Interventions to improve the appropriate use of polypharmacy for older people - PubMed (original) (raw)

Review

Interventions to improve the appropriate use of polypharmacy for older people

Judith A Cole et al. Cochrane Database Syst Rev. 2023.

Abstract

Background: Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review.

Objectives: To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'.

Selection criteria: For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

Data collection and analysis: Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

Main results: We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants).

Authors' conclusions: It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.

Trial registration: ClinicalTrials.gov NCT01034761.

Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Conflict of interest statement

JC is currently employed as a systematic reviewer at the Clinical Trial Service Unit, University of Oxford and is a co‐author on another Cochrane Review. JC was involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme.

DCG‐B is a Cochrane editor and was not involved in the editorial process for this review.

MA: none known.

HB: involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme.

CAC is an associate editor with the Cochrane Effectiveness of Practice and Organisation of Care (EPOC) group and was involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme.

AR: involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme.

SP: none known.

NK: holds the position of the Joyce Cook Chair in Ageing Well at the University of Auckland, which was funded by a gift from the Cook family. Health Research Council of New Zealand grant held by the University of Auckland. Recipient of payment as member of the Health Research Council of New Zealand Data Safety Monitoring Board. Payment made by New Zealand Retirement Villages Association to the University of Auckland to conduct research and for expert witness services. Works as a locum general practitioner for Auckland City Mission. Affiliated to the Royal New Zealand College of General Practitioners, which has opinions on prescribing. Involved in studies funded by the Health Research Council of New Zealand on the impact of falls in residential care.

CRC: none known.

CR: involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme.

CH: is an editor with the Cochrane EPOC Group and was not involved in the editorial process for this review. CH was involved in conducting a study eligible for inclusion in this review: An external pilot cluster randomised controlled trial of a theory‐based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime), funded by the HSC R&D Division Cross‐border Healthcare Intervention Trials in Ireland Network (CHITIN) programme through the European Union’s INTERREG VA Programme. CH is a registered pharmacist and has published papers and opinion pieces in medical journals, and is a non‐executive director with the Belfast Health and Social Care Trust and a Trustee with the Dunhill Medical Trust.

Figures

1

1

Study flow diagram.

2

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

3

Risk of bias summary: review authors' judgements about each 'Risk of bias' item for each included study.

4

4

Funnel plot of comparison: Postintervention analysis: The proportion of patients with one or more potentially inappropriate medication

1.1

1.1. Analysis

Comparison 1: Postintervention analysis, Outcome 1: Medication appropriateness (as measured by an implicit tool)

1.2

1.2. Analysis

Comparison 1: Postintervention analysis, Outcome 2: Medication appropriateness (as measured by an implicit tool) (excluding Crotty 2004a)

1.3

1.3. Analysis

Comparison 1: Postintervention analysis, Outcome 3: Number of potentially inappropriate medications

1.4

1.4. Analysis

Comparison 1: Postintervention analysis, Outcome 4: Proportion of patients with one or more potentially inappropriate medication

1.5

1.5. Analysis

Comparison 1: Postintervention analysis, Outcome 5: Number of potential prescribing omissions

1.6

1.6. Analysis

Comparison 1: Postintervention analysis, Outcome 6: Proportion of patients with one or more potential prescribing omission

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References

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References to studies excluded from this review

DRKS00013588 {unpublished data only}
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References to studies awaiting assessment

