Background
Methods
Participants and recruitment
Sample
Agent group according to the PRISCUS-list | Number of patients taking a PIM from this agent groupa
|
---|---|
1. Analgesics, antiphlogistics | 2 |
2. Antiarrhythmics | 3 |
3. Antibiotics | 1 |
4. Anticholinergics | 1 |
5. Antidepressants | 1 |
6. Antihypertensives, cardiovascular drugs | 2 |
7. Sedatives, hypnotic drugs | 5/3b
|
8. Anti-dementia drugs, vasodilators, circulation-enhancing drugs | 2 |
Agents from different agent groups (combinations of 7/8; 2/5; 1/8; 5/7 and 7/antiemetic drug)c
| 5 |
neuroleptics, ergotamine/ergotamine derivates, laxatives, muscle relaxants, antiepileptic drugs and anticoagulants/antiplatelet drugs | 0 |
Interview guideline
Problematic medication
Data collection and transcription
Data analysis
Results
PRISCUS list and problematic medication
“The PRISCUS list is a pain I’ll say. […], if I were to adhere to the PRISCUS list, I wouldn’t be able to prescribe them a single pill. […] I simply find it better to have concrete recommendations made for the elderly. […] I would prefer something with a positive formulation.”(paragraph 38–44, HA_L_PIM09)
“[…] Surely some are unjustly on the list because the experts who created the PIM list were no practitioners […] I say this a bit degradingly: The list is politically correct. Everything is on it that should be on it.”(paragraph 30, HA_HH_Pt2)
“[…] when the kidney function slowly decreases problems can come up, or when the liver function is reduced, […]. That’s why I do bloodwork regularly. […]”(paragraph 41–43, HA_HH_nonPIM01)
“[…], the medication [Acetyldigoxin is defined as PIM according to the PL] is actually used to, to reduce or regulate, to normalize the heartrate. […] the other organs function fine, in this case particularly if the kidney function is good, then the active metabolites can be excreted and there is no accumulation, which in turn wouldn’t lead to other side-effects. In this case, with Mrs. K, everything is in balance and (.) under control and without risks. […], in her case, too, it is a safe therapy, even though it has a negative connotation.”(paragraph 152–157, HA_BN_PIM05)
“Well, when I started out, I always said three medications are enough. There generally aren’t any more. […] when they come out of the hospital categorized […] according to their CHADS-scores and guidelines, one has quite a time of it because God knows they have way more than three medications, you know?”(paragraph 11, HA_HH_nonPIM07)
Aspects of (long-term) use of PIM and other problematic medication
Prescription- and medication-related aspects
“ […] that it is written on a private prescription. […], that it isn’t followed up on then. Otherwise there are very clear rules from the KV [Association of Statutory Health Insurance Physicians], one isn’t allowed to prescribe them longer than 4 weeks with very few exceptions. Some then receive a private prescription. […] The good thing about the private prescription is (.) that they actually use less. […]”(paragraph 26, HA_HH_PIM02)
“[…], that a medication, […] is potentially problematic for a patient or has significant side-effects, then you may have to restrict the medication to the available alternatives, which are not always equal in their effect, you know? […]”(paragraph 78–80, HA_BN_PIM09)
“Well, certain blood pressure medications, […] like Doxazosin [Doxazosin is defined as PIM by the PL] […], some elderly patients still have in their medication. […] Because they’ve had it for 20 years and, thus far, everything went well. […], if they say, […] they feel well, then I leave it with them. […]”(paragraph 37–39, HA_L_noPat1)
GP-related aspects
“When I send someone to a specialist, then I want to make use of that specialist’s expertise, it would be absurd if I would say “That’s nice, but we aren’t doing any of that.”. […]”(paragraph 89, HA_HH_nonPIM05)
“Except for the incontinence medication [Solifenacin is defined as a PIM according to the PL], she gets all her prescriptions from me, yes. There are certain specialists who I don’t want to exclude/from their responsibilities. […] that the patients remain in contact with the treating specialists and can give direct feedback […]. And I don’t want to take on the responsibilities of all specialists by myself; I want to keep them in the boat. […]”(paragraph 126, HA_HH_PIM10)
