MediQuit – an electronic deprescribing tool: a pilot study in German primary care; GPs’ and patients’ perspectives

Between December 2018 and July 2019, we conducted a single group feasibility pilot study in primary care practices in two regions of Germany (Lower Saxony and Hesse).

Sixteen GPs were recruited using convenience sampling from our academic primary care research networks. Patients were recruited by their GPs consecutively when meeting eligibility criteria. GPs were asked to include three to five patients each. To be eligible for study inclusion, patients had to be at least 60 years of age, take five or more long-term medications and have a minimum of three chronic diseases. Patients with deficient language proficiency or with severe cognitive impairment were excluded. Since MQu was not yet compatible with mobile devices, patients seen on home or nursing home visits only, were excluded.

The ethics committees of Hannover Medical School (No 2326–2014) and Marburg University (No 160/15) gave approval to the study. GPs gave written informed consent after written and oral explanations of the study procedure and its objective. Patients were informed by their GP about the study objectives and that during their consultation a computer tool is used to identify potential optimizations of their drug regimen. Patients gave written informed consent.

Each practice was initially instructed on the study procedure and documentation requirements via visits of a research team member. Practice nurses were shown how to pre-select suitable candidates, collect pre-specified patient data, and perform documentation using protocols. GPs additionally received individual training sessions on how to apply MQu that was installed on local hardware. Training included familiarisation with its three-step structure and its information and visualisation features, as well as practical application using a clinical case vignette. After initiation, practices started including patients on a continuous basis. GPs subsequently conducted MQu-assisted medication counselling in their practices. They rendered patient baseline-data and documented their experiences using case reporting forms.

The developmental process was based on results of a systematic literature review [4], our own clinical experience, and iterative discussions within the research team. Additionally, ten external experts from different fields (pharmacology, polypharmacy, primary care guidelines, geriatric medicine, multimorbidity, technology, public health, and shared decision-making (SDM)) were asked to comment on the tool. We decided to use the arriba platform, since this is an already broadly disseminated clinical decision support system (CDSS) used for shared decision-making in various contexts (e.g. risk-estimation in cardio-vascular prevention) in German primary care [16]. We designed an arriba module (MQu) supporting deprescribing and guiding through three consecutive steps.

Screenshots and a video of MQu are available on https://​arriba-hausarzt.​de/​module/​mediquit (English screenshots supplementary file 1).

After each MediQuit consultation, GPs were asked to complete two case reporting forms (CRF):

Additionally, every GP was asked to fill a final questionnaire after completion of all consultations rating the tool’s comprehensibility, helpfulness, satisfaction with elements, patient-involvement (SDM), and intention for future use.

Patients were followed up by telephone at T1 (2–4 days after consultation) und T2 (4 weeks later). They were asked to name the medication(s) discussed, prior trials of withdrawal, result of consultation, their involvement (understandability, room for questions, decision-making, satisfaction), implementation (discontinuation, occurrence of health issues), assessment of duration, evaluation of print-out, general assessment of medication consultation and tool.

Data were imported into IBM SPSS Statistics 26 and analysed descriptively.

Sixteen GPs were enrolled in the study (eight each in Hesse and Lower Saxony). Six of them were not able to perform medication counselling with the help of MQu, because of organizational or time constraints, language barriers, or technical issues. Ten GPs recruited patients and performed medication counselling with the help of MQu (see Table 1 for characteristics of actively recruiting GPs).

GPs conducted consultations using MQu with a total of 41 patients, thereof 16 men and 25 women, mean age 77 years with a mean number of 10.9 prescribed medications (see Table 2).

Of the 41 patients, 37 participated in T1-follow-up (2–4 days), and 35 patients participated in T2-follow-up (4 weeks). Patients lost to follow-up could not be contacted by telephone (3), withdrew consent (2) or were medically not able to participate in follow-up interview (1).

All GPs were familiar with the arriba platform in advance, and 7 of 10 GPs used the platform regularly (all used arriba module for cardiovascular prevention). The arriba MQu module was introduced to GPs for the first time during this study.

In mean, deprescribing consultations lasted 15 min (Interquartile range IQR 10–20 min). The majority (87%) of consultations were perceived of perfect duration by GPs. Fifteen percent were perceived as too long. Patients in turn, marked 95% of consultations as perfect in length, whereas 5% of patients considered consultations as too short.

GPs indicated to have used the MQu steps 1 and 3 frequently (71–87%) (s. Table 3).

Whereas, shared decision-making elements in step 2 as well as information boxes and external sources were used less often (7–46%).

When GPs were asked on how helpful MQu elements were during counselling, the elements of step 3 implementation (patient print-out and deprescribing schedule) were perceived as most helpful (Fig. 1). Whereas, elements of step 2 developed to promote shared decision-making (communication cues and scales) were perceived as least helpful.

When GPs were finally asked for their evaluation after all of their consultations with MQu, they found the program generally suitable for their patients (70%) and would be most suitable for elderly patients on multiple drugs with complex regimes.

In general, GPs reported that MQu supported communication with patients rather or very much in 40% (Fig. 2). While 70% of GPs reported the decision had been a shared one, only 49% of patients did report so (data not shown). However, SDM elements were seen supportive by 30% of GPs, whereas the implementation of the deprescribing regime was experienced supportive by 60% (Fig. 2).

In general, 50% of GPs were satisfied with the assistance of MQu in deprescribing.

GPs made various suggestions for improvements mainly referring to a more intuitive and clearer design, adjustable SDM components (scale and communication cues) for more individual counselling, and embedding of specific drug as well as guideline recommendations.

