Background
Polypharmacy is a situation in which a patient takes multiple oral medications. It is known to increase the risk of adverse drug events and the hospitalization rate and cause a decline in adherence to treatment as well as a deterioration in quality of life (QOL) [
1‐
3]. In addition, calculations have shown that in Japan, pharmaceuticals worth a total of 50 billion Japanese yen a year are destroyed and discarded without being used because of polypharmacy [
4], which has contributed to increased medical costs. Thus, addressing polypharmacy is an urgent issue.
The reduction of medication use in polypharmacy patients is known to improve the quality of medical care [
5]. Standard criteria currently used for the detection of inappropriate prescriptions among older adults include the Beers Criteria [
6] in the United States and the STOPP/START Criteria [
7] in Europe. The guideline for safe drug therapy for older adults [
8], which uses a modified version of the STOPP criteria, has developed into a standard, reflecting current drug treatment in Japan. Measures against polypharmacy have been taken, for example, use of the medication booklet to identify prescription drugs, assess adherence, and recommend non-pharmacological treatments.
Patient awareness surveys on polypharmacy have been reported previously [
9,
10], but no previous study has examined the effects of sending feedback to health professionals on reducing medication use. Our study aimed to conduct a patient awareness survey to examine the factors contributing to polypharmacy (Study 1) and elucidate changes in the number of polypharmacy patients and in the number of prescribed medications that result from sharing survey results as feedback to health professionals (Study 2).
Discussion
Study 1 showed that the following three items were contributing factors to polypharmacy: age (75 years or older), the number of medical institutions visited on a regular basis for medical care (2 different locations or more), and patients’ difficulty with asking their doctors to deprescribe their medications. The finding that age is a risk factor for polypharmacy was consistent with previous reports [
12]. In Japan, the number of patients with multimorbidities have increased as population aging has advanced [
13]. Reports from previous studies conducted in the United States and Europe have shown that the percentage of polypharmacy is high in older adults because of coexisting chronic diseases [
14‐
17]. Previous reports have shown that the risk of polypharmacy is higher when the number of prescribing physicians is large [
18]. In Japan, the health insurance system has enabled free access to medical institutions [
19]. As a result, most patients visit multiple medical institutions [
20] and receive prescriptions from several physicians. There is a lack of cooperation between medical institutions, which are unaware of each other’s prescriptions. This situation promotes “prescription cascades” in which similar drugs are prescribed more than once [
21], and the number of prescribed medications increases. There have been no previous reports on the difficulty that patients have with asking their doctors to deprescribe their medications; it is a newly identified risk factor for polypharmacy. Asking to deprescribe medications can impact the relationship between the patient and the physician in some cases [
22], which may have been the reason why it presented a challenge for some respondents. Health professionals need to actively confirm polypharmacy patients’ intentions. They should ask them whether they wish their physician to deprescribe their medications. Thereafter, health professionals need to work on deprescribing the medications that the patients wish to reduce.
Study 2 showed that when feedback on the risk factors for polypharmacy was sent to health professionals, the proportion accounting for the polypharmacy group decreased, and the number of prescribed medications declined. Previous reports have shown that the promotion of changes in consciousness (aimed at improving the quality of medical care) through sending feedback to health professionals has led to an improvement in the quality of medical care [
23]. In the questionnaire survey results on the feedback submitted to healthcare professionals in our study, all respondents answered that a survey of the current situation regarding polypharmacy was useful, and answered that after hearing the results of the survey, they would implement changes in the medical care they provide. In addition, all respondents answered that the results of the questionnaire survey conducted in Study 1 were unexpected. Many respondents answered the percentage of polypharmacy patients was higher than expected, suggesting a change in awareness of polypharmacy before and after the feedback. Health professionals make behavioral changes in medical care (e.g., considering risk of drug-induced harm in determining the required intensity of deprescribing intervention, assessing whether the drug is necessary based on risks and benefits, and deprescribing less useful drugs) [
24]. This may lead to a decrease in the number of polypharmacy patients. Nearly all respondents answered that more patients understood the reasons for prescribing than expected. In Study 1, more than 90% of patients answered that they understood the reasons for prescribing, which could be interpreted as health professionals continued to prescribe to patients while thinking they did not understand the reasons for prescribing. It is also possible that patients had an incorrect self-interpretation of the reasons for prescribing. Sharing the reasons for prescribing between health professionals and patients can lead to the discontinued use of less important drugs and improve adherence of important drugs.
Conducting a fact-finding survey of polypharmacy and submitting the results as feedback promotes changes in consciousness and behavior among health professionals [
23] and may reduce the percentage of polypharmacy. Martin et al. [
25] explained that following a method consisting of submitting a written opinion (from a pharmacist to a physician) regarding oral medications and giving patients pamphlets on polypharmacy, the number-needed-to-treat (NNT) was 3.22 for reducing medication by one drug. In our study, the NNT was 71. Therefore, the intervention conducted in our study was not as efficient as those in previous studies. However, the method we undertook is inexpensive, can be performed in any type of medical institution, and based on written opinions, is easier to do than the interventions mentioned in previous studies [
25]. Thus, our method can be expected to yield beneficial effects when carried out consistently in routine medical care.
Instead of relying on physicians alone, intervention through multi-sectoral collaboration involving nurses, pharmacists, and social workers is important to eliminating polypharmacy [
26]. Physicians can assess the prescriptions; nurses can ask patients about their oral medications and submit reports to the treating physicians; pharmacists can intervene by answering questions (regarding drug prescriptions), and social workers can monitor the condition of polypharmacy patients receiving nursing care and submit reports to the treating physicians.
Our study has several limitations. The study was conducted in a single clinic, and it remains unverified that the data can be used in other facilities with a different medical care setting. To check its validity, an additional study will need to be conducted at multiple facilities. The second limitation of our research is that it was designed as a pre- and post-intervention study. The change in the percentage of polypharmacy may have been due to confounding factors beyond our provision of feedback on the questionnaire survey results to the healthcare professionals. The third limitation is the questionnaire used here itself has not been validated. The fourth limitation is that there was no way to confirm long-term behavior modification among the health professionals regarding polypharmacy. A follow-up study needs to be conducted to determine the period within which the residual effects of a single intervention can be expected and whether repeating the intervention could serve as a “booster” for decreasing polypharmacy.
Conclusion
Factors contributing to polypharmacy included age (57 years or older), the number of medical institutions visited on a regular basis (2 or more institutions), and patients’ difficulty with asking their doctors to deprescribe their medications, which, importantly, was previously unreported. Moreover, sending health professionals feedback on the factors contributing to polypharmacy led to changes in awareness among health professionals. It may also lead to a decrease in the percentage of polypharmacy patients and in the number of prescribed medications.
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