Interventions to improve the appropriate use of polypharmacy for older people

120 Pages·2017·1.54 MB·English

Interventions to improve the appropriate use of polypharmacy for older
people
Patterson, S. M., Cadogan, C. A., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Cochrane Effective
Practice and Organisation of Care Group (2014). Interventions to improve the appropriate use of polypharmacy
for older people. Cochrane database of systematic reviews (Online), 10, CD008165.
https://doi.org/10.1002/14651858.CD008165.pub3
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Cochrane database of systematic reviews (Online)
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Queen's University Belfast - Research Portal:
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Copyright © 2014 The Cochrane Collaboration.
This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2014, Issue 10:
Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of
polypharmacy for older people. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD008165.
http://dx.doi.org/10.1002/14651858.CD008165.pub3.
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Download date:31. Jan. 2023
Interventions to improve the appropriate use of
polypharmacy for older people (Review)
Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2014,Issue10
http://www.thecochranelibrary.com
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review)
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis1.1.Comparison1Postinterventionanalysis,Outcome1ChangeinMAIscore. . . . . . . . . . . 77
Analysis1.2.Comparison1Postinterventionanalysis,Outcome2ChangeinMAI(exclCrotty2004a). . . . . . 78
Analysis1.3.Comparison1Postinterventionanalysis,Outcome3ChangeinMAI(exclCrotty2004aandSpinewine
2007). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis1.4.Comparison1Postinterventionanalysis,Outcome4SummatedMAIscore. . . . . . . . . . . 79
Analysis1.5.Comparison1Postinterventionanalysis,Outcome5NumberofBeersdrugsperpatient. . . . . . 80
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 117
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) i
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Interventions to improve the appropriate use of
polypharmacy for older people
SusanMPatterson1,CathalACadogan2,NgaireKerse3,ChrisRCardwell4,MarieCBradley2,CristinRyan2,CarmelHughes2
1No affiliation, Belfast, UK. 2School of Pharmacy, Queen’s University Belfast, Belfast, UK. 3Department of General Practice and
PrimaryHealthCare,UniversityofAuckland,Auckland,NewZealand.4CentreforPublicHealth,Queen’sUniversityBelfast,Belfast,
UK
Contactaddress:CarmelHughes,SchoolofPharmacy,Queen’sUniversityBelfast,97LisburnRoad,Belfast,NorthernIreland,BT9
7BL,[email protected].
Editorialgroup:CochraneEffectivePracticeandOrganisationofCareGroup.
Publicationstatusanddate:Newsearchforstudiesandcontentupdated(nochangetoconclusions),publishedinIssue10,2014.
Reviewcontentassessedasup-to-date: 21August2014.
Citation: Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the
appropriateuseofpolypharmacyforolderpeople.CochraneDatabaseofSystematicReviews2014,Issue10.Art.No.:CD008165.DOI:
10.1002/14651858.CD008165.pub3.
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Inappropriatepolypharmacyisaparticularconcerninolderpeopleandisassociatedwithnegativehealthoutcomes.Choosingthebest
interventionstoimproveappropriatepolypharmacyisapriority,henceinterestinappropriatepolypharmacy,wheremanymedicines
maybeusedtoachievebetterclinicaloutcomesforpatients,isgrowing.
Objectives
This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of
polypharmacyandreducingmedication-relatedproblemsinolderpeople.
Searchmethods
In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and
handsearchingofreferencelistswasperformed.Searchtermsincluded’polypharmacy’,’medicationappropriateness’and’inappropriate
prescribing’.
Selectioncriteria
Arangeofstudydesignswereeligible.Eligiblestudiesdescribedinterventionsaffectingprescribingaimedatimprovingappropriate
polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria,
MedicationAppropriatenessIndex(MAI)).
Datacollectionandanalysis
Tworeviewauthorsindependentlyreviewedabstractsofeligiblestudies,extracteddataandassessedriskofbiasofincludedstudies.
