Outcome prioritisation tool for medication review in older patients with multimorbidity: a pilot study in general practice

Jojanneke JGT van Summeren; Jan Schuling; Flora M Haaijer-Ruskamp; Petra Denig

doi:10.3399/bjgp17X690485

Abstract

Background Several methods have been developed to conduct and support medication reviews in older persons with multimorbidity. Assessing the patient’s priorities for achieving specific health outcomes can guide the medication review process. Little is known about the impact of conducting such assessments.

Aim This pilot study aimed to determine proposed and observed medication changes when using an outcome prioritisation tool (OPT) during a medication review in general practice.

Design and setting Participants were older patients with multimorbidity (aged ≥69 years) with polypharmacy (five or more chronic medications) from the practices of 14 GPs.

Method Patients were asked to prioritise four universal health outcomes — remaining alive, maintaining independence, reducing pain, and reducing other symptoms — using an OPT. GPs used this prioritisation to review the medication and to propose and discuss medication changes with the patient. The outcomes included the proposed medication change as documented by the GP, and the observed medication change in the electronic health record at follow-up. Descriptive analyses were conducted to determine medication changes according to the prioritised health outcomes.

Results A total of 59 patients using 486 medications prioritised the four health outcomes. GPs proposed 34 changes of medication, mainly stopping, for 20 patients. At follow-up, 14 medication changes were observed for 10 patients. The stopping of medication (mostly preventive) was particularly observed in patients who prioritised ‘reducing other symptoms’ as most important.

Conclusion Using an OPT leads mainly to the stopping of medication. Medication changes appeared to be easiest for patients who prioritised ‘reducing other symptoms’ as most important.

INTRODUCTION

With the ageing of the population, the number of people with multiple chronic conditions, or multimorbidity, is increasing.¹^–³ Such multimorbidity leads to polypharmacy, especially among the eldest.² The situation may be exacerbated by the application of clinical guidelines, which are usually developed for the management of single diseases.¹^,⁴ Treatment according to the respective guidelines for patients with multimorbidity results in polypharmacy, because no attention is given to prioritising recommendations for individuals in whom the treatment burden weighs heavily.¹

Healthcare providers, such as prescribers and pharmacists, have taken actions to reduce inappropriate polypharmacy.⁵ Methods developed to reduce inappropriate prescribing in older patients with multimorbidity include the STOPP/START criteria and the Beers criteria.⁵ Although this may reduce prescribing of medication that is considered inappropriate from a clinical point of view, it is not clear whether the individual patient’s needs and preferences are sufficiently taken into account.⁶^,⁷ GPs have reported being hesitant to use patient priorities instead of evidence-based guidelines to deprescribe medication, and would welcome decision support when dealing with multiple guidelines for one patient.⁸

Fried et al developed a simple tool — the outcome prioritisation tool (OPT) — to elicit preferences of older persons based on prioritisation of four universal health outcomes: remaining alive, maintaining independence, reducing pain, and reducing other symptoms. Prioritisation of these health outcomes differed between individuals.⁹^–¹¹ Individual preferences can be used as a guide to treatment decisions in patients with multimorbidity with polypharmacy for whom disease-specific guidelines are no longer sufficient.¹² The application of a tool to assess patient treatment priorities and preferences during medication review in patients with multimorbidity in practice has not yet been tested.⁷

The aim of this study was to determine proposed and observed medication changes when using an OPT during a medication review in older patients with multimorbidity with polypharmacy. A secondary aim was to explore the relationship between the prioritised health outcome of patients and the type of medication change, such as a stop, a dose adjustment, or a switch.

METHOD

Study design and participants

In this pilot study, each GP used the OPT to conduct a medication review for between two and seven patients. GPs, who were mostly also GP trainers, working in the northern Netherlands were recruited.

