Background
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An indication check for all prescribed medications according to the diagnoses provided in the eCRF.
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A summary of laboratory test results that are relevant for the appropriate and safe use of the drugs on the medication list, and alerts if a result is outside recommended limits or if a repeat measurement may be due.
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Suggested evidence-based recommendations related to the medication. These can include, but are not limited to recommendations on: discontinuing drugs where there is no evidence for a positive risk/benefit balance, or where evidence points out that risks may outweigh benefits in older people; discontinuing drugs that are on lists of potentially inappropriate drugs for older people (PIM lists), such as the EU(7)-PIM list [27]; discontinuing drugs that have been used for a longer period than recommended in guidelines; discontinuing drugs that are not indicated on the basis of a small or questionable anticipated effect; ordering follow-up laboratory tests for monitoring and improving patient safety.
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Alerts related to drug prescribing in cases of renal malfunction.
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Alerts about known potentially harmful interactions between the patient’s drugs.
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Alerts about contraindications in case the patient has a recorded diagnosis that is a contraindication for one of his/her current drugs.
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Dose warnings in case daily doses exceed the recommended maximal levels according to the indication provided.
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A table listing the risks of nine standard adverse effects (anticholinergic effect, risk of bleeding, constipation, orthostatic dysregulation, QT-prolongation, renal toxicity, sedation, risk of seizures, serotonergic effect) possibly associated with each current drug.
Methods
Recruitment and data collection
1. Polypharmacy in everyday practice (Icebreaker) | |
Which role do polypharmacy patients play in your daily practice? | |
2. Using the eCRF | |
You have entered [number of] patients, what experiences did you have with the eCRF? | |
3. General overview of the CMR | |
What are your experiences with the PRIMA-eDS CMR? | |
4. Output of the CMR and how GPs responded to the recommendations | |
Going through the CMR of one of the GP’s patient
| |
What do you think about the various sections? | |
What happens between reading the recommendations and the moment of discontinuing medication? | |
How did the CMR influence you in treating your patients? | |
5. Implementation of the PRIMA-eDS tool into daily practice routine | |
Which benefits/barriers do you see in using the PRIMA-eDS tool in the future? | |
Do you have any recommendations for further development? |
Characteristic | N (%) | Median (range) |
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Female | 7 (33.3) | |
Age (in years) | 53 (41–65) | |
Years in practice* | 16 (7–32) | |
Working in a single-handed practice | 5 (23.8) | |
Number of patients included in the main trial | 11 (4–18) |
Data analysis
Ethics
Results
Adoption of the intervention: The eCRF
In the beginning it took a while, but then it went pretty quickly. […] For the first one I took 45 minutes I think and in the end it took me ten minutes. (GP 14).
In the beginning you had to familiarise yourself a bit with this programme first. This required some getting used to it, and for sure the error rate was high at first, too. But somehow in the course of time you learned how to use it. (GP 21).
I added his medication later, without him being there. If you sit there and type something, it can be rather impersonal. I don’t like doing that too much. (GP 14).
I put in the important facts to the best of my knowledge, but I often thought that I didn’t talk about it. (GP 8).
Once or twice I wanted to go back [to the patient in the eCRF], but it said that I can’t. (GP 5).
Adoption of the intervention: The CMR
Usage
Sometimes I did it after they left, the next day or the same day or during the break or something like that. Sometimes I did it with the patients, provided they were mentally fit. (GP 16).
I did it after the patient was here. […] I usually make notes and I put them on my desk. Until I discuss them with my patients […] that can take a few days. (GP 17).On the weekends here. It’s impossible to do it in between the practice hours. […] I printed out the medication plan and noted down what [medication changes] I wanted to discuss. (GP 8).So, I usually don’t use it in the presence of the patient, but when the patient is present in the practice. When the patient is waiting in the treatment room. Then I call up [the CMR] and then I go to [the patient]. (GP 13).
At home […] because I’m not online here. So I looked through it and then I noted for each patient down the recommendation from your list of suggestions. And then I thought about which of them I should implement and what things I keep in spite of the recommendation from the list. (GP 12).