Study-specificestimateswerepooled,andarandom-effectsmodelwasusedtoyieldsummaryestimatesofeffectand95%confidence
intervals(CIs).TheGRADE(GradesofRecommendation,Assessment,DevelopmentandEvaluation)approachwasusedtoassessthe
overallqualityofevidenceforeachpooledoutcome.
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) 1
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Twostudieswereaddedtothisreviewtobringthetotalnumberofincludedstudiesto12.Oneinterventionconsistedofcomputerised
decisionsupport;11complex,multi-facetedpharmaceuticalapproachestointerventionswereprovidedinavarietyofsettings.Inter-
ventionsweredeliveredbyhealthcareprofessionals,suchasprescribersandpharmacists.Appropriatenessofprescribingwasmeasured
using validated tools, including the MAI score post intervention (eight studies), Beerscriteria (four studies), STOPP criteria (two
studies)and STARTcriteria(one study). Interventions includedinthisreviewresultedinareduction ininappropriate medication
usage.BasedontheGRADEapproach,theoverallqualityofevidenceforallpooledoutcomesrangedfromverylowtolow.Agreater
reductioninMAIscoresbetweenbaselineandfollow-upwasseenintheinterventiongroupwhencomparedwiththecontrolgroup
(fourstudies;meandifference-6.78,95%CI-12.34to-1.22).Postintervention pooleddatashowedalowersummatedMAIscore
(fivestudies;meandifference-3.88,95%CI-5.40to-2.35)andfewerBeersdrugsperparticipant(twostudies;meandifference-0.1,
95%CI-0.28to0.09)intheinterventiongroupcomparedwiththecontrolgroup.Evidenceoftheeffectsofinterventionsonhospital
admissions(fivestudies)andofmedication-relatedproblems(sixstudies)wasconflicting.
Authors’conclusions
Itisunclearwhetherinterventionstoimproveappropriatepolypharmacy,suchaspharmaceuticalcare,resultedinclinicallysignificant
improvement;however,theyappearbeneficialintermsofreducinginappropriateprescribing.
PLAIN LANGUAGE SUMMARY
Areviewofthewaysthathealthcareprofessionalscanimprovetheuseofsuitablemedicinesforolderpeople
Takingmedicinetotreatsymptomsofchronicillnessandtopreventworseningofdiseaseiscommoninolderpeople.However,taking
toomanymedicinescancauseharm.Thisreviewexaminesstudiesinwhichhealthcareprofessionalshavetakenactiontomakesurethat
olderpeoplearereceivingthemosteffectiveandsafestmedicationfortheirillness.Actionstakenincludedprovidingpharmaceuticalcare,
aserviceprovidedbypharmaciststhatinvolvesidentifying,preventingandresolvingmedication-relatedproblems,aswellaspromoting
thecorrectuseofmedicationsandencouraginghealthpromotionandeducation.Anotherstrategywascomputeriseddecisionsupport,
whichinvolvesaprogrammeonthedoctor’scomputerthathelpshim/hertoselectappropriatetreatment.
Thisreviewprovideslimitedevidencethatinterventions,suchaspharmaceuticalcare,maybesuccessfulinensuringthatolderpeople
arereceivingtherightmedicines,butitisnotclearwhetherthisalwaysresultsinclinicalimprovement.