Patient inclusion criteria were ≥69 years of age, two or more chronic diseases (one of which had to be cardiovascular disease), and daily use of five or more medications. Patient exclusion criteria were cognitive impairment, a life expectancy of <6 months, and insufficient understanding of the Dutch language, all based on the judgement of the GP. Patients provided written informed consent.

How this fits in

Several methods have been developed to conduct and support medication review in older persons with multimorbidity. However, this is the first study in which health outcome prioritisation is used during medication review of older multimorbid patients by GPs. In contrast to medication reviews conducted by community pharmacists, this study showed relatively more proposed medication stops and dose decreases, and fewer switches and additions of new medications. Stopping medication appeared to be easier for patients who prioritised ‘reducing other symptoms’ as the most important health outcome, compared with patients who prioritised ‘remaining alive’ or ‘maintaining independence’ as the most important. Further research is needed to determine whether patients benefit from a medication review with an outcome prioritisation tool.

Medication review using the OPT

The intervention took place from October 2013 to April 2014. GPs were instructed about the use of the OPT to elicit patients’ prioritisation (for example, www.optool.nl). The OPT is a conversation support tool with four movable buttons sliding on a scale of 0 to 100, each representing one of the four health outcomes.⁹ When using the OPT in a consultation or home visit, the GP first explained the four health outcomes. Patients then had to score the four health outcomes on their importance, prioritising between the outcomes. Next, the GP reviewed the medication in view of the patient’s prioritisation. No specific guidance was provided, leaving the GPs free to make their own decisions to propose medication changes. For example, if a patient prioritised reducing pain as most important and remaining alive as less important, the GP might propose to maintain medication for symptom relief but stop preventive medication. When discussing this with the patient, attention was to be paid to the possible consequences of medication changes on other health outcomes, such as maintaining independence. The GP could decide to plan a second consultation, for example, to allow consultation with a pharmacist or to give the patient more time to reflect on the OPT score. If desired, a relative or friend could accompany and support the patient during the consultation.

Outcome measure

The outcome measure consisted of the proposed medication change as documented by the GP, and the observed medication change in the electronic health record (EHR) at follow-up.

Data collection and analysis

All medication used by the patient before the intervention, including dosage and regimen, was recorded by the GP on a structured questionnaire. Next, the patient’s scores on the four health outcomes (OPT scores) were recorded by the GP. Having compared the patient’s OPT score to the patient’s medication list, the GP recorded the proposed medication changes for adapting the treatment to the patient’s prioritised health outcome on the questionnaire. The observed medication changes at follow-up were retrieved from the EHR of the patient at least 2 months and not later than 8 months after medication review. In the Netherlands, every GP uses an EHR software package approved by the Dutch College of General Practitioners. In this system, the patient’s prescriptions and prescription changes are recorded by the GP. New and changed prescriptions are directly sent digitally to the patient’s pharmacist. In this study all chronic prescriptions (duration >3 months) were included, whereas non-prescription medication, such as paracetamol, eye/ear drops, and dermatologicals, were excluded. The type of medication change was categorised as being a start, a stop, a dose increase, a dose decrease, or a switch. The patient’s sex and age were retrieved from the EHR, and education and living conditions were collected using a questionnaire.

Descriptive statistics were used to describe the population, as well as the proposed and observed medication changes. Medications were classified using the therapeutic groups of the anatomical therapeutic subgroup (ATC) system (http://www.whocc.no/atc/structure_and_principles).

RESULTS

Characteristics of GPs and patients

In total, 17 GPs and 63 patients were recruited. Three GPs dropped out because of time constraints. The median work experience of the 14 participating GPs was 28 years (interquartile range [IQR] 12.5–33.0 years); six were females; nine worked in a city; five were dispensing GPs; three worked in a single practice, two worked in duo practices, and nine worked in seven group practices. The questionnaire was lost in the mail for four patients (resulting in all questionnaires lost for one GP), and two additional patients were lost to follow-up in the EHR. This resulted in 59 patients for the analysis of proposed medication changes, and 57 patients for the analysis of observed medication changes. The patients’ median age was 83 years (IQR 81–86 years), 30 were female, and patients’ used on average 9.4 ± 3.1 medications. Living conditions were unknown for two of the patients, six patients lived in a home for older persons, and 52 patients lived independently.

