Background
Current care and best practice
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Recommendation A on communication about medication: All patients with polypharmacy and additional risk factors for medication problems should receive structured medication counselling (SMC) at least once per year. Beside medication-related information, SMC comprises a complete inventory of the medication actually taken by the patient (so called “brown bag review”) and an assessment of adherence and possible application problems. A separate appointment should be planned for SMC [9, 10].
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Recommendation B on documentation of medication: All patients with polypharmacy should take along an updated, complete and comprehensible medication list, concordant with the template of the Drug Commission of the German Medical Association [11].
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Recommendation C on prescribing: Physicians should perform structured medication reviews with the aid of tools, such as the PRISCUS list [12] or the Medication appropriateness index (MAI) [13], to reduce potentially inappropriate medication regimes. PRISCUS lists 83 substances which should be avoided in older, multimorbid patients. The MAI is a compilation of implicit criteria which should be taken into account when reviewing a medication regimen.
Tailoring
Strategies to implement recommendations on polypharmacy
Effectiveness of the tailored programme
Methods
Study design
Sample
Data collection
Item number | Survey item | Group | Agree % (n) | Partly agree % (n) | Do not agree % (n) |
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1 (a) | I need more knowledge to implement these recommendations into my practice | IG + CG | 14.3 (3) | 57.1 (12) | 28.6 (6) |
IG | 20.0 (2) | 60.0 (6) | 20.0 (2) | ||
CG | 9.1 (1) | 54.5 (6) | 36.4 (4) | ||
1 (b) | The workshop of the PomP study conveyed useful knowledge for the implementation of the recommendations into my practice | IG | 60.0 (6) | 40.0 (4) | 0.0 (0) |
2 (a) | The lack of work routines hinders the implementation of the recommendations into my practice | IG + CG | 19.0 (4) | 33.3 (7) | 47.6 (10) |
IG | 10 (1) | 20.0 (2) | 70 (7) | ||
CG | 27.3 (3) | 45.5 (5) | 27.3 (3) | ||
2 (b) | The elaboration of implementation action plans helped to establish routines for the implementation of the recommendations | IG | 30.0 (3) | 60.0 (6) | 10.0 (1) |
3 (a) | It is difficult for me to select the patients who profit most from SMC | IG + CG | 0.0 (0) | 23.8 (5) | 76.2 (16) |
IG | 0.0 (0) | 40.0 (4) | 60.0 (6) | ||
CG | 0.0 (0) | 9.1 (1) | 90.9 (10) | ||
3 (b) | The patient list provided at the beginning of the study helped me to identify suitable patients for SMC | IG | 40.0 (4) | 40.0 (4) | 20.0 (2) |
4 (a) | Instruments for medication reviews such as the PRISCUS list or the MAI are not feasible enough to use them regularly | IC + CG | 42.9 (9) | 47.6 (10) | 9.5 (2) |
IG | 30.0 (3) | 60.0 (6) | 10.0 (1) | ||
CG | 54.5 (6) | 36.4 (4) | 9.1 (1) | ||
4 (b) | The online-tools and checklists provided on the tablet PC helped me to conduct medication reviews. | IG | 50.0 (5) | 30.0 (3) | 20.0 (2) |
5 (a) | The lacking standardization of medication lists impede the implementation of recommendation B into my practice | IG + CG | 23.8 (5) | 38.1 (8) | 38.1 (8) |
IG | 20.0 (2) | 40.0 (4) | 40.0 (4) | ||
CG | 27.3 (3) | 36.4 (4) | 36.4 (4) | ||
5 (b) | The provided template for medication lists helped me to bring the medication list of my practice in line with defined minimum standards. | IG | 50.0 (5) | 20.0 (2) | 30.0 (3) |
6 (a) | The lacking self-management abilities of patients impede the implementation of the recommendations into my practice | IG + CG | 19.0 (4) | 71.4 (15) | 9.5 (2) |
IG | 20.0 (2) | 70.0 (7) | 10.0 (1) | ||
CG | 18.2 (2) | 72.7 (8) | 9.1 (1) | ||
6 (b) | The information material (posters, tablet pc) induced patients to take their medication list with them. | IG | 50.0 (5) | 30.0 (3) | 20.0 (2) |
7 (a) | Language barriers of non-German-speaking patients impede the implementation of recommendation A into my practice | IG + CG | 52.4 (11) | 23.8 (5) | 23.8 (5) |
IG | 50.0 (5) | 20.0 (2) | 30.0 (3) | ||
CG | 54.5 (6) | 27.3 (3) | 18.2 (2) | ||
7 (b) | The info-tool on the tablet PC helped to reduce problems due to language barriers | IG | 30.0 (3) | 40.0 (4) | 20.0 (2) |
8 (a) | Difficulties of comprehension between me and my patients impede the implementation of recommendation A into my practice | IG + CG | 28.6 (6) | 28.6 (6) | 42.9 (9) |
IG | 30.0 (3) | 30.0 (3) | 40.0 (4) | ||
CG | 27.3 (3) | 37.3 (3) | 45.5 (5) | ||
8 (b) | The info-tool on the tablet PC facilitated the communication with my patients | IG | 40.0 (4) | 50.0 (5) | 10.0 (1) |
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What is the participants’ view of the recommendations on polypharmacy?
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How did the participants use the strategies offered to them?
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How did the participants evaluate the feasibility and helpfulness of the applied strategies?
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Did the strategies from their perspective help to modify the determinants as intended?
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How successful was the implementation of the recommendations from the perspective of the participants?
