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Rankin A, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018 Sep 3;9:CD008165. doi: 10.1002/14651858.CD008165.pub4. (Systematic review)
Abstract

BACKGROUND: Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES: To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA: We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS: We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS: It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Ratings
Original Articles included in this ReviewReviews that include this article
Discipline Area Score
Nurse 6 / 7
Physician 5 / 7
Comments from MORE raters

Nurse rater

Excellent. This updated, well-conducted review confirms previous findings: there is no well-known strategy to reduce medication-related problems. It was disappointing that our trial, demonstrating a successful intervention, was not mentioned, at least in the narrative. Feedback on this would be helpful. Jordan S, Gabe-Walters ME, Watkins A, Humphreys I, Newson L, Snelgrove S, Dennis M. (2015) Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial. PLoS ONE 10(10): e0140203. doi:10.1371/journal.pone.0140203 http://dx.plos.org/10.1371/journal.pone.0140203

Nurse rater

The results were not significant and may provide some benefit to healthcare. It does reiterate the point that medications for the elderly should be reviewed at each visit or hospitalization for polypharmacy.

Nurse rater

While I found the outcomes of this research disappointing (because I'd like to think that there are interventions that we know will make a difference to this problem), I also appreciated and understood the reasons why this research provided the result it did. The authors documented that very carefully in the section on 'Overall completeness and applicability of evidence'. I look forward to seeing the outcomes of future documented population based research informed by the guidelines mentioned in this study and the implementation of COS (core outcome sets).

Nurse rater

Negative outcomes from polypharmacy in the elderly is increasing as people live longer and develop more illnesses. It is very disappointing that there is a lack of evidence based practice guidelines as shown in this review.

Nurse rater

This is an interesting and timely review of 32 published interventional studies (up to February 2018) aimed at improving the appropriate use of polypharmacy for 28, 672 older people in 12 countries. The results indicated that while healthcare professionals (physicians, pharmacists, and geriatricians) implemented and studied interventions to improve appropriate polypharmacy in older people, it was uncertain if pharmaceutical care improved medication appropriateness, or reduced the number or proportion of people with potentially inappropriate medications. Studies reviewed suggested that pharmaceutical care for older people may decrease potential prescribing omissions.

Physician rater

This is a common issue in primary care. Unfortunately, there is no clear proof of benefit, aside from a possible increase in adding appropriate drugs. Given the 32 attempts/studies to answer this question in this review have failed to give a clear answer, I suspect a clear answer is not likely here. Perhaps we are looking at this wrong? Maybe we need a cultural shift approach away from treating symptoms with medications (beyond a few clear indications)?
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