Christin Löffler

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis

AIM The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs. METHODS Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality. RESULTS Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls. CONCLUSIONS There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

Coping with multimorbidity in old age – a qualitative study

BackgroundComparatively few studies address the problems related to multimorbidity. This is surprising, since multimorbidity is a particular challenge for both general practitioners and patients. This study focuses on the latter, analyzing the way patients aged 65–85 cope with multimorbidity.Methods19 narrative in-depth interviews with multimorbid patients were conducted. The data was analysed using grounded theory. Of the 19 interviewed patients 13 were female and 6 male. Mean age was 75 years. Participating patients showed a relatively homogeneous socio-economic status. Patients were recruited from the German city of Hamburg and the state of North Rhine-Westphalia.ResultsDespite suffering from multimorbidity, interviewees held positive attitudes towards life: At the social level, patients tried to preserve their autonomy to the most possible extent. At the emotional level, interviewees oscillated between anxiety and strength - having, however, a positive approach to life. At the practical level, patients aimed at keeping their diseases under control. The patients tended to be critical in regards to medication.ConclusionsThese findings might have implications for the treatment of multimorbid patients in primary care and further research: The generally presumed passivity of older individuals towards medical treatment, which can be found in literature, is not evident among our sample of older patients. In future, treatment of these patients might take their potential for pro-active cooperation more strongly into account than it is currently the case.

Depressive mood mediates the influence of social support on health-related quality of life in elderly, multimorbid patients

BackgroundIt is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life.MethodsCross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity.ResultsMediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel’s p < 0.001). Multiple linear regression showed that the influence of depressive mood (β = −0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (β = −0.234, p < 0.01).ConclusionSocial support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.Trial registrationISRCTN89818205

Activating GENeral practitioners dialogue with patients on their Agenda (MultiCare AGENDA) study protocol for a cluster randomized controlled trial

BackgroundThis study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient’s agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients’ quality of life. Secondary hypotheses include a better knowledge of GPs about their patients’ medication, a higher patient satisfaction and a more effective and/or efficient health care utilization.Methods/designMulti-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. Inclusion criteria: Patients aged 65–84 years with at least 3 chronic conditions. Intervention: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. Control: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures.DiscussionThere is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients’ health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity.Trial registrationCurrent Controlled Trials ISRCTN46272088.

Optimizing polypharmacy among elderly hospital patients with chronic diseases--study protocol of the cluster randomized controlled POLITE-RCT trial.

BackgroundTreatment of patients with multimorbidity is challenging. A rational reduction of long-term drugs can lead to decreased mortality, less acute hospital treatment, and a reduction of costs. Simplification of drug treatment schemes is also related to higher levels of patient satisfaction and adherence. The POLITE-RCT trial will test the effectiveness of an intervention aiming at reducing the number of prescribed long-term drugs among multimorbid and chronically ill patients. The intervention focuses on the interface between primary and secondary health care and includes a pharmacist-based, patient-centered medication review prior to the patients discharge from hospital.MethodsThe POLITE-RCT trial is a cluster randomized controlled trial. Two major secondary health care providers of Mecklenburg-Western Pomerania, Germany, take part in the study. Clusters are wards of both medical centers. All wards where patients with chronic diseases and multimorbidity are regularly treated will be included. Patients aged 65+ years who take five or more prescribed long-term drugs and who are likely to spend at least 5 days in the participating hospitals will be recruited and included consecutively. Cluster-randomization takes place after a six-month baseline data collection period. Patients of the control group receive care as usual. The independent two main primary outcomes are (1) health-related quality of life (EQ-5D) and (2) the difference in the number of prescribed long-term pharmaceutical agents between intervention and control group. The secondary outcomes are appropriateness of prescribed medication (PRISCUS list, Beers Criteria, MAI), patient satisfaction (TSQM), patient empowerment (PEF-FB-9), patient autonomy (IADL), falls, re-hospitalization, and death. The points of measurement are at admission to (T0) and discharge from hospital (T1) as well as 6 and 12 months after discharge from the hospital (T2 and T3). In 42 wards, 1,626 patients will be recruited.DiscussionIn case of positive evaluation, the proposed study will provide evidence for a sustainable reduction of polypharmacy by enhancing patient-centeredness and patient autonomy.Trial registrationCurrent Controlled Trials ISRCTN42003273

Converting habits of antibiotic prescribing for respiratory tract infections in German primary care--the cluster-randomized controlled CHANGE-2 trial.