Aharaz 2021 {published data only}
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Grischott 2022 {published data only}
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    1. Kornholt J, Feizi ST, Hansen AS, Laursen JT, Reuther LO, Petersen TS, et al. Effects of a comprehensive medication review intervention on health-related quality of life and other clinical outcomes in geriatric outpatients with polypharmacy: A pragmatic randomized clinical trial. British Journal of Clinical Pharmacology 2022;88(7):3360-9. [DOI: 10.1111/bcp.15287] - DOI - PMC - PubMed
Mahlknecht 2021 {published data only}
    1. Mahlknecht A, Wiedermann CJ, Sandri M, Engl A, Valentini M, Vogele A, et al. Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial. BMC Geriatrics 2021;21(1):1-19. [DOI: 10.1186/s12877-021-02612-0] - DOI - PMC - PubMed
McCarthy 2022 {published data only}
    1. McCarthy C, Clyne B, Boland F, Moriarty F, Flood M, Wallace E, et al. GP-delivered medication review of polypharmacy, deprescribing, and patient priorities in older people with multimorbidity in Irish primary care (SPPiRE Study): a cluster randomised controlled trial. PLOS Medicine 2022;19(1):1-19. [DOI: 10.1371/ journal.pmed.1003862] - PMC - PubMed
McDonald 2022 {published data only}
    1. McDonald EG, Wu PE, Rashidi B, Wilson MG, Bortolussi-Courval E, Atique A, et al. The MedSafer Study-Electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial. JAMA Internal Medicine 2022;182(3):265-73. [DOI: 10.1001/jamainternmed.2021.7429] - DOI - PMC - PubMed
Rankin 2022 {published data only}
    1. Rankin A, Gorman A, Cole J, Cadogan CA, Barry HE, Agus A, et al. An external pilot cluster randomised controlled trial of a theory-based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime). Pilot and Feasibility Studies 2022;8(1):1-19. [DOI: 10.1186/s40814-022-01161-6] - DOI - PMC - PubMed
Rudolf 2021 {published data only}
    1. Rudolf H, Thiem U, Aust K, Krause D, Klaassen-Mielke R, Greiner W, et al. Reduction of potentially inappropriate medication in the elderly — results of a cluster-randomized, controlled trial in German primary care practices (RIME). Deutsches Ärzteblatt International 2021;118:875–82. [DOI: 10.3238/arztebl.m2021.0372] - DOI - PMC - PubMed