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) 2
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopInte SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
yright©rvention
2s
01to Patientorpopulation:olderpeoplereceivingpolypharmacy
4Tim Settings:community,nursinghome,hospital
hp
ero
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oe Intervention:pharmaceuticalcare
chth
re Comparison:usualcare
aneapp
Cr
ollaboraopriateu Outcomes EUfsfueactlceastriemate Pharmaceuticalcare N(sotu.doifepsa)rticipants Q(GuRaAlitDyEo)ftheevidence Comments
tiose
no
.f
Pp SummatedMAIscore Mean summated MAI Mean summated MAI 965 ⊕⊕(cid:13)(cid:13)
uo
blishlyph Summated MAI score scorerangedacrosscon- score in the intervention (5studies) lowa,b
edarm postintervention trolgroupsfrom groupswas
byJohnacyfor mFoollnotwhs-up: 0 to 12 6.5to19.3 3(5.8.48tloow2.e3r5lower)
Wo
ileylder ChangeinMAIscore Mean change in MAI Mean change in MAI 424 ⊕(cid:13)(cid:13)(cid:13) A sensitivity analysis showed that
&pe ChangeinMAIscorefrom scorerangedacrosscon- score in the intervention (4studies) verylowa,b,c,d themeanchangeinMAIscoreinthe
So
ons,Lple(R bFoaslloelwin-eupto:0fotlolow3-muponths t0r.o4l1grtoou2p.s86from g6r.7ou8plsowwears i(n3t.e7r3velnotwioenrtgoro0u.1p6whiagshe1r.)7e9 lower
td.evie (12.34to1.22lower)
w
)
Number of Beers drugs Mean number of Beers Mean number of Beers 586 ⊕(cid:13)(cid:13)(cid:13)
perparticipant drugs per participant drugs per participant in (2studies) verylowa,c,d
The number of Beers ranged across control the intervention groups
drugsperparticipantpost groupsfrom was0.1lower
intervention 0.04to0.4 (0.28 lower to 0.09
Follow-up: 0 to 12 higher)
months
GRADEWorkingGroupgradesofevidence.
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
3
CIn
opte
yright©rvention Verylowquality:Weareveryuncertainabouttheestimate.
201sto MAI:MedicationAppropriatenessIndex.
4Tim aLimitations inthe designof studies included intheanalysis such as lack ofprotection against contamination and lack of allocation
hepro concealmentresultedindowngradingofthequalityofevidence.
Cove bAvalidatedassessmentofunder-prescribingwasnotincludedinallstudies;therefore,thefindingsansweredarestrictedversionofthe
chrthe researchquestion.Thisresultedindowngradingofthequalityofevidence.
aneapp cStatisticallysignificantheterogeneity,variationineffectestimatesandnon-overlappingCIsbetweenstudiesresultedindowngradingof
Cr
ollaboraopriateu tdehTImewqpouresactluiitsydiioeonsfeiwnveiedrfeefeneccxtece.lsutdimedatferosmwathseoabnsaelryvseidswbehcearuebseyCofIsawuenriteowfiadneaalynsdi/sorercrroors(sCerdottthye2li0n0e4oaf)naondefafencto.utlyingeffectestimatewitha
tionseo highriskofbias(Spinewine2007).
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4
BACKGROUND includingdepression,hypertension,anaemia,asthma,angina,di-
verticulosis,osteoarthritis,gout,diabetesmellitus,poorself-per-
Prescribingforolderpeopleiscomplexbecauseoffactorssuchas
ceivedhealthandpoorlifesatisfaction;andfactorsrelatedtoaccess
age-relatedchanges inbody composition and multiple patholo-
tohealthcaresuchasnumberofhealthcarevisits,useofsupple-
gies. Finding the balance between aggressively treating diseases
mentalinsuranceandaccesstomultipleprovidersofhealthcare
and avoiding medication-related harm is a critical objective of-
(Espino1998;Hajar2007).