BackgroundWith an average prescription rate of 50%, in German primary care antibiotics are still too frequently prescribed for respiratory tract infections. The over-prescription of antibiotics is often explained by perceived patient pressure and fears of a complicated disease progression. The CHANGE-2 trial will test the effectiveness of two interventions to reduce the rate of inappropriate antibiotic prescriptions for adults and children suffering from respiratory tract infections in German primary care.Methods/DesignThe study is a three-arm cluster-randomized controlled trial that measures antibiotic prescription rates over three successive winter periods and reverts to administrative data of the German statutory health insurance company AOK. More than 30,000 patients in two regions of Germany, who visit their general practitioner or pediatrician for respiratory tract infections will be included. Interventions are: A) communication training for general practitioners and pediatricians and B) intervention A plus point-of-care testing. Both interventions are tested against usual care. Outcome measure is the physicians’ antibiotic prescription rate for respiratory tract infections derived from data of the health insurance company AOK. Secondary outcomes include reconsultation rate, complications, and hospital admissions.DiscussionMajor aim of the study is to improve the process of decision-making and to ensure that patients who are likely to benefit from antibiotics are treated accordingly. Our approach is simple to implement and might be used rapidly among general practitioners and pediatricians. We expect the results of this trial to have major impact on antibiotic prescription strategies and practices in Germany, both among general practitioners and pediatricians.Trial registrationThe study is registered at the Current Controlled Trials Ltd (ISRCTN01559032)

Perceptions of interprofessional collaboration of general practitioners and community pharmacists - a qualitative study

BackgroundDespite numerous evidences for the positive effect of community pharmacists on health care, interprofessional collaboration of pharmacists and general practitioners is very often limited. Though highly trained, pharmacists remain an underutilised resource in primary health care in most western countries. This qualitative study aims at investigating pharmacists’ and general practitioners’ views on barriers to interprofessional collaboration in the German health care system.MethodsA total of 13 narrative in-depth interviews, and two focus group discussions with 12 pharmacists and general practitioners in Mecklenburg-Western Pomerania, a predominantly rural region of North-Eastern Germany, were conducted. The interviews aimed at exploring general practitioners’ and pharmacists’ attitudes, views and experiences of interprofessional collaboration. At a second stage, two focus group discussions were performed. Fieldwork was carried out by a multi-professional team. All interviews and focus group discussions were audio taped and transcribed verbatim. The constant comparative method of analysis from grounded theory was applied to the data.ResultsThere are three main findings: First, mutual trust and appreciation appear to be important factors influencing the quality of interprofessional collaboration. Second, in light of negative personal experiences, pharmacists call for a predefined, clear and straightforward way to communicate with physicians. Third, given the increasing challenge to treat a rising number of elderly patients with chronic conditions, general practitioners desire competent support of experienced pharmacists.ConclusionsOn the ground of methodological triangulation the findings of this study go beyond previous investigations and are able to provide specific recommendations for future interprofessional collaboration. First, interventions and initiatives should focus on increasing trust, e.g. by implementing multi-professional local quality circles. Second, governments and health authorities in most countries have been and still are reluctant in advancing political initiatives that bring together physicians and pharmacists. Proactive lobbying and empowerment of pharmacists are extremely important in this context. In addition, future physician and pharmaceutical training curricula should focus on comprehensive pharmacist-physician interaction at early stages within both professional educations and careers. Developing and fostering a culture of continued professional exchange and appreciation is one major challenge of future policy and research.

Multimorbidität aus Hausarzt- und Patientensicht

BACKGROUND For general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize. OBJECTIVE Given this situation the study aimed at analyzing how GPs and patients deal with this challenge and what their priorities are. MATERIAL AND METHODS Narrative interviews were conducted with 9 GPs and 19 of their multimorbid patients. The data were analyzed by means of content analysis. RESULTS The majority of interviewed patients felt well or very well cared for by their GPs; however, GPs and multimorbid patients often had relatively different priorities. Whereas GPs mostly focused on the management of diseases that could lead to life-threatening situations, patients put an emphasis on maintaining autonomy and a social life. CONCLUSION The results of this study suggest that there is room for development in the way GPs and multimorbid patients communicate with each other, particularly as far as shared priority setting is concerned.ZusammenfassungHintergrundFür Hausärzte ist die Betreuung von Patienten mit Multimorbidität eine alltägliche Herausforderung. Leitlinien, die jeweils nur einzelne Erkrankungen im Fokus haben, können hier nicht umfassend und „gleichberechtigt“ Anwendung finden. Stattdessen müssen Prioritäten gesetzt werden.FragestellungVor diesem Hintergrund wird herausgearbeitet, wie Hausärzte und ihre Patienten diesen Herausforderungen begegnen und welche Prioritäten sie jeweils setzen.Material und MethodenNeun Hausärzte und 19 ihrer Patienten mit Multimorbidität wurden narrativ interviewt. Die Analyse erfolgte inhaltsanalytisch.ErgebnisseDie Mehrzahl der interviewten Patienten fühlte sich durch ihren Hausarzt gut oder sehr gut betreut. Dennoch stellten sich die Prioritäten der Hausärzte und die ihrer Patienten häufig unterschiedlich dar. Während die Ärzte die meiste Energie auf das Management von Erkrankungen verwendeten, die zu potenziell lebensbedrohlichen Situationen führen können, stand bei den Patienten der unmittelbare Erhalt von Autonomie und sozialem Miteinander im Vordergrund.DiskussionDie Ergebnisse der Studie legen den Schluss nahe, dass die Kommunikation zwischen Hausärzten und ihren Patienten gerade in Bezug auf einen gemeinsamen Prozess der Prioritätensetzung bei Multimorbidität weiterentwickelt werden kann.AbstractBackgroundFor general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize.ObjectiveGiven this situation the study aimed at analyzing how GPs and patients deal with this challenge and what their priorities are.Material and methodsNarrative interviews were conducted with 9 GPs and 19 of their multimorbid patients. The data were analyzed by means of content analysis.ResultsThe majority of interviewed patients felt well or very well cared for by their GPs; however, GPs and multimorbid patients often had relatively different priorities. Whereas GPs mostly focused on the management of diseases that could lead to life-threatening situations, patients put an emphasis on maintaining autonomy and a social life.ConclusionThe results of this study suggest that there is room for development in the way GPs and multimorbid patients communicate with each other, particularly as far as shared priority setting is concerned.