[I] wrote a memo “change study this to that”. [… I] then put it on my desk, then it takes two, three weeks until eventually I find a small hole and then I changed it. (GP 2).
Experiences with the patient
I discuss it, I propose it [to the patient] and explain that this and that is the reason and that I read this [in the CMR of the] study and explain what could happen, the reason, [and ask] should we give it a try? (GP 2).
Discussing is a bit difficult, it depends, and the thing is that those [patients that are in the study] are mostly not the kind of people that value discussions. […] They don’t like it, they’re not used to discuss extensively why one should […] change something. […] Older people, sick people, they normally accept what one offers them. It rarely happens that they ask ‘why’. (GP 9).
They are happy. Those people who didn’t want something like this; they are simply not part of the study. So, when I tell [the patient] that this medication check recommends this and that, then they are actually quite positive. (GP 7).
Generally, these are older patients and to convince them that certain drugs, that we need to change them, that’s not always easy. […] Patients are anyway quite worried because of these discount contracts [between the pharmaceutical companies and] the health insurances. (GP 18).
The patients, they were really enthusiastic, they enjoyed getting a lot of attention and felt properly checked up, figuratively spoken, concerning their drugs. Those [patients] really left beaming with joy. (GP 15).
Expenditure of time
It [the time required] is relatively little. But on the other hand also still too much for me to do it directly during the daily business. […] If I had to do it by hand, I’d take forever to finish. (GP 17).That was not time-consuming at all. (GP 11).
In the longer term it is a tool which might tell you for the next patient, man, that’s not a very good combination, so it creates a learning effect as well. Therefore the time spent in relation to the benefit will clearly get better at some point. (GP 1).
Evaluation of the CMR
Prior knowledge pre-existed in many ways, but especially for example with interactions of psychotropic drugs, of neurological drugs, risk of haemorrhage in SSRIs and these things, these are not always that [present]. Risk of falling, especially things which are relevant to older people, that is helpful information for sure. (GP 1).
You can’t possibly have all that in mind and it can be very helpful to be shown everything that you should basically take into consideration. (GP 17).
So I think it’s good to actually think about critical stuff and also to be made aware of it, but […] it is very ‘pacific’ [in the sense of not aggressive enough regarding recommendations to discontinue drugs]. (GP 13).
Adoption of the recommendations
[I] did change quite a bit and also discontinued [some drugs] and it didn’t affect the treatment of the patients negatively. Rather positively, because I tried harder to notice the one or other. (GP 8).I made changes for almost everyone; I think except for one, I think I’ve changed something based on the recommendation dose reduction with reduced renal functioning. (GP 4).
Mainly small changes. To some extend only in between one group of drugs, for instance simvastatin instead of atorvastatin. One time it was about reducing the dosage by half because of some renal function. I would not rate it that high right now. (GP 12).
Despite the medication check, I could hardly discontinue anything. (GP 13).
Unfortunately that didn’t work. But here I have to say, this really is something where one has to accept it, if one says, there’s no other way. This is of course a deliberate thing. What is important is that one simply always does everything deliberately and that one can justify why one’s doing something. (GP 14).
We also followed that and it actually worked out well. People are also coping fairly well with less or with an adjustment. (GP 8).
I wanted to somehow slowly reduce. It cannot be stopped all of a sudden. (GP 20).