tensetbyhealthcareprofessionals,yetrarelyachieved(Steinman
2007). This review updates a Cochrane review of interventions Recentpromotionoftheuseofclinicalguidelineshasinfluenced
toimprovetheappropriateuseofpolypharmacyforolderpeople prescribingpatterns,whichoftenadvocatetheuseofmorethan
(Patterson2012).Thepreviousversionofthisreview(Patterson onedrugtomanagecommondiseases.Manyguidelinesforpre-
2012)found that, despite thepotential to reduce inappropriate ventionandmanagementofdiseasescommoninolderpeoplerec-
prescribing,itwasunclearwhetherinterventionstoimproveap- ommend adding medications for secondary prevention. For ex-
propriatepolypharmacyinolderpeopleresultedinclinicallysig- ample,withinEurope,guidelinesdevelopedbyajointtaskforce
nificantimprovement. on cardiovascular disease prevention in clinical practice, which
involved the European Society of Cardiology (Joint Task Force
Polypharmacy has a range of definitions that refer to the use of
2012),advocatethisapproach.However,ithasbeenreportedthat
multiplemedicationregimens,butnostandarddefinitionisused
someclinicalguidelinesdonotmodifyordiscusstheapplicability
consistently(King’sFund2013;Stewart1990).Asimpledefini-
oftheirrecommendations forolderpatientswithmultiplemor-
tion-’theadministrationofmoremedicinesthanareclinicallyin-
bidities,nordotheytakeaccountofpatientpreferencesorcom-
dicated,representingunnecessarydruguse’(Montamat2004)-has
mentonthequalityofevidencesupportingtheguideline(Boyd
beenused,but forthepurpose of thisreview, we haveusedthe
2005).Useofclinicalguidelinesmaythereforepromotepolyphar-
commondefinitionof’theconcomitantingestionoffourormore
macyandincreasetheriskofadverseeventssuchasdrug-drugand
medications’(DoH2001;Rollason2003).
drug-disease interactions. Inlightof this,theNationalInstitute
Polypharmacyiscommoninolderpeople,conventionallydefined forHealthandCareExcellence(NICE)isconsideringthedevel-
as those aged 65 years and over, as this age group often suffers opment of guidelines for theclinical treatment of patients with
from multiple morbidities (Barnett 2012) such as heart disease multiplemorbidities(NICE2012).
anddiabetesthatrequiremultiplemedicationsfortreatmentand
Appropriateortherapeuticpolypharmacyalsooccurswhenthere-
prophylaxis.IntheUSA,theprevalenceofpolypharmacy,defined
sultsofclinicaltrialssuggestthatmultiplemedicationsshouldbe
intheSloneSurveyasfiveormoremedicines,inolderpeoplehas
usedtotreatspecificdiseases(Gurwitz2004).Acceptanceofthe
increased overtime, and themostrecentavailable data indicate
ideathatsuchappropriatepolypharmacymaybebeneficialisin-
thatapproximately28%ofolderpeopleintheUSAarereceiving
creasing,andthecombineduseofmultiplemedicationsisbenefi-
polypharmacy (SloneSurvey 2007).Thisis relativelyconsistent
cialandappropriateformanyconditions,especiallythoseinolder
withdatafromTheIrishLongitudinal Study onAgeing, which
peoplewithmultiplemorbidities.Forexample,diabetesmellitus
hasreportedpolypharmacyin31%oftheolderpopulationusing
isoftentreatedwithseveraldrugsatonce(Standl2003).However,
thesamedefinitionoffiveormoremedicines(Richardson2012).
itisimportanttoconsiderwhethereachdrughasbeenprescribed
Hence,olderpeopleuseadisproportionatequantityofhealthser-
appropriatelyorinappropriately,bothindividuallyandinthecon-
viceresources.Forexample,in2013,patientsaged60andolder
textofthewholeprescription(Aronson2006).Improvingappro-
accounted for23% ofthepopulation inEnglandandweredis-
priatepolypharmacyinvolvesencouraginguseofthecorrectdrugs
pensed60%ofallprescriptionitems(InformationCentre2014).
underappropriateconditionstotreattherightdiseases.Incertain
Inappropriatemedicationscanbedefined,intermsofolderpeo- circumstances,thismayincludetheremovalofunnecessarydrugs
ple,as’medicationsormedicationclassesthatshouldgenerallybe orthosewithnovalidclinicalindicationandtheadditionofuseful
avoidedinpersons65yearsorolderbecausetheyareeitherinef- ones.
