Background
Methods
Study design
Inclusion of study participants
Data collection
FP | Documented chronic conditions of the case (ICD-10) | Documented acutediagnosis of the case (ICD-10) | Prescription of PIM per quarter: agents/amount (prescribed daily dosage) | Further agents for long-term treatment/same quarter |
---|---|---|---|---|
FP1 | D25: Leiomyoma of uterus | F43: Reaction to severe stress, and adjustment disorders | Zolpidem/80 pellets (missing) | Candesartan, Carbamazepine, Doxepin, Gabapentin, Metoprolol, Metformin, Pravastatin |
E22: Hyperfunction of pituitary gland | ||||
E78: Disorders of lipoprotein metabolism | ||||
G25: Other extrapyramidal and movement disorders | ||||
G47: Sleep disorders | ||||
G56: Mononeuropathies of upper limb | ||||
G58: Other mononeuropathies | ||||
I10: Essential (primary) hypertension | ||||
I65: Occlusion and stenosis of precerebral arteries | ||||
R55: Syncope and collapse | ||||
FP2 | F13: Mental and behavioral disorders due to use of sedatives or hypnotics | M54: Dorsalgia | Zopiclone/60 pellets (7.5 mg/day), Lorazepam/missing (2.5 mg/day) | Acetylsalicylic acid, Amlodipine, Calcitrol, Carvedilol, Cholecalciferol, Minoxidil, Mirtazapine, Pantoprazole, Torasemide, Valsartan |
F34: Persistent mood [affective] disorders | ||||
F40: Phobic anxiety disorders G47: Sleep disorders | ||||
I10: Essential (primary) hypertension | ||||
N18: Chronic kidney disease | ||||
T88: Other complications of surgical and medical care, not elsewhere classified | ||||
FP3 | E03: Hypothyroidism | J06: Acute upper respiratory infections of multiple and unspecified sites | Zolpidem/80 pellets (10 mg/day) | Beclomethasone, Bisoprolol, Cobalamin, Duloxetine, Hydrochlorothiazide, Lactulose, Levothyroxine, Metoclopramide, Omeprazole, Salbutamol, Tramadol, |
E53: Deficiency of other B group vitamins | ||||
I35: Nonrheumatic aortic valve disorders I50: Heart failure | ||||
K29: Gastritis and duodenitis | ||||
M48: Other spondylopathies | ||||
Q61: Cystic kidney disease | ||||
R15: Faecal incontinence | ||||
R52: Pain, not elsewhere classified | ||||
FP4 | D86: Sarcoidosis | none | Zolpidem/100 pellets (10 mg/day) | Hydrochlorothiazide, Naloxone, Nitrendipine, Pregabalin, Tilidine, Valsartan |
E78: Disorders of lipoprotein metabolism and other lipidaemias | ||||
G47: Sleep disorders | ||||
H53: Visual disturbances | ||||
I10: Essential (primary) hypertension | ||||
I83: Varicose veins of lower extremities | ||||
M25: Other joint disorders, not elsewhere classified | ||||
M81: Osteoporosis without pathological fracture | ||||
N17: Acute renal failure | ||||
R26: Abnormalities of gait and mobility | ||||
Z93: Artificial opening status | ||||
FP5 | C80: Malignant neoplasm, without specification of site | R07: Pain in throat and chest | Zopiclone/missing (7.5 mg/day) | Bisoprolol, Hydrochlorothiazide, Ramipril, Trimipramine, Pantoprazole, Acetylsali-cylic acid, Ibuprofen |
H53: Visual disturbances | ||||
I10: Essential (primary) hypertension | ||||
I27: Other pulmonary heart diseases | ||||
I34: Atrial fibrillation and flutter | ||||
K43: Ventral hernia | ||||
R26: Abnormalities of gait and mobility | ||||
Z93: Artificial opening status | ||||
Z96: Presence of other functional implants | ||||
FP6 | E11: Type 2 diabetes mellitus | none | Zopiclon/120 pellets (missing) | Allopurinol, Amlodipine, Enalapril, Moxonidine |
I10: Essential (primary) hypertension | ||||
I50: Heart failure | ||||
M10: Gout | ||||
N08: Glomerular disorders in diseases classified elsewhere | ||||
N18: Chronic kidney disease | ||||
FP7 | E78: Disorders of lipoprotein metabolism and other lipidaemias | M54: Dorsalgia | Zopiclon/180 pellets (7.5 mg/day) | Allopurinol, Felodipine, Metoprolol, Olmesartan |
E79: Disorders of purine and pyrimidine metabolism | ||||
F51: Nonorganic sleep disorders I10: Essential (primary) hypertension | ||||
J44: Other chronic obstructive pulmonary disease |
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to explain their case-related decisions of the prescription of a PIM substance and influencing factors on it for the respective case vignette,
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to discuss reasons for prescription of PIM in contrast to known recommendations generally and
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to assess their knowledge, usage and acceptance of recommendations in daily practice (German PRISCUS-list).