Barriers to adopt recommendations
Reasons for not following the recommendations | Quotes |
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Alternatives and recommendations had already been tested and the GP and/or the patient felt that this was not the optimal way of treatment. | It's a long way making that decision and once it’s made and then it is an important drug. I don’t care if there is a contraindication, he’ll get it nevertheless. (GP 19) |
Why in this patient I won’t follow the recommendations is that it has already been tried out in the past. (GP 3) | |
The GP regarded the medication as being necessary. | Out of the multimorbidity of the people, it is inevitable that one gives them [the drug]. (GP 6) |
The GP and/or the patient had other priorities compared to the PRIMA-eDS tool. | Then the patient decides for me. From a certain age on it is about the quality of life. (GP 10) |
Concerning diclofenac for the older patients it simply is like that, he just doesn’t want [to discontinue the drug] and says, “you can’t take this away from me. [I am] free of pain for the first time in 7 years. I need that.” (GP 10) | |
The GP feared that changing medication could get complex. | In case of a patient for whom this medication works so well, in inverted commas, over such a long period of time I won’t change anything. This would just rock the boat. (GP 3) |
The GP had been prescribing the medication for years and lacked motivation to reconsider. | And that is simply a drug that the patient is using for 30 years now and under which she is well managed concerning her blood levels. [And] as mentioned leading a life with very little hardship with over 90 years. I would not touch it, that is [a case of] ‘never change a winning team’, therefore these are things I wouldn’t change. (GP 12) |
The GP did not want to diverge too far from a standard of therapy (guidelines). | So you have to ultimately stick to the general guidelines, because if you go there now radically, then you contravened the guidelines of the professional societies. It’s difficult. (GP 9) |
The GP found the recommendation to be new and not comprehensible. | I’ve never heard that before, it somehow was completely new to me and so I ignored it. (GP 16) |
The GP considered the recommendation as not applicable to the individual patient. | Where I say that the patient is biologically younger. (GP 1) |
The GP found that the patient was a barrier to discontinue medications. | The patient won’t cooperate. If there wasn’t the patient, everything would be easier. (GP 15) |
The prescription was made by another medical specialist and the GP did not want/ did not dare to change it. | Who is responsible for which prescription. The things I do not prescribe, the four medications I do not prescribe, the four psychotropic drugs, I can’t change that. (GP 7) |
It seems that due to the infrastructure medication changes resulting from the CMR could have been delayed or even forgotten. | This actually is a relatively long process, as I don’t have internet access here. […] I print it [the CMR] and make notes. […] Then I wait until the patient comes again. But I have [a study patient] who doesn’t come very often and then it's difficult. (GP 2) |
Other effects resulting from the CMR
Effects of the CMR | Quotes |
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The CMR stimulated GPs to critically reflect on the medication more than usual and to make more conscious decisions. | Of course you engage more intensively with the patient and what he actually has to swallow. (GP 1) |
With other things I looked them up again and assured myself. It really is a push to grapple with things again that one should actually be mastering. (GP 18) | |
The CMR increased GPs’ awareness of risks associated with drug use in polypharmacy patients. | What is good about it, of course, it makes me aware again and again. (GP 4) |
The CMR supported GPs in the dialogue with other medical specialists as the CMR provided good evidence for the GPs’ decision. | I can now say that the European study has recommended it. (GP 10) |
GPs were able to transfer CMR results to patients outside of the study. | [I] changed quite a bit and also discontinued [some drugs] and it didn’t affect the treatment of the patients negatively. Rather positively, because I tried harder to notice the one or other and also with patients not participating in the study. (GP 8) |
Future implementation
It has to be included in every software and then it is easy and then it will also be used. (GP 19).
Possible barriers | Quotes |
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GPs worry that a possible barrier for the future use of the PRIMA-eDS tool could be… | |
the time required. | If I should benefit from this in any way, it can’t go beyond the limitations of a certain time frame. (GP 12) |
the required internet access (for those that are not connected yet). | Well we don’t have any internet access. (GP 9) |
possible costs without being reimbursed. | It depends somewhat on the price. (GP 17) |
the technical implementation and data security. | Besides [technical problems] none. (GP 5) |
If data security is given, none. (GP 3) |
Possible enhancing factors | Quotes |
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GPs consider a strength for the future implementation of the PRIMA-eDS CMR that… | |
it supports them in optimising medications and improving patient safety. | Yes, in first place patient security. That one really protects the patient from being harmed by drugs. (GP 14) |
Certainly reduces mistakes. (GP 10) | |
it provides a quick way of checking medications. | That one really can quickly control a patients’ [prescriptions], especially when he’s taking multiple drugs or a rare combination, that one then really succeeds in checking during everyday practice. (GP 17) |
they can get direct feedback when prescribing a medication for the first time. | I think it’s great. That one might not take the wrong drug when making a new prescription but that one already sees a warning. (GP 8) |
it is free of commercial advertisement and independent from the pharmaceutical industry. | Yes, I could imagine [to use it], especially if it's free of commercial advertisements and not sponsored by the pharmaceutical industry. (GP 16) |