fectiveortheyposeunnecessarilyhighriskforolderpersonsanda
However, polypharmacy is associated with negative health out-
saferalternativeisavailable’(Beers1991).Theterm’inappropri-
comesincludingadversedrugreactions,pooradherenceandgeri-
ateprescribing’ alsoencompassestheuseof medicinesthatlead
atricsyndromessuchasurinary incontinence, cognitive impair-
toa significant riskof adverse drug events(ADEs) arising from
ment and impaired balance leading to falls (Hajar 2007). The
prescribingpracticessuchascontinuing therapyforlongerthan
chanceofoccurrenceofmedication-relatedproblemsisincreased
necessary,inadditiontounnecessarypolypharmacy.
inolderagebecausetheageingprocessreducestheefficiencyof
Reasons for the occurrence of polypharmacy in older patients thebody’sorgansineliminatingdrugs(Mangoni2003).Therisk
havebeendescribedintheliteratureandcanbebroadlyclassified of an ADE is 13% with the use of two medications, but when
into threegroups: demographic factors such as race and educa- fivemedications are used,itincreasesto58% (Fulton2005).If
tion(Fillenbaum1996);healthstatusfactorssuchaspoorhealth seven or more medications are used, the incidence increases to
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) 5
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
82% (Prybys2002).Inaddition, thenumber ofmedicinespre- aminingpatientadherencetoprescribedmedicationstoidentify
scribedpredictsthenumber of druginteractions likelytooccur targetareasforintervention(Barat2001;Bedell2000).
(Gallagher2001).Poorunderstandingofcausesofcertaindisor-
dersmakesprescribingdrugcombinationsmoredifficult.Treating
poorlyunderstooddiseasesmayincreasetheriskforinappropriate
polypharmacy(Werder2003). Descriptionoftheintervention
Under-prescribingisdefinedaslackofdrugtreatmentforaclinical Improvement in appropriate polypharmacy can be achieved
conditionforwhichdrugtherapyisindicatedaccordingtoclin- throughawiderangeofinterventions.Thesecanbeclassifiedas
icalpracticeguidelines(Lipton1992).Under-prescribingcanbe professional,forexample,educationalprogrammesforprescribers
aschallengingaspolypharmacyinolderpeople,andithasonlyre- orconsumers;organisational,forexample,medicationreviewclin-
centlygainedrecognitionasamatterofconcern.Under-prescrib- icsandspecificauditsonbenzodiazepineuse;orfinancial,forex-
inghasbeenshowntobeassociatedwithpolypharmacy,whereby ample,prescribedincentiveschemesandregulatoryinterventions.
theprobability ofunder-prescriptionincreaseswiththenumber Interventionsthatreducetheriskofmedication-relatedproblems
ofmedicinesused(Kuijpers2007).Usingasampleof150older are important to consider (Fick 2008). These may be provided
studyparticipants,Kuijpers2007reportedthattheprevalenceof byhealthcareprofessionals,educators,policymakersandhealth-
polypharmacyandunder-prescribingwas61%and31%,respec- care service planners. The traditional approach to intervention
tively.Amongparticipants receivingpolypharmacy,42.9%were inpolypharmacy,basedontheassumptionthatpolypharmacyis
under-treated,incontrastto13.5%ofthoseusingfourorfewer harmful,hasbeentoreduceinappropriatemedication. Byiden-
medicines(oddsratio(OR)4.8,95%confidenceinterval(CI)2.0 tifyingriskfactorsforpolypharmacy,itispossibletodecreaseits
to11.2). associatedmorbidity,mortalityandcost(Werder2003).
Methodsrecommendedinmanyinterventionstudiesincludeuse
Thesefindingsmaybeexplainedbytheunwillingnessofgeneral
of computer data entry and feedback procedures, which have
practitioners(GPs)toprescribeadditionaldrugsforpatientswith
been shown to decrease polypharmacy and drug-drug interac-
polypharmacy(forreasonssuchascomplexityofdrugregimens,
tions(Werder2003);visualidentificationofmedicines;continu-
fear of ADEs and drug-drug interactions and poor adherence)
ous medication review and thorough patient education toopti-
(Kuijpers 2007). This so-called treatment/risk paradox or risk/
misepolypharmacy(Fulton2005).
treatmentmismatch is seenwhenpatients with thehighestrisk
This review seeksto identify evidence regarding which types of
ofcomplicationsaredeterminedtohavethelowestprobabilityof
interventionscanimproveappropriatepolypharmacy.
receivingtherecommendedmedications(Ko2004;Lee2005).
