Reference
Rieckert A, Reeves D, Altiner A et al. Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial. BMJ 2020;369:m1822 (Published 18 June 2020)
At a glance
Polypharmacy is common in elderly people (those aged 65 or over) and is generally the result of different indications from a number of specialists.
The situation is not ideal, especially if the patient does not have a single reference doctor who manages it: some drugs can interact with other drugs or diseases and in any case it increases the risk of a poor compliance to the prescribed treatments. So it happens that the negative effects of poly-pharmacy outweigh the benefits introduced by every single therapy.
The question is well known and its action goes under the word “deprescibing: when in a patient the negative effects of polypharmacy outweigh the positive ones, all the drugs he is taking are reviewed to find the less indicated ones that can be discontinued because they are inappropriate with respect to treatment objectives ot the patient’s state of health, preferences and life expectancy. Responsible for the deprescription is generally the general practitioner: to help him review all the drugs a decision support software has been developed and its usefulness has been evaluated in this study.
What is already known
Polypharmacy is common in elderly people (those aged 65 or over) and is generally the result of different indications from a number of specialists.
The situation is not ideal, especially if the patient does not have a single reference doctor who manages it: some drugs can interact with other drugs or diseases and in any case it increases the risk of a poor compliance to the prescribed treatments. So it happens that the negative effects of poly-pharmacy outweigh the benefits introduced by every single therapy.
The question is well known and its action goes under the word “deprescibing: when in a patient the negative effects of polypharmacy outweigh the positive ones, all the drugs he is taking are reviewed to find the less indicated ones that can be discontinued because they are inappropriate with respect to treatment objectives ot the patient’s state of health, preferences and life expectancy. Responsible for the deprescription is generally the general practitioner: to help him review all the drugs a decision support software has been developed and its usefulness has been evaluated in this study.
Design and Method
It is a randomized, controlled pragmatic (, i.e. down-to-earth ) trial, involving 359 general practitioners from 6 cities: Bolzano (Italy), Rostock and Witten (Germany), Salzburg (Austria) and Manchester (Great Britain). A total of 3,900 patients over 75 years of age were enrolled, who had been prescribed regular intake of at least 8 drugs.
Randomisation took place on doctors, so one half were asked to use electronic decision support that contains an Evidence-based review of all drugs, called PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support), while the other was asked to carry out its activity without electronic decision support.
The data collection lasted two years.
The primary end-point chosen for the study is an indicator of the number of deaths and unscheduled hospitalisations over the next 24 months; the number of drugs removed (“deprescribed”) and any health effects were also recorded.
Main Results
Between the two groups there were no significant differences in the two values that make up the primary end point, while the deprescription was greater in the group of practitioners who used electronic decision support, without adversely affecting the health of their patients.
What the Prospects
Among the strengths of the study is the duration of the observation, longer than that of other similar studies (although probably not sufficient to show an advantage in terms of mortality reduction) and the fact that it was a trial conducted in outpatient settings. Therefore, the indication that comes out on the deprescription itself and on the possibility of using a software to facilitate its application, is encouraging and easily exportable.
By Giulia Candiani