When asked for their intention for future use, GPs appeared highly encouraged to pick up MQu step 3 (implementation) in future consultations. The use of SDM elements (step 2) revealed least attractive. This goes in parallel with GPs’ satisfactions with MQu as well as their suggests for improvements mentioned above.

Patients generally appreciated the medication consultation targeting deprescribing (80%). The use of an electronic tool (MQu) was generally considered positive in the majority of cases (63%). Patients reported general satisfaction with the deprescribing consultation (85%) as well as satisfaction with their decision made (90%).

When asked for MQu, 51% indicated to have looked at the MQu screen during consultation (Table 4), whereby most were not able to specify or did not remember what they had seen. Given information during counselling was perceived rather and completely comprehensive in most cases (85%), and most patients described enough room for questions (83%). Twentyfive patients (61%) received a print out, what was read by about half of them (Table 4). One third of patients indicated to be willing to check their mediation for deprescribing again with MQu, preferably with a focus on antihypertensives and statins.

Arriba MediQuit (MQu) is a novel electronic three step tool, developed to support GPs and their patients in consultations dealing with polypharmacy and deprescribing. It was tested with ten GPs in 41 consultations. Here, we offer a detailed insight into technological parameters and vizualization of MQu, for the first time. GPs rated identification (step 1) and implementation support (step 3) most helpful and showed intention for future use of these elements, when asked for an overall evaluation of the tool. Whereas, SDM elements and auxiliary information sources revealed room for improvement. Patients generally appreciated consultations and the use of MQu. While they were broadly satisfied with the deprescribing consultation and their decision made, only half of the patients looked at the MQu screen and about two thirds received a printout.

A strength of this pilot study lies in its pragmatic design in two German regions, with urban as well as rural practices and with a diverse group of GPs. Most of the GPs were able to successfully integrate a MQu deprescribing consultation into their surgery. However, even in this small sample, six of 16 GPs did not manage to test MQu with their patients. GPs reported obstacles in finding time to familiarise with MQu, technical difficulties in installing and handling the program as well as language barriers with some patients. Due to the usual limitations in the design of pilot studies (short follow up, potential selection bias, no blinding, no control and no randomisation), we cannot yet make a statement on the actual efficacy of MQu. Nevertheless, the elementary design helped us generating pivotal results for future development of MQu and other tools in the context. Furthermore, the simple approach to meet in an extra appointment (with or without MQu) may alone improve the uptake of deprescribing efforts.

To our knowledge, arriba MediQuit (MQu) is the first electronic deprescribing tool that integrates SDM. However, the helpfulness in communication and patient-involvement were shown to need further improvements. There still seem to be some obstacles to make advantage of SDM in this context. The minority of patients looked at the MQu screen or remembered what they had seen.

Notwithstanding, patients showed high willingness to participate in the study and discuss medication optimization with their GP. They were highly satisfied with the consultation, the use of MQu and their decisions made. Some even wished further consultations with MQu. The majority reached a sustained discontinuation of discussed drugs [15].

The missing ability to extract information from electronic health records (EHR) was another point of critics by GPs. Whereas, identification and implementation elements of MQu were perceived extremely helpful by them.

In contrast to other electronic tools (as TRIM [10], Prima-eDS [11], TaperMD [18]), MQu has no automated drug assessment, does not automatically align EHR data (laboratory, comorbidities, medication interaction etc.) with clinical guidelines and thus does not automatically generate advice for changing drugs.

MQu, on the contrary, requires the skilled input and evaluation by GPs. MQu assists GPs where support is needed. The reliance on the GP’s judgement avoids time-consuming data input (up to 20 Min in Prima-eDS [19]). But even more importantly, this opens the space for GPs and their patients to discuss the topic and find individual solutions based on the patients’ personal goals of care.

Janssen et al. stress the importance of SDM in deprescribing [20]. Their ‘analysis’ offers advice and narrative suggestions in this context. In parallel with the SDM literature, we found conflicting ratings about the presence of SDM between patients and GPs [21]. However, as far as we know, MQu is the only electronic tool that focuses on this topic and presents special support in communication and shared-decision making.

The integration of explicit lists of avoidable medication is not integral part of MQu in contrast to other tools. Since their explicit character might be helpful in some circumstances, we integrated links to useful projects like Medstopper [22] and others.

Scott and Couteur (2015) are right when calling (hospital) physicians for active deprescribing [23]. On the other hand, patient empowerment falls short in this respect. By elucidating patients’ preferences and involving patients in decision, we want patients to take the lead in deprescribing.

In line with the literature, patients were open in this study to discuss their medication and discontinue drugs [24]. Patients even wish to be more involved [24].

Implementation of deprescribing approaches revealed multiple obstacles [25]. MQu was able to overcome some of them, while support in implementing of deprescribing intentions was rated most helpful.

On the one hand, this study once again demonstrates that deprescribing is possible and that GPs as well as patients welcome the approach to discuss and decide on polypharmacy. Deprescribing in primary care is feasible and further development worth its effort.

On the other hand, we had to realise that communication and SDM in MQu need improvements in terms of a more intuitive and more individualizable design. GPs need a real interactive screen that itself stimulates interaction and discussion of the parties. Just by a true involvement of patients, a real sharing of information and decisions becomes achievable.

In this trial, GPs were asked to go through all components of MQu sequently. This seemed too inflexible for their needs. GPs wished for a more flexible tool that selectively supports, where support really is needed.

Further development has to go along with technical improvements as well. An easily accessible platform that runs on portable devices is strongly needed. Integration of an interface to communicate with existing HER could further open up opportunities.

Finally, the improved tool needs a robust validation in an effectiveness RCT.