Thus,’polypharmacy’canrefertotheprescribingofmanydrugs
(appropriately) or too many drugs (inappropriately) (Aronson
2004).Whatconstitutes’many’or’toomany’drugsisaprescriber’s Howtheinterventionmightwork
dilemma,andchoosingthebestinterventionsaimedatensuring
Interventionstoimprovepolypharmacyarelikelytoachievethe
appropriatepolypharmacyremainsachallengeforhealthcareprac-
followingoutcomes.
titionersandorganisations.
• Improvedappropriatepolypharmacythroughremovalof
inappropriatelyprescribedmedication.
• Increasedappropriatemedicationsbypromotionof
Descriptionofthecondition
adherencetoevidence-basedtherapy.
Inappropriate polypharmacy, as described above, occurs when
olderpeopleareprescribedmoremedicinesthanareclinicallyindi- Computerised decision support (CDS) aimed at prescribers,
cated.Asunder-prescribingisalsoinappropriatetherapyforolder wherebyelectronicalertsareproducedtoguidetheprescriberto
people, we have included in this review interventions provided therighttreatment,hasbeensuccessfulinreducinginappropriate
to address this problem, such as the promotion of appropriate prescribingforolderpeople.Pharmacist-ledinterventionssuchas
polypharmacy. medicationreview,co-ordinatedtransitionfromhospitaltolong-
Inappropriatepolypharmacyhasbeenmeasuredbyusingvalidated termcarefacilityandpharmacistconsultationswithpatientsand
instrumentsorscreeningtoolssuchasavalidatedlistofmedicines physicians have been shown to effectively reduce inappropriate
consideredinappropriateforolderpeople(AGS2012;Beers1991; prescribing and ADEs (Hanlon 1996; Kaur 2009). Multi-disci-
Fick 2003), a list of clinically significant criteria for potentially plinarycaseconferencesinvolvingGPs,geriatricians,pharmacists
inappropriateprescribinginolderpeople(Gallagher2008)orthe andresidentialcarestaff,whereinindividualpatientcasesaredis-
MedicationAppropriatenessIndex(MAI)(Knight2001).Other cussed,havereducedtheuseofinappropriatemedicationsinres-
methodsofassessmentofinappropriatepolypharmacyincludeex- identialcare(Crotty2004a)
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) 6
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Whyitisimportanttodothisreview Weexcludedstudiesinwhichtheinterventionfocusedonpeople
withasinglelong-termmedicalconditionorwhowerereceiving
Asystematicreviewmayhelptoidentifyhowwecanimproveap-
short-termpolypharmacy,forexample,thosewhowereterminally
propriatepolypharmacyinolderpeople.Inappropriateprescrib-
illorwerereceivingcancerchemotherapy.
ingforolderpeopleisbothhighlyprevalentandcommonlyasso-
ciatedwithpolypharmacy(Bradley2012;Cahir2010).Itisim-
portantthatthegapincurrentevidencebeaddressed,sothatin- Typesofinterventions
terventionsthatareeffectiveinmanagingdiseasewithappropriate
We examined alltypesof interventions aimedatimproving ap-
polypharmacymaybeidentifiedandputintopractice.
propriatepolypharmacyinanysettingcomparedwithusualcare
asdefinedbythestudy.Weincludedallunifacetedinterventions,
forexample,thosetargetedsolelyatdrugprescription,andmulti-
facetedinterventions,forexample,specialistclinicsinvolvingcom-
OBJECTIVES prehensivegeriatricassessment,instudiesinwhichmostoutcomes
were relatedtopolypharmacy. We included studies of interven-
This review sought to determine which interventions, alone or
tionsforwhichthetargetwaspolypharmacyacrossallages,pro-
incombination,areeffectiveinimprovingtheappropriateuseof
videdresultsforthoseaged65yearsandoverwereavailablesepa-
polypharmacyandreducingmedication-relatedproblemsinolder
rately.Weexaminedalltypesofinterventionsthatdirectlyorin-
people.
directlyaffectedprescribingandwereaimedatimprovingappro-
priatepolypharmacy.Theseincludedthefollowing.
