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      Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA

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          Abstract

          Objectives

          To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life.

          Design

          Two-arm cluster-randomised controlled trial.

          Setting

          55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany.

          Participants

          604 patients 65 to 84 years of age with at least three chronic conditions.

          Interventions

          Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a ‘brown bag’ review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual.

          Primary outcome measures

          We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group’s health-related quality of life would not be statistically significantly inferior to the control group.

          Results

          The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI −0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; −0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (−3.07; −5.25 to −0.89; P=0.006).

          Conclusions

          Intensifying the doctor–patient dialogue and discussing the patient’s agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life.

          Trial registration number

          ISRCTN46272088; Pre-results.

          Related collections

          Most cited references44

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          Polypharmacy in elderly patients.

          Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.
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            Appropriate prescribing in elderly people: how well can it be measured and optimised?

            Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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              Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

              Objective To synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults. Design A qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings. Setting All healthcare settings. Participants Medical and non-medical prescribers of medicines to adults. Outcomes Prescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults. Results 21 studies were included; most explored primary care physicians’ perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported. Conclusions A multitude of highly interdependent factors shape prescribers’ behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2018
                23 January 2018
                : 8
                : 1
                : e017653
                Affiliations
                [1 ] departmentDepartment of Primary Medical Care , University Medical Center Hamburg-Eppendorf , Hamburg, Germany
                [2 ] departmentMedical Faculty, Institute of General Practice , University of Kiel , Kiel, Germany
                [3 ] departmentFaculty of Medicine, Institute of General Practice , Heinrich-Heine-University Düsseldorf , Düsseldorf, Germany
                [4 ] departmentInstitute of General Practice , Rostock University Medical Center , Rostock, Germany
                [5 ] departmentInstitute for General Practice , Hannover Medical School , Hannover, Germany
                Author notes
                [Correspondence to ] Dr Ingmar Schäfer; in.schaefer@ 123456uke.de
                Article
                bmjopen-2017-017653
                10.1136/bmjopen-2017-017653
                5786138
                29362248
                f7ba3685-26a3-477a-9ad7-66348d926eaa
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 05 May 2017
                : 03 November 2017
                : 19 December 2017
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100002347, Bundesministerium für Bildung und Forschung;
                Categories
                General practice / Family practice
                Research
                1506
                1696
                Custom metadata
                unlocked

                Medicine
                multimorbidity,polypharmacy,narrative based medicine,chronic care model
                Medicine
                multimorbidity, polypharmacy, narrative based medicine, chronic care model

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