References to ongoing studies

ACTRN12617000665336 {unpublished data only}
    1. ACTRN12617000665336. Impact of clinical pharmacist medication review on appropriate prescribing in elderly patients: a randomized, controlled trial. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372670 (first received 30 March 2017).
Correard 2020 {published data only}
    1. Correard F, Montaleytang M, Costa M, Astolfi M, Baumstarck K, Loubière S, et al. Impact of medication review via tele-expertise on unplanned hospitalizations at 3 months of nursing homes patients (TEM-EHPAD): study protocol for a randomized controlled trial. BMC Geriatrics 2020;20:147. [DOI: 10.1186/s12877-020-01546-3] - DOI - PMC - PubMed
Dauphinot 2017 {published data only}
    1. Dauphinot V, Jean-Bart E, Krolak-Salmon P, Mouchoux C. A multi-center, randomized, controlled trial to assess the efficacy of optimization of drug prescribing in an elderly population, at 18 months of follow-up, in the evolution of functional autonomy: the OPTIM study protocol. BMC Geriatrics 2017;17(1):195. - PMC - PubMed
DRKS00003610 {unpublished data only}
    1. Thiem U, Wilm S, Greiner W, Rudolf H, Trampisch HJ, Müller C, et al. Reduction of potentially inappropriate medication in the elderly: design of a cluster-randomised controlled trial in German primary care practices (RIME). Therapeutic Advances in Drug Safety 2020;11:1-13. [DOI: 10.1177/2042098620918459] - DOI - PMC - PubMed
Greiver 2019 {published data only}
    1. Greiver M, Dahrouge S, O’Brien P, Manca D, Lussier MT, Wang J, et al. Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada. Implementation Science 2019;14:55. [DOI: 10.1186/s13012-019-0904-4] - DOI - PMC - PubMed
Husebo 2015 {published data only}
    1. Husebo BS, Flo E, Aarsland D, Selbaek G, Testad I, Gulla C, et al. COSMOS - improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial. Implementation Science 2015;10:131. - PMC - PubMed
Ie 2020 {published data only}
    1. Ie K, Hirose M, Sakai T, Motohashi I, Aihara M, Otsuki T, et al. Protocol of a randomised controlled trial on the efficacy of medication optimisation in elderly inpatients: medication optimisation protocol efficacy for geriatric inpatients (MPEG) trial. BMJ Open 2020;10(10):e041125. [DOI: 10.1136/bmjopen-2020-041125] - DOI - PMC - PubMed
ISRCTN18427377 {unpublished data only}
    1. Grischott T, Zechmann S, Rachamin Y, Markun S, Chmiel C, Senn O, et al. Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT. Implementation Science 2018;13:155. [DOI: 10.1186/s13012-018-0839-1] - DOI - PMC - PubMed
    1. ISRCTN18427377. Hospital discharge study. https://www.isrctn.com/ISRCTN18427377 2018;(first received 3 January 2018).
ISRCTN18752158 {published data only}
    1. ISRCTN18752158. The general practice-based pharmacist: supporting medicines management in older adults. www.isrctn.com/ISRCTN18752158 (first received 3 March 2020).
ISRCTN41009897 {published data only}
    1. ISRCTN41009897. Pilot testing of a new approach to improving the prescribing of many drugs for older people who live in their own home and are cared for by general practitioners. www.isrctn.com/ISRCTN41009897 (first received 18 November 2019).
ISRCTN90146150 {published data only}
    1. ISRCTN90146150. Improving medicines use in people who take multiple medicines. https://www.isrctn.com/ISRCTN90146150 (first received 19 March 2019).
Johansen 2018 {published data only}
    1. Johansen JS, Havnes K, Halvorsen KH, Haustreis S, Skaue LW, Kamycheva E, et al. Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial. BMJ Open 2018;8(1):e020106. - PMC - PubMed
    1. NCT02816086. A new interdisciplinary collaboration structure to improve medication safety in the elderly. clinicaltrials.gov/ct2/show/NCT02816086 (first received 28 June 2016).
Jungo 2019 {published data only}
    1. Jungo KT, Rozsnyai Z, Mantelli S, Floriani C, Lowe AL, Lindemann F, et al. 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial. BMJ Open 2019;9(9):e031080. - PMC - PubMed
Komagamine 2018 {published data only}
    1. Komagamine J, Sugawara K, Kaminaga M, Tatsumi S. Study protocol for a single-centre, prospective, non-blinded, randomised, 12-month, parallel-group superiority study to compare the efficacy of pharmacist intervention versus usual care for elderly patients hospitalised in orthopaedic wards. BMJ Open 2018;8:e021924. [DOI: 10.1136/bmjopen-2018-021924] - DOI - PMC - PubMed
Kua 2017 {published and unpublished data}
    1. Kua CH, Yeo C YY, Char CWT, Tan CWY, Tan PC, Mak VS, et al. Nursing home team-care deprescribing study: a stepped-wedge randomised controlled trial protocol. BMJ Open 2017;7(5):e015293. - PMC - PubMed
    1. NCT02863341. Nursing home team-care deprescribing study. clinicaltrials.gov/ct2/show/NCT02863341 2018;(first received 11 August 2016).
Loffler 2014 {published data only}
    1. Loffler C, Drewelow E, Paschka SD, Frankenstein M, Eger J, Jatsch L, et al. Optimizing polypharmacy among elderly hospital patients with chronic diseases: study protocol of the cluster randomized controlled POLITE-RCT trial. Implementation Science 2014;9:151. - PMC - PubMed
