Main findings
Our study identified barriers and facilitators for four main topics regarding the implementation of MRs in primary care. These four topics comprised patient participation, GP-led MRs, pharmacist-led MRs, and involvement of HCAs in MRs.
Barriers to patient participation related to patient autonomy and included reluctance to change current drug regime, unwillingness to disclose psychiatric and OTC drugs, as well as disapproval of excessive rigidity in the intervals between MRs. However, as the majority of patients had already reflected upon the appropriateness of their medications, their awareness of medication-related problems was a facilitator. During an MR, patients expected indications for their medicines to be checked, possible interactions with other drugs identified, information provided on the availability of new and better medicines, and possibilities to reduce the number of drugs they were taking to be investigated. Barriers to GP-led MRs concerned GP’s lack of resources, whereas facilitators related to the trusting relationship between patient and GP. Respondents had differing views on the pharmaceutical competence of GPs. Although most had confidence in their doctor’s skill, some doubted he or she had sufficient pharmaceutical knowledge. Pharmacist-led MRs may be hindered by patients’ mistrust of pharmacists’ expertise, but could be facilitated by pharmacies’ digital records of a patient’s medicines. With regard to the involvement of HCAs in an MR, a potential barrier was that some patients doubted whether their training and competence were sufficient. However, most patients were happy with the idea that GPs would delegate some aspects of MRs to an HCA and thus facilitate their implementation.
Findings in relation to the literature
Our findings are supported in the literature [
15,
27,
28,
37] insofar as our patients’ attitudes towards MRs were mostly positive. Unlike as in some other studies, none of our patients viewed MRs negatively or as unnecessary due to the workload of existing medical appointments [
26,
38]. Fears and suspicions that the purpose of MRs was to save money by stopping or changing medicines were mentioned by Petty et al. [
27,
39]. Some of our patients also feared a change in a drug regimen they were satisfied with, but did not voice fears that the aim was to cut costs. Others found that additional drugs, such as herbal treatments, had only been documented by approximately 60% of GPs [
40], and that some patients withheld information on these drugs from their doctor [
41,
42]. Our interviewees also mentioned this problem. As inappropriate use can lead to potentially hazardous drug interactions, structured MRs should explicitly ask about additional drugs [
43]. However, our findings suggest that patients need to be informed about the importance of disclosing additional drugs, as some of our interviewees perceived for instance herbal medicines as not important and never mentioned them to their GPs. Patients should not be forced to reveal all their medicines, but motivated to do so in a supportive manner.
Reports by patients that they had no opportunity to discuss medication-related questions and problems with a health professional can be found in the literature [
15,
41]. These patients want to be properly informed about their medications, including possible side effects, and to receive detailed instructions on taking them [
27,
44]. Such patients would undoubtedly appreciate the opportunity to discuss these issues in an MR [
27,
45], and to have their questions answered [
29], just like our interviewees. The wish to cease taking medications that are no longer necessary and to reduce the number of drugs being taken was a point mentioned in both telephone interviews and focus groups. Other authors have reported similar finding [
46].
The majority of our patients had reflected upon the appropriateness of their medicines, and a few had even asked their GP to check their current medicines. However, in other studies, GPs’ lack of time and patients’ fears of wasting it were barriers to seeking help [
47]. This may explain why many of our interviewees had not asked their GPs to review their medicines. Nonetheless, the inclusion of MRs in routine primary care would be welcomed by patients who are aware of potential problems and willing to do something about it, e.g. by seeking advice from journals, or on the internet [
48,
49]. Our participants also undertook measures to check their medicines by, for instance, reading patient information leaflets. Our patients were able to imagine being actively involved in MRs. This could well be a facilitator, as patients would then be more likely to provide information on their actual drug use (including OTC drugs), adverse drug events, and practical and management problems [
25].
Our interviewees welcomed the idea of GPs conducting MRs in preference to pharmacists. Other authors have also reported that patients welcomed MRs conducted by GPs [
15,
27,
50]. However, considering the lack of research into patients’ views on MRs, it cannot be ruled out that many patients would be happy for pharmacists to perform them. Patients that had undergone an MR with a pharmacist spoke positively about it, and viewed the pharmacist as an expert on medicines [
51]. Indeed, some of our interviewees could imagine that a pharmacist would conduct their MR.
Strengths and limitations
One strength of our study is that some of our elderly patients expressed their opinions in telephone interviews and some in focus groups. Their average age was 74, and ranged from 62 to 88 years, enabling us to cover a wide spectrum of patients. Furthermore, our sample was balanced with respect to gender. As a result of our inclusion criteria, we selected patients who had most likely experienced medication-related problems, and could contribute to the discussion.
The study has several limitations. As we recruited patients in general practice, where patients generally have confidence in their GPs, our participants may have overemphasized the role of the GP in MRs. Furthermore, as we work at an institute of general practice, we may also have tended to overstate the role of GPs. To prevent this, we thoroughly discussed codes during the analysis. Studies inviting patients to community pharmacies might find slightly different attitudes. Although we conducted test interviews, our interview guide was not systematically pilot tested. Furthermore, patients could choose between telephone interview and focus group. The choice enabled us to lower the threshold for participation because housebound people could participate in a telephone interview. A similar study, by contrast, excluded housebound patients [
27].
Patients participated voluntarily, so it is likely that they had a greater interest in MRs than the average patient. Furthermore, in the “project background” section of our interview guide, we state that taking many different medicines can cause problems. This may have encouraged patients to speak in more detail about their medication-related problems, as they felt confident that their problems were of interest to others. In general, participants’ statements have to be rated as assumptions – none had experienced a structured MR so far. Limitations usually associated with focus groups such as difficulties surrounding mutual self-disclosure on uncomfortable subjects may apply to our study as well [
52]. However, in anticipation of this limitation we also conducted telephone interviews, which created a more personal atmosphere. Additionally, we used circular questions, inviting our interviewees to refer to other patients’ viewpoints, e.g. relatives or friends who had different experiences and problems [
53]. Nevertheless, such viewpoints remain speculative.