Proposed and observed medication changes

Before the medication review, the 59 patients used a total of 486 medications (Table 1). Looking at the most frequently prescribed therapeutic subgroups, 57 antithrombotic agents (B01) were prescribed for 49 patients, 42 diuretics (C03) for 33 patients, 41 agents acting on the renin–angiotensin system (C09) for 40 patients, and 41 antacids (A02) for 40 patients.

View this table:

Table 1.

Number of medications per therapeutic subgroup prescribed before the consultation, and number of proposed and observed medication changes in 59 patients

In total, 34 changes in medication (7% of 486) were proposed for 20 patients (34% of 59) (Table 1). The most common therapeutic subgroups with relatively the most proposed medication changes were lipid-modifying drugs (C10), analgesics (N02), urologicals (G04), laxatives (A06), and mineral supplements (A12). In three of the 15 most frequently prescribed therapeutic subgroups no changes were proposed — agents acting on the renin–angiotensin system (C09), cardiac drugs (C01), and calcium channel blockers (C08). The types of proposed changes were mainly stopping the medication (22 times) or decreasing the dosage (six times). No new medication was started, but three switches to another medication from the same therapeutic subgroup were proposed. For two medications, an increase in dosage was proposed.

Following up on the 34 proposed medication changes in 20 patients, the authors observed 14 changes in the EHR of 10 patients (Table 1). This included 13 medications being stopped and one medication with a decrease in dosage (Table 2). In four of these cases, medication was stopped after a proposed decrease or switch. The observed changes occurred in a wide range of therapeutic subgroups, but no changes were observed for the proposed changes of drugs used in benign prostatic hypertrophy (G04, urologicals), hypnotics/sedatives (N05, psycholeptics), and bronchodilators (R03, respiratory drugs) (Table 1). Proposed medication changes that were not observed in the EHR occurred for all types of changes.

View this table:

Table 2.

Proposed and observed medication changes related to the patient’s prioritised health outcome

Prioritised health outcome and medication changes

Table 2 shows the prioritised health outcome of the patients with the proposed and observed medication changes. For the six patients who prioritised remaining alive as the most important health outcome, 11 medication changes were proposed, mainly stopping (5 times) or dose decrease (4 times). Proposed changes involved mainly drugs for the alimentary tract (A02, A03, A06) and respiratory system (R03, R06). For three patients a medication stop was observed at follow-up, all for the alimentary tract (Table 2).

For the seven patients who gave maintaining independence the highest priority, 10 medication changes were proposed, mainly stopping (7 times) or lowering in dosage (2 times). This partly involved drugs for the cardiovascular system (C03, C07, C10), but also drugs from a range of other therapeutic subgroups (Table 2). For three patients a medication stop was observed at follow-up.

For the patient who prioritised reducing pain as most important, one medication stop was proposed but not observed.

For the five patients who gave reducing other symptoms the highest priority, 11 medication changes were proposed, mainly stopping (8 times) of preventive medication, including lipid-modifying agents and drugs for osteoporosis (Table 2). For three patients, seven medications were stopped and one was decreased in dose at follow-up.

DISCUSSION

Summary

GPs proposed 34 medication changes for 20 patients when using a health outcome prioritisation tool during medication review of 59 patients. At follow-up, 14 medication changes for 10 patients were observed, four of which were adaptations of the originally proposed changes. The proposed and observed changes involved mainly stopping of medication. More changes were observed for patients who prioritise ‘reducing other symptoms’ than for patients whose highest priority was ‘remaining alive’ or ‘maintaining independence’.

