8.

    Article  PubMed  Google Scholar 

  63. Sinnott C, McHugh S, Browne J, et al. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3:e003610.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Reeve E, To J, Hendrix I, et al. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30:793–807.

    Article  PubMed  Google Scholar 

  65. Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78:738–47.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Neuner-Jehle S, Krones T, Senn O. Systematic deprescribing of medicaments is accepted and feasible among polymorbid family medicine patients. Praxis. 2014;103:317–22.

    Article  PubMed  Google Scholar 

  67. Cooper JA, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open. 2015;5:e009235.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Scottish Government Model of Care Polypharmacy Working Group. Polypharmacy Guidance. 2nd ed. Scottish Government; 2015.

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Authors and Affiliations

  1. Institute of General Practice, Hannover, Lower Saxony, Germany

    Beate Bokhof & Ulrike Junius-Walker

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  1. Beate Bokhof
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  2. Ulrike Junius-Walker
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Correspondence to Beate Bokhof.

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Beate Bokhof and Ulrike Junius-Walker declare that they have no conflicts of interest relevant to the content of this review.

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Bokhof, B., Junius-Walker, U. Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies. Drugs Aging 33, 249–266 (2016). https://doi.org/10.1007/s40266-016-0354-5

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