Improving individualized prescription in patients with multimorbidity through medication review

Abstract

Background Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index. Methods This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals. Results Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001). Conclusions An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Effectiveness of a Person-Centered Prescription Model in Hospitalized Older People at the End of Life According to Their Disease Trajectories and Frailty Index

“…The degree of frailty was not a differential element in the intensity of the model’s effect. Nevertheless, notably, a recently published before–after study reported that the application of a PCP model was valid for reducing polypharmacy, MRCI, and DBI in patients with a moderate or advanced degree of frailty and multimorbidity but who were not necessarily at EOL [ 32 ]. However, in this last case, the results could be because people with a more advanced frailty index were entering a final stage of life, whereas the PCP model has greater efficacy when optimizing pharmacotherapy.…”

Patient and general practitioner experiences of implementing a medication review intervention in older people with multimorbidity: Process evaluation of the SPPiRE trial

“…The most common medication change related to priority assessment in SPPiRE was a dose change (compared with stopping a medicine for the PIP assessment and brown bag processes), indicating that optimizing medications in polypharmacy is not just about changes in the number of medicines. A recently completed uncontrolled before‐after study of a similar patient‐centred medication review resulted in reduced medication regime complexity and enhanced adherence 38,39 . Future research in this area should focus on the development and evaluation of tools to assist both GPs and older people with multimorbidity in the identification of treatment priorities.…”

“…A recently completed uncontrolled before‐after study of a similar patient‐centred medication review resulted in reduced medication regime complexity and enhanced adherence. 38 , 39 Future research in this area should focus on the development and evaluation of tools to assist both GPs and older people with multimorbidity in the identification of treatment priorities.…”

Application of a person-centered prescription model improves pharmacotherapeutic indicators and reduces costs associated with pharmacological treatment in hospitalized older patients at the end of life

“…The application of PCP models is clearly established ( 37 – 41 ) in the scientific literature and can identify inappropriate prescriptions, optimize polypharmacy and improve medication adherence in different profiles of older patients. Additionally, the use of tools with explicit criteria [OncPal ( 42 ) and STOPPFrail ( 28 )] to determine inappropriate drugs at the EOL is valid for deprescription and produces beneficial effects ( 43 ).…”