Overall, the GPs proposed medication changes that seemed partly in line with the patient’s prioritised health outcome. In patients with ‘remaining alive’ as the highest prioritised health outcome, GPs proposed to stop or decrease especially symptom-relieving medication, such as omeprazole, tamsulosin, or macrogol. Few of these proposed changes, however, were observed at follow-up, but the proposed dose decreases for macrogol resulted in medication stops. This suggests that a stepwise reduction of medication was followed and may be a good approach to stop symptom-relieving medication. In patients who prioritised ‘maintaining independence’ as most important, GPs proposed to stop various preventive medication, such as statins and antihypertensives. Few of these proposed changes were observed at follow-up, and one may question whether stopping preventive medication is in line with the patient’s prioritisation. GPs may have had difficulty in deciding which medication might be stopped when patients prioritise ‘maintaining independence’ as most important. In contrast, in patients who judged ‘reducing other symptoms’ as most important, such preventive medication was often stopped as proposed.

Strengths and limitations

The GPs included in this study were mostly GP trainers and may thus be more experienced in consultations with older patients with complex care plans than the average GP. Also, because GPs were free to choose which patients they would invite for the OPT consultation, these patients may have been more open to participate in a medication review than the average older patient with multimorbidity. Data on the medication used before consultation and on proposed medication changes were reported by the GPs in a questionnaire, whereas data on medications at follow-up were extracted from the EHR. Although this ensured objective assessment of the prescribed medication changes at follow-up, this does not guarantee that the patient has used the medications. In the case of chronic medication, it indicates that the patient has requested a repeat prescription. However, the follow-up period varied and may have been too short for some patients to detect medication changes in repeat medications in the EHR. In other patients, medication changes may not have been detected because they were amended in the meantime.

Comparison with existing literature

The method provided by Fried, as applied in the OPT, is the only approach developed to identify priorities of patients with multimorbidity.⁷ Previously, it was found that consultations in which an OPT was used led to a better understanding of the medication by patients, a deepening of the patient–doctor relationship, and a better insight of the GP in the patient’s views on illness and treatment.⁹ Therefore, health outcome prioritisation could support patients and GPs to change medication.¹³^,¹⁴ Knowing more about patient priorities may especially support decision-making when guideline recommendations are conflicting. For both doctors and patients, a shared determination of health priorities is not common practice.¹⁵

This is the first study in which health outcome prioritisation was used by GPs during medication review. In total, 34 medication changes were proposed for the 59 patients (0.6 per patient). In comparison, a combined clinical medication review with a web-based pharmaceutical care plan conducted in the Netherlands resulted in 0.9 proposed care interventions per patient, half of which were not medication changes but involved additional monitoring and compliance management.¹⁶ In another study looking at medication reviews conducted by community pharmacists in the Netherlands, 1.0 proposed interventions to stop or adjust the dose of medication were observed per patient.¹⁷ These rates, however, will depend on the number of patients included, the severity of morbidity, and the appropriateness of their current medication. Of more interest is the finding that using a tool that supports patient involvement in medication review leads mainly to proposed medication stops and dose decreases, but not the start of new medication. This is in contrast to medication reviews conducted by community pharmacists, where relatively fewer stops and more switches were proposed, as well as additions of new medication.¹⁷

At follow-up, 42% of the proposed changes led to observed changes. This is comparable to the medication reviews conducted by Dutch community pharmacists, which showed 46% of implemented interventions.¹⁷ It thus seems that using a tool supporting patient involvement does not increase the implementation rate of proposed medication changes. On the other hand, the type of proposed changes influences the success rate for implementation. High percentages are found for stopping potentially harmful medication.¹⁶ In this study, however, many proposals were made to stop preventive and symptom-relieving medication that was not necessarily harmful. The study showed that such medication was indeed stopped in around half of the proposed cases. The authors can only speculate as to why medication appeared not to be stopped in the other cases. Uncertainty about the benefits and risks of discontinuing medication in older patients with multimorbidity might play a role.¹³^,¹⁸^,¹⁹ Patients may become afraid or reluctant to stop when they believe in some benefit of the medication.¹³^,¹⁴^,²⁰ It is currently not clear whether such beliefs are consistent with health outcome prioritisation. Another reason why proposed medication changes did not result in observed medication changes could lie in the process of cessation. The GP and patient may have agreed to stop the medication, including a reconsideration of this decision after a specific period.¹⁴^,²⁰ This may have led to restarting the medication. Also, external influences, such as from a specialist or family member, may lead to a reconsideration of the proposed medication change.²⁰