• Professionalinterventionssuchaseducationalprogrammes
METHODS
aimedatprescribers.
• Organisationalinterventionssuchasskill-mixchanges,
pharmacist-ledmedicationreviewservicesorspecialistclinics,
Criteriaforconsideringstudiesforthisreview informationandcommunicationtechnology(ICT)
interventionssuchasclinicaldecisionsupportsystemsoruseof
riskscreeningtools.
Typesofstudies • Financialinterventionssuchasincentiveschemesfor
We included all randomised controlled trials (RCTs), includ- changesinprescribingpractice.
ingcluster-randomisedcontrolledtrials(cRCTs),non-randomised • Regulatoryinterventionssuchaschangesingovernment
controlledclinicaltrials(CCTs),controlledbefore-and-afterstud- policyorlegislationaffectingprescribing.
ies(CBAs)andinterruptedtimeseries(ITS)studiesmeetingthe
EffectivePracticeandOrganisationofCare(EPOC)specification
Typesofoutcomemeasures
(EPOC2009)inthereview.
Weclassifiedtrialseligibleforinclusionaccordingtothereader’s Validated measures of inappropriate prescribing were the main
degreeofcertaintythatrandomallocationwasusedtoformcom- outcomemeasuresconsideredinthereview.Increasingappropri-
parisongroupsinthetrial.Ifstudyauthor(s)statedexplicitlythat atepolypharmacycouldimproveindicatorsofmorbiditysuchas
groupscomparedinthetrialwereestablishedbyrandomalloca- reductioninADEsorhospitaladmissions,butclinicaloutcomes
tion,weclassifiedthetrialasanRCT.Ifstudyauthor(s)didnot werenotclearlyreportedbecauseofconfoundingfactorssuchas
stateexplicitlythatthetrialwasrandomised,butrandomisation multi-morbidity in older people. We excluded studies in which
couldnotberuledout,weclassifiedthereportasaCCT. expertopinionwasusedtodeterminemedicationappropriateness.
Typesofparticipants Primaryoutcomes
The review included studies of older people aged 65 years and Theprimaryoutcomewaschangeintheprevalenceofappropriate
older,whohadmorethanonelong-termmedicalcondition,in- useofpolypharmacy,asmeasuredbyavalidatedinstrument.This
cludingthoseforwhompolypharmacy(classifiedasfourormore wasdefinedasmeetingoneormoreofthefollowingcriteria.
medicines)wascommonpractice,forexample,thosewithParkin- • Appropriatenessofmedicationsprescribed,asmeasuredby
son’sdiseaseordiabetes.Weconsideredtrialsforinclusionifthey avalidatedinstrument,forexample,Beerscriteria(Fick2003)or
includedamajority(80%ormore)ofparticipantsaged65years MAI(Knight2001).
and older,or if the mean age of study participants was over 65 • Prevalenceofappropriatemedication,forexample,an
years.Ifstudiesincludedbotholderandyoungerpeople,wein- increaseinthenumberofappropriatedrugs,asdefinedbya
cludedthemifwewereabletoextractrelevantdata.Wecontacted validatedtool,forexample,ScreeningTooltoAlertdoctorsto
studyauthorstochecktheavailabilityofrelevantdata. theRightTreatment(START)criteria(Barry2007).
Interventionstoimprovetheappropriateuseofpolypharmacyforolderpeople(Review) 7
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.