Analysis
Results
Description of participating family physicians
Description of the sample: elderly patients
Chronic diagnosis | Absolute frequency | Relative frequency | Acute diagnosis | Absolute frequency | Relative frequency | ||
---|---|---|---|---|---|---|---|
I10 | Essential hypertension | 1076 | 84.0 | M54 | Dorsalgia | 38 | 5.4 |
E78 | Dyslipidemia | 632 | 49.3 | J06 | Acute upper respiratory infections | 35 | 5.0 |
E11 | Diabetes mellitus type 2 | 503 | 39.3 | N39 | Other disorders of urinary system | 23 | 3.3 |
I25 | Chronic ischaemic heart disease | 422 | 32.9 | R10 | Abdominal and pelvic pain | 22 | 3.1 |
M81 | Osteoporosis | 209 | 16.3 | R21 | Rash and other nonspecific skin eruption | 22 | 3.1 |
I83 | Varicosis of lower extremities | 193 | 15.1 | M53 | Other dorsopathies, not elsewhere classified | 21 | 3.0 |
I48 | Atrial flutter/fibrillation | 193 | 15.1 | F43 | Reaction to severe stress | 21 | 3.0 |
Z92 | long-term (current) use of anticoagulants | 183 | 14.3 | M25 | Other joint disorders, not elsewhere classified | 19 | 2.7 |
M17 | Gonarthrosis | 182 | 14.2 | G47 | Sleep disorders | 15 | 2.1 |
E79 | Disorders of purine and pyrimidine metabolism | 163 | 12.7 | F32 | Depressive episode | 14 | 2.0 |
Prescription of potentially inappropriate medication
Range | Agent | Total frequency | Total frequency (%) |
---|---|---|---|
1 | Zopiclone (>3.75 mg/d) | 53 | 4.3 |
2 | Zolpidem (>5 mg/d) | 29 | 2.3 |
3 | Diazepam | 24 | 1.9 |
Doxazosin | 24 | 1.9 | |
4 | Nifedipine | 23 | 1.9 |
5 | Etoricoxib | 18 | 1.5 |
6 | Medazepam | 17 | 1.4 |
7 | Lorazepam (>2 mg/d) | 16 | 1.3 |
8 | Brotizolam (>0.125 mg/d) | 15 | 1.2 |
9 | Amitryptiline | 13 | 1.1 |
Nitrazepam | 13 | 1.1 | |
10 | Indomethacin | 10 | 1.0 |
Influencing factors on prescription of PIM
Knowledge and application of PRISCUS-list
FPs’ arguments pro PRISCUS | FPs’ arguments contra PRISCUS |
---|---|
•Includes no-go-medication you have to remember every time | Not practicable in FPs’ daily practice since |
•Good for orientation | •does often not fit individual patients’ needs |
•Possible argument if FP wants to refuse a medication | •within its complex context of multimorbidity |
•does not recommend practicable and pharmacologically based alternatives | |
•does not fit experience-based practice | |
•does not fit patient demands for a certain PIM based on individual positive experiences | |
•limited time in consultations a) to check additional recommendation lists and b) to convince patients for new medication | |
•chronological age does not match biological age: lot of patients > 65 years have a younger biological age | |
•mistrust in PRISCUS based on missing evidence for medication of multimorbid elderly patients |
Yes, both me and my colleagues have a short version pinned up at our desks. But if you look at the list you get lost even before the consultation with the patient starts. It is not useful at all, unless you want to refuse a prescription of a medication, of course. [FP6]
Reported causes for prescription of potentially inappropriate medication
Regarding polypharmacy, there are no convincing recommendations as to what to prescribe as an alternative. Full stop. That is why I consult these patients (note: with PIM) closely. I will see them several times in the quarter at my practice to keep a close eye on them. [FP2]
(Note: As with PIM) you have similar issues with these huge amounts of pain pellets or patients receiving Falithrom (note: Phenprocoumon). Every time something can happen. But this is unavoidable, isn’t it? [FP5]
If you keep the wellbeing of the patient as the primary goal in mind, then a lot will be sorted based on this prioritization. Age seems to be a difficult criterion in general, so patients’ health status and perspectives should be more important. [FP2]
Regarding sedatives, benzodiazepine vs. z-drugs it is like being caught between a rock and a hard place. I am certain that it (note: PIM) is not recommended by PRISCUS but there are no alternatives. And the patient needs to get sleep and be pain-free from time to time. So we talk to the patient about the medication, how to limit it time-wise and how to monitor it closely. [FP1]
You can start making changes in medication, yes, but most of them are not successful. [FP1]
Well, you can speak like a priest in the church: if patients have a certain level of addiction it is really difficult. I could refuse them the medication, but then they will go to a different [physician], so this doesn’t make any sense. [FP7]
I had special cases of patients, when I said, okay, let’s keep them in “one hand” and see if we can somehow take responsibility for it. Yes, we try to care for them individually. Last time I had a patient, she picked up sleeping pills from her neurologist, from me and from another GP. And then at night she had a bad fall because she was just completely in the swash. Finally she was hospitalized, but how to manage her? I have no magic remedy for this problem. [FP4]