Implications for research and practice

Using an OPT to support GPs in proposing medication changes in line with the patient’s priorities resulted mostly in medication stops and dose decreases. Medication changes may be easiest for patients who prioritise reducing other symptoms as most important. Future research is needed to determine whether patients benefit from a medication review with an OPT.

Acknowledgments

The authors wish to thank the GPs and patients for their participation, and Lisa Louer for data entry.

Notes

Funding

Stoffels-Hornstra Foundation, Coevorden, the Netherlands.

Ethical approval

The medical ethical committee of the University Medical Center Groningen gave a waiver for ethical approval.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Received November 6, 2016.
Revision requested January 15, 2017.
Accepted January 24, 2017.

This is an OpenAccess article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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[1] 1.↵
Barnett K,
Mercer SW,
Norbury M,
et al.
(2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380(9836):37–43.
OpenUrl CrossRef PubMed

[2] Barnett K,

[3] Mercer SW,

[4] Norbury M,

[5] et al.

[6] 2.↵
van Oostrom SH,
Gijsen R,
Stirbu I,
et al.
(2016) Time trends in prevalence of chronic diseases and multimorbidity not only due to aging: data from general practices and health surveys. PLoS One 11(8):e0160264.
OpenUrl CrossRef PubMed

[7] van Oostrom SH,

[8] Gijsen R,

[9] Stirbu I,

[10] et al.

[11] 3.↵
van Oostrom SH,
Picavet HS,
de Bruin SR,
et al.
(2014) Multimorbidity of chronic diseases and health care utilization in general practice. BMC Fam Pract 15:61.
OpenUrl CrossRef PubMed

[12] van Oostrom SH,

[13] Picavet HS,

[14] de Bruin SR,

[15] et al.

[16] 4.↵
Hughes LD,
McMurdo ME,
Guthrie B
(2013) Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing 42(1):62–69.
OpenUrl CrossRef PubMed

[17] Hughes LD,

[18] McMurdo ME,

[19] Guthrie B

[20] 5.↵
Lavan AH,
Gallagher PF,
O’Mahony D
(2016) Methods to reduce prescribing errors in elderly patients with multimorbidity. Clin Interv Aging 11:857–866.
OpenUrl

[21] Lavan AH,

[22] Gallagher PF,

[23] O’Mahony D

[24] 6.↵
Voigt K,
Gottschall M,
Koberlein-Neu J,
et al.
(2016) Why do family doctors prescribe potentially inappropriate medication to elderly patients? BMC Fam Pract 17:93.
OpenUrl

[25] Voigt K,

[26] Gottschall M,

[27] Koberlein-Neu J,

[28] et al.

[29] 7.↵
Mangin D,
Stephen G,
Bismah V,
Risdon C
(2016) Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity. BMJ Open 6(6):e010903.
OpenUrl Abstract/FREE Full Text

[30] Mangin D,

[31] Stephen G,

[32] Bismah V,

[33] Risdon C

[34] 8.↵
Schuling J,
Gebben H,
Veehof LJ,
Haaijer-Ruskamp FM
(2012) Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract 13:56.
OpenUrl CrossRef PubMed

[35] Schuling J,

[36] Gebben H,

[37] Veehof LJ,

[38] Haaijer-Ruskamp FM

[39] 9.↵
van Summeren JJGT,
Haaijer-Ruskamp FM,
Schuling J
(2016) Eliciting preferences of multimorbid elderly adults in family practice using an outcome prioritization tool. J Am Geriatr Soc doi:10.1111/jgs.14415.
OpenUrl CrossRef

[40] van Summeren JJGT,

[41] Haaijer-Ruskamp FM,

[42] Schuling J

[43] 10.
Fried TR,
Tinetti ME,
Iannone L,
et al.
(2011) Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med 171(20):1854–1856.
OpenUrl CrossRef PubMed

[44] Fried TR,

[45] Tinetti ME,

[46] Iannone L,

[47] et al.