Data analysis
Results
Participants
Hypotheses of the logic model
Hypothesis 1: training increased expert knowledge and routines
What was most helpful for me: the exchange with the other colleagues (GP)I would like to reinforce this in our quality circle and discuss specific or difficult patients (GP)
Hypothesis 2: implementation action plans increased routine
This helped us a lot. The motivation of the staff was stronger and as you can see we have realised most of the issues we have elaborated. That was most helpful (GP).The essential thing is to become aware of the difficulties (…) this is for sure what [helped] most (GP).
All this happens already automatically in our practice and this is why there was nothing to change (MA)
Hypothesis 3: patient lists helped to identify suitable patients for SMC
I can just pick patients here and then, when I have the feeling, I should have a look here (…) But this patient with the insulin, that was actually no risk patient for me, he would not have struck me due to the lab results. So the question is: How to reach these people? That’s virtually impossible! (GP)There were not so many news or changes in those specific patients (…), but you are more sensitized and you pay more attention in other patients as well (GP)
Hypothesis 4: the checklist helped to establish routines for SMC in the practice
I think you shouldn’t try to take away someone’s experience because of some checklist or guideline (GP).I need a checklist only if I don’t have knowledge (…) you should trust the doctors more, they have knowledge and that they don’t need checklists! (GP)
Hypothesis 5: the aids for medication reviews increased expert knowledge and feasibility of instruments for systematic medication reviews
No, we didn’t use the tablet very much. If I go online, I do it with [my computer] (…) so we didn’t use it (…) because [these tools] were disconnected from our system (GP).
Hypothesis 6: the template helped to bring medication lists in line with the standards
That’s a problem of the system, we cannot simply change this (…). That’s beyond our possibilities (GP).
Hypothesis 7: the information material for patients increased the self-management abilities of patients and reduced language barriers and difficulties of comprehension
I think mainly the posters, that they should always have their medication list with them, maybe this sensitised them [the patients]. That was good! (MA)Almost none of our patients was able to use this tablet themselves. I think the medical assistant did it with them and read it to them or showed it to them (GP)
Hypothesis 8: implementation of the recommendations has improved
It’s not that we have not done this before. We have always done this in patients with dementia or when other problems played a role and when we believed that something is going wrong. But I think we will do it more often in the future (GP).Of course it is our job to take care that the medications fit and so on. But due to the study I was sensitised to do this more often. And in that respect it helped me (GP).
We ask more about it and are more interested in it. Before it was only the problem of the doctor and now we do it as well (MA)
We made it a rule – based on the experience – to let [patients] bring their medications for the DMPs (…). Because you saw how necessary it is and, yes, how many dangerous things happen as well, I think (GP).The risk patients come any way, at least once per year for the check-up (…) and I think you can combine this very well (…). The only thing is that we, the assistants, have to accustom ourselves to telling the patients, when they make an appointment: Bring your medications with you! (MA)I think we will adopt this to 100%, mainly the thing with the check-ups, when patients come anyway (MA).
The patients made more efforts to understand and update their medication list. This did a lot for us (…), that was surprisingly positive. I wouldn’t have thought this, to be honest. (GP)I think the patients take it more serious now, that they carry the medication list with them (MA)I think many became aware what it means to have a medication list and to show it to everyone (GP).
Hypothesis 9: the implementation of the recommendations leads to improved health outcomes
Yes % (n)* | No % (n)* | |
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1. Did you conduct structured medication counselling with this patient? | 96.7 (116) | 3.3 (4) |
1.1 If yes, did the patient require any information? | 53.4 (62) | 46.5 (54) |
1.2 If yes, did you receive any useful information from the patient or his/her relatives? | 43.1 (50) | 56.9 (66) |
2. Did you conduct a complete inventory of the medication actually taken by the patient (“brown bag review”)? | 82.5 (99) | 17.5 (21) |
2.1 If yes, did the patient bring his medication packages to the practice for this purpose? | 74.7 (74) | 25.3 (25) |
2.2 If yes, were there any irregularities? | 20.2 (20) | 29.8 (79) |
2.3 If yes, did you receive useful information due to the “brown bag review”? | 31.3 (31) | 67.7 (67) |
2.4 If yes, did the brown bag review result in useful instructions for the patient? | 43.4 (43) | 56.6 (56) |
3. Did you give the patient an updated medication list at the end of the appointment? | 84.2 (101) | 15.8 (19) |
4. Did you review the medication of the patient systematically? | 89.2 (107) | 10.8 (13) |
4.1 If yes, did you use the checklist for medication reviews provided by the study? | 59.8 (64) | 40.2 (43) |
4.2 Did you use any other instrument for the medication review? | 17.8 (19) | 82.2 (88) |
4.3 Did the medication review result in a change of the medication? | 21.5 (23) | 78.5 (84 |
4.4 If yes, what changes did you make? | ||
Stopping a medication | 34.8 (8) | |
Prescription of a new drug | 30.4 (7) | |
Change of the dosis | 47.8 (11) | |
Change of application | 0.0 | |
Other | 13.0 (3) |
Many patients are unsettled, even by the package insert (…) The patients are not able to understand all this (…) you weigh up, how is the benefit and then we make the decision. But I take the decision and we don’t know if there will be a side effect, but they have to trust me that the medication is right for them. They are not able to understand all this, I don’t even know if they understand me. If I would list all side effects (…) they would be very concerned (GP).
This is my next question: What’s the point of it? What do you want to reach? That less patients die from side effects or what? (…) Of course we are interested in treating our patients better, but to talk about medication just like this? (…). Is there any statistical prove that more patients become sick from drug administration? Is this certain? I can’t judge this. (GP).