McCarthy 2017 {published and unpublished data}
    1. ISRCTN12752680. Supporting medicines management in older adults with multiple medical conditions. isrctn.com/ISRCTN12752680 (first received 26 September 2016).
    1. McCarthy C, Clyne B, Corrigan D, Boland F, Wallace E, Moriarty F, et al. Supporting prescribing in older people with multimorbidity and significant polypharmacy in primary care (SPPiRE): a cluster randomised controlled trial protocol and pilot. Implementation Science 2017;12(1):99. - PMC - PubMed
Mestres 2017 {published data only}
    1. Mestres Gonzalvo C, Wit HA, Oijen BP, Hurkens KP, Janknegt R, Schols JM, et al. Supporting clinical rules engine in the adjustment of medication (SCREAM): protocol of a multicentre, prospective, randomised study. BMC Geriatrics 2017;17(1):35. - PMC - PubMed
NCT00844025 {unpublished data only}
    1. NCT00844025. Pharmaceutical care and clinical outcomes for the elderly taking potentially inappropriate medication. clinicaltrials.gov/ct2/show/NCT00844025 (first received 13 February 2009).
NCT01034761 {unpublished data only}
    1. NCT01034761. Using clinical alerts to decrease inappropriate medication prescribing. clinicaltrials.gov/ct2/show/NCT01034761 (first received 17 December 2009).
NCT02942927 {published and unpublished data}
    1. NCT02942927. Team approach to polypharmacy evaluation and reduction. clinicaltrials.gov/ct2/show/NCT02942927 (first received 24 October 2016).
NCT03156348 {unpublished data only}
    1. NCT03156348. Impact of clinical pharmacist on adverse drug events in older adults. clinicaltrials.gov/ct2/show/NCT03156348;(first received 17 May 2017).
NCT03298386 {unpublished data only}
    1. NCT03298386. Elderly Appropriate Treatment in primary care (EAT). clinicaltrials.gov/ct2/show/NCT03298386;(first received 2 October 2017).
NCT03909035 {published data only}
    1. NCT03909035. A collaborative approach to medication reviews for older patients with polypharmacy (BIMEDOC). clinicaltrials.gov/ct2/show/NCT03909035 (first received 9 April 2019).
NCT04004936 {published data only}
    1. NCT04004936. Reducing potentially inappropriate medication prescribing for older patients in the ED (EQUIPPED). clinicaltrials.gov/ct2/show/NCT04004936 (first received 2 July 2019).
NCT04028583 {published data only}
    1. NCT04028583. Tool for Inappropriate Prescription Evaluation: The TaIPE Study (TaIPE). clinicaltrials.gov/ct2/show/NCT04028583 (first received 22 July 2019).
NCT04087109 {published data only}
    1. NCT04087109. MedSafer E-care: an automated deprescribing solution (E-CARE Study) (E-CARE) [MedSafer E-care: an automated deprescribing solution for community-dwelling older adults lving with polypharmacy (E-CARE Study)]. clinicaltrials.gov/ct2/show/NCT04087109 (first received 12 September 2019).
NCT04147130 {published data only}
    1. NCT04147130. MultiPAP Plus: improving prescription in primary care patients with multimorbidity and polypharmacy (MultiPAP Plus). clinicaltrials.gov/ct2/show/NCT04147130 (first received 31 October 2019).
NCT04181879 {published data only}
    1. NCT04181879. Appropriate polypharmacy in older people in primary care (PolyPrime). clinicaltrials.gov/ct2/show/NCT04181879 (first received 2 December 2019).
NTR6644 {published data only}
    1. NTR6644. Improving medication prescription in the context of advanced care planning for patients receiving nursing home care. trialsearch.who.int/Trial2.aspx?TrialID=NTR6644 (first received 23 August 2017).
    1. Pouw CAM, Smalbrugge MS, Hugtenburg JG, Van Marum RJ, Hertogh CMPM. Improving medication prescription in the context of advanced care planning for patients receiving nursing home care (IMPETUS): study protocol of a cluster randomized controlled trial. European Geriatric Medicine 2017;8:S218.
Prados‐Torres 2017 {published and unpublished data}
    1. NCT02866799. Multi-PAP RCT: Improving prescription in primary care patients with multimorbidity and polypharmacy. clinicaltrials.gov/ct2/show/NCT02866799 (first received 15 August 2016).
    1. Prados-Torres A, Del Cura-Gonzalez I, Prados-Torres D, Lopez-Rodriguez JA, Leiva-Fernandez F, Calderon-Larranaga A, et al. Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy: study protocol of a cluster randomized clinical trial (Multi-PAP project). Implementation Science 2017;12(1):54. - PMC - PubMed
Selic 2016 {published data only}
    1. Cedilnik Gorup E, Petek-Ster M. Use of web-based application to improve prescribing in home-living elderly: a randomised controlled study protocol. In: 9th Congress of the European Union Geriatric Medicine Society, Venice, Italy. 2013.
    1. Selic P, Gorup EC, Gorup S, Ster MP, Rifel J, Ketis ZK. The effects of a web application and medical monitoring on the quality of medication, adverse drug events and adherence in the elderly living at home: a protocol of the study. Materia Socio Medica 2016;28(6):432-6. - PMC - PubMed

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References to other published versions of this review

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