Multimorbidität aus Hausarzt- und Patientensicht: Qualitative Studie

BACKGROUND For general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize. OBJECTIVE Given this situation the study aimed at analyzing how GPs and patients deal with this challenge and what their priorities are. MATERIAL AND METHODS Narrative interviews were conducted with 9 GPs and 19 of their multimorbid patients. The data were analyzed by means of content analysis. RESULTS The majority of interviewed patients felt well or very well cared for by their GPs; however, GPs and multimorbid patients often had relatively different priorities. Whereas GPs mostly focused on the management of diseases that could lead to life-threatening situations, patients put an emphasis on maintaining autonomy and a social life. CONCLUSION The results of this study suggest that there is room for development in the way GPs and multimorbid patients communicate with each other, particularly as far as shared priority setting is concerned.ZusammenfassungHintergrundFür Hausärzte ist die Betreuung von Patienten mit Multimorbidität eine alltägliche Herausforderung. Leitlinien, die jeweils nur einzelne Erkrankungen im Fokus haben, können hier nicht umfassend und „gleichberechtigt“ Anwendung finden. Stattdessen müssen Prioritäten gesetzt werden.FragestellungVor diesem Hintergrund wird herausgearbeitet, wie Hausärzte und ihre Patienten diesen Herausforderungen begegnen und welche Prioritäten sie jeweils setzen.Material und MethodenNeun Hausärzte und 19 ihrer Patienten mit Multimorbidität wurden narrativ interviewt. Die Analyse erfolgte inhaltsanalytisch.ErgebnisseDie Mehrzahl der interviewten Patienten fühlte sich durch ihren Hausarzt gut oder sehr gut betreut. Dennoch stellten sich die Prioritäten der Hausärzte und die ihrer Patienten häufig unterschiedlich dar. Während die Ärzte die meiste Energie auf das Management von Erkrankungen verwendeten, die zu potenziell lebensbedrohlichen Situationen führen können, stand bei den Patienten der unmittelbare Erhalt von Autonomie und sozialem Miteinander im Vordergrund.DiskussionDie Ergebnisse der Studie legen den Schluss nahe, dass die Kommunikation zwischen Hausärzten und ihren Patienten gerade in Bezug auf einen gemeinsamen Prozess der Prioritätensetzung bei Multimorbidität weiterentwickelt werden kann.AbstractBackgroundFor general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize.ObjectiveGiven this situation the study aimed at analyzing how GPs and patients deal with this challenge and what their priorities are.Material and methodsNarrative interviews were conducted with 9 GPs and 19 of their multimorbid patients. The data were analyzed by means of content analysis.ResultsThe majority of interviewed patients felt well or very well cared for by their GPs; however, GPs and multimorbid patients often had relatively different priorities. Whereas GPs mostly focused on the management of diseases that could lead to life-threatening situations, patients put an emphasis on maintaining autonomy and a social life.ConclusionThe results of this study suggest that there is room for development in the way GPs and multimorbid patients communicate with each other, particularly as far as shared priority setting is concerned.

Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA

Objectives To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. Design Two-arm cluster-randomised controlled trial. Setting 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. Participants 604 patients 65 to 84 years of age with at least three chronic conditions. Interventions Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a ‘brown bag’ review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. Primary outcome measures We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group’s health-related quality of life would not be statistically significantly inferior to the control group. Results The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI −0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; −0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (−3.07; −5.25 to −0.89; P=0.006). Conclusions Intensifying the doctor–patient dialogue and discussing the patient’s agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. Trial registration number ISRCTN46272088; Pre-results.