[48] 11.↵
Fried TR,
Tinetti M,
Agostini J,
et al.
(2011) Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns 83(2):278–282.
OpenUrl CrossRef PubMed

[49] Fried TR,

[50] Tinetti M,

[51] Agostini J,

[52] et al.

[53] 12.↵
American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity
(2012) Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc 60(10):1957–1968.
OpenUrl CrossRef PubMed

[54] American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity

[55] 13.↵
Anderson K,
Stowasser D,
Freeman C,
Scott I
(2014) Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open 4(12):e006544.
OpenUrl Abstract/FREE Full Text

[56] Anderson K,

[57] Stowasser D,

[58] Freeman C,

[59] Scott I

[60] 14.↵
Reeve E,
To J,
Hendrix I,
et al.
(2013) Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 30(10):793–807.
OpenUrl CrossRef PubMed

[61] Reeve E,

[62] To J,

[63] Hendrix I,

[64] et al.

[65] 15.↵
Wrede J,
Voigt I,
Bleidorn J,
et al.
(2013) Complex health care decisions with older patients in general practice: patient-centeredness and prioritization in consultations following a geriatric assessment. Patient Educ Couns 90(1):54–60.
OpenUrl CrossRef PubMed

[66] Wrede J,

[67] Voigt I,

[68] Bleidorn J,

[69] et al.

[70] 16.↵
Geurts MM,
Stewart RE,
Brouwers JR,
et al.
(2016) Implications of a clinical medication review and a pharmaceutical care plan of polypharmacy patients with a cardiovascular disorder. Int J Clin Pharm 38(4):808–815.
OpenUrl

[71] Geurts MM,

[72] Stewart RE,

[73] Brouwers JR,

[74] et al.

[75] 17.↵
Chau SH,
Jansen AP,
van de Ven PM,
et al.
(2016) Clinical medication reviews in elderly patients with polypharmacy: a cross-sectional study on drug-related problems in the Netherlands. Int J Clin Pharm 38(1):46–53.
OpenUrl

[76] Chau SH,

[77] Jansen AP,

[78] van de Ven PM,

[79] et al.

[80] 18.↵
Bokhof B,
Junius-Walker U
(2016) Reducing polypharmacy from the perspectives of general practitioners and older patients: a synthesis of qualitative studies. Drugs Aging 33(4):249–266.
OpenUrl

[81] Bokhof B,

[82] Junius-Walker U

[83] 19.↵
Ailabouni NJ,
Nishtala PS,
Mangin D,
Tordoff JM
(2016) General practitioners’ insight into deprescribing for the multimorbid older individual: a qualitative study. Int J Clin Pract 70(3):261–276.
OpenUrl PubMed

[84] Ailabouni NJ,

[85] Nishtala PS,

[86] Mangin D,

[87] Tordoff JM

[88] 20.↵
Luymes CH,
van der Kleij RM,
Poortvliet RK,
et al.
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[89] Luymes CH,

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[92] et al.

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Outcome prioritisation tool for medication review in older patients with multimorbidity: a pilot study in general practice

Abstract

INTRODUCTION

METHOD

Study design and participants

How this fits in

Medication review using the OPT

Outcome measure

Data collection and analysis

RESULTS

Characteristics of GPs and patients

Proposed and observed medication changes

Prioritised health outcome and medication changes

DISCUSSION

Summary

Strengths and limitations

Comparison with existing literature

Implications for research and practice

Acknowledgments

Notes

Funding

Ethical approval

Provenance

Competing interests

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