“[…] Well the reduction of medications is certainly a high priority, in my opinion a GP’s greatest skill, taking away medications.”(paragraph 11, HA_L_nonPIM08)
“[…], for every type of illness, let’s say, one uses particular substances and always the same ones and one knows them well and doesn’t go along with every new medication trend. I, for one, tend to use medications, which have long since been tried and tested […].”(paragraph 85, HH_HA_nonPIM01)
Patient-related aspects
“And he will always give a plausible explanation as to why he still needs the [sleep-inducing drug] or still needs it for a while, you know? […] And sometimes it is easier to just fulfill the wish and say “OK, for God’s sake,” than to say “I won’t do it anymore.”.”(paragraph 92–96, HA_BN_PIM09)
“[…] some patients are very demanding; Mrs. S is also very, very demanding. […], they want a pill for every little thing. […] But Mrs. S is someone, who simply wants everything, everything that is available. […]”(paragraph 9, HA_L_nonPIM06)
“[…] Well, she has a tinnitus, which […] keeps her from sleeping. That is also the reason why she became addicted to sleep inducing medications. […] Oh, tried with all alternatives, to somehow solve the problem in another way. […] It is such a vicious cycle, where she says “If I cannot sleep, my blood pressure goes through the roof, I get totally nervous, my depression gets worse when I don’t sleep.” In the end, the sleep-inducing medication is the lesser of two evils. […]”(paragraph 468, HA_BN_PIM02)
“[…] “Oh, I’m already so old now, what does it matter now.” Right? And when I tell them that they can become dependent on [sleep-inducing medications] and that they then won’t sleep more but increase their risk of falling and reduce their cognitive abilities. “Oh well, what does that matter now?”. […]”(paragraph 8, HA_HH_PIM02)
“ Especially the co-medications which are available over the counter without a prescription are extreme amongst sleep-inducing medications and pain-killers. […] One has to actively ask about them, because the patients generally don’t consider these medications. […] They rather think “Well if I can buy them like that they cannot be that bad.”.”(paragraph 107–113, HA_BN_PIM02)“Especially with the new oral anticoagulants, […]. In the practice we ask “Do you take Marcumar or Aspirin?” and they say “No.”, because it has a different name. And just like that you’ve given an injection or a medication which can cause complications.”(paragraph 58, HA_HH_PIM06)
System-related aspects
“[…] If he goes to the urologist and to this and that specialist with his chip card and without my knowledge, I don’t get a report and I don’t know what all was prescribed. […] The orthopaedist never, doesn’t write a report. Urologist X, right around the corner from the patient, never does. The otolaryngologist is Mr. Y, he doesn’t either. […]”(paragraph 31, HA_HH_nonPIM06)
“[…] A classic is of course Ibuprofen. Well, Diclofenac, NSAIDs which are taken very, very often. […] I always try to include the orthopaedist, […] they very, very quickly recommend […] this group [of medications] without asking themselves, “Is there a pre-existing internal condition?”. […]”(paragraph 42, HA_HH_PIM08)
“And the more physicians are consulted, the more is added. Seldom subtracted, right?”(paragraph 24, HA_BN_nonPIM06)
“If I see an elderly lady/[…] whose bloodwork etc. I have due to regular consultations, unlike colleagues, (.) and specialized colleagues, and I know, for example, about […] the kidney function or the heart attack in the history etc., then […] they come back from the orthopaedist and have their painkillers in their bag, and I immediately discontinue their use. Rigorously. (..) And then they receive a different (.) painkiller from me.”(paragraph 42, HA_HH_PIM05)
“[…] if the patients are well informed about what, yes, what’s important and what use and risks are behind it, then one can often make a good, mutual decision […] OK, I’ll say one doesn’t do that with every patient in daily practice, who, well not during every consultation, you know?[…], of course even now you don’t start from scratch, rather, if you see that things are going well and the patient feels well, then one doesn’t change anything. […]”(paragraph 66–68, HA_BN_nonPIM05)