Appropriateness of care: from medication reconciliation to deprescribing

Abstract

National and international organizations in charge of ensuring patient safety goals, as the Joint Commission International and the World Health Organization, have highlighted the importance of medication reconciliation, the complex process that identifies medication discrepancies at every transition point along the continuum of care [1]. The manuscript by Masse et al. reports the results of a prospective observational study analyzing the risk factors associated with unintentional medication discrepancies (UMDs) at admission in an Internal Medicine Department [2]. Since the authors underline that UMDs were associated with polymedication, we believe that this issue deserves a thorough comment. Nowadays, multimorbid patients often suffer from fragmentation of care among multiple specialists, which leads to prescription of multiple drugs so that a comprehensive evaluation of these complex therapeutic regimens is warranted, especially by internists who should be aware of the whole clinical picture. Remarkably, as highlighted also by the analysis of data gathered in the prospective register REPOSI (Registro POliterapie SIMI, Società Italiana di Medicina Interna), it has been shown that polypharmacy is associated not only with poor adherence to therapy but also to increased risks of drug–drug interactions and related adverse effects, prescription and intake errors, re-hospitalization and mortality [3]. Interestingly, the term polypharmacy has been described with a wide range of definitions in the literature and no commonly shared consensus is available. Even though some authors have tried to define polypharmacy as the simultaneous use of five or more medications, most reports point out that adherence tends to become poorer with increasing number of co-prescribed drugs, with a linear correlation [4–6]. Especially in high-risk frail patients, as the elderly, the number of drugs prescribed is correlated to non-compliance to therapy, often also due to poor understanding of the purpose of each prescribed drug. Remarkably, as underlined by Masse et al. [2], both “living at home” and “medication preparation not performed by patient” are associated with UMDs, thus highlighting the need to pursue some clear targets: improving patients’ awareness thanks to better education programs and direct involvement of patients in the process of care and, when this is not feasible, supporting patients by promoting continuity of care, coordinating the social network and caregivers, both for institutionalised and noninstitutionalised patients [4, 6]. Furthermore, as reported in a recent cohort study investigating medication errors among elderly patients admitted to an internal medicine ward, 22% of UMDs (above all drug omission) were judged to have the potential to cause moderate to severe discomfort or clinical deterioration [7], suggesting the need for pursuing a strict and accurate review of drug therapy in the daily clinical practice, along with educational and behavioral interventions [6]. * Maddalena Alessandra Wu [email protected]; [email protected]; [email protected]