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Open Access 01-12-2018 | Research article

Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS study): a qualitative study of practical implementation in primary care

Authors: Anja Rieckert, Christina Sommerauer, Anja Krumeich, Andreas Sönnichsen

Published in: BMC Primary Care | Issue 1/2018

Abstract

Background

Within the EU-funded project PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support) an electronic decision support tool (the “PRIMA-eDS-tool”) was developed for general practitioners (GPs) to reduce inappropriate medication in their older polypharmacy patients. After entering patient data relevant to prescribing in an electronic case report form the physician received a comprehensive medication review (CMR) on his/her screen displaying recommendations regarding missing indications, necessary laboratory tests, evidence-base of current medication, dose adjustments for renal malfunction, potentially harmful drug-drug interactions, contra-indications, and possible adverse drug events. We set out to explore the usage of the PRIMA-eDS tool and the adoption of the recommendations provided by the CMR to optimise the tool and prepare it for its future implementation.

Methods

In a qualitative study carried out in North Rhine-Westphalia, Germany, 21 GPs using the PRIMA-eDS tool within the PRIMA-eDS study were interviewed. Interviews encompassed the GPs’ attitudes regarding use of the electronic case report form and the CMR, their response to the recommendations, and the implementation of the tool into daily practice routine. The collected data were analysed applying thematic qualitative text analysis.

Results

GPs found the patient data entry into the electronic case report form to be inconvenient and time-consuming. The CMR was conducted often outside practice hours and without the patient present. GPs found that the PRIMA-eDS CMR provided relevant information for and had several positive effects on the caring process. However, they encountered several barriers when wanting to change medication.

Conclusions

It is unlikely that the PRIMA-eDS CMR will be used in the future as it is now as patient data entry is too time-consuming. Several barriers towards deprescribing medications were found which are common in deprescribing studies. Given the positive attitude towards the CMR, a new way of entering patient data into the PRIMA-eDS tool to create the CMR needs to be developed.

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Eurostat. Population structure and ageing. 2016. http://ec.europa.eu/eurostat/statistics-explained/index.php/Population_structure_and_ageing#Further_Eurostat_information.

Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011;10:430–9. https://doi.org/10.1016/j.arr.2011.03.003.CrossRefPubMed

Fried TR, Tinetti ME, Iannone L. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171:75–80. https://doi.org/10.1001/archinternmed.2010.318

Bokhof B, Junius-Walker U. Reducing polypharmacy from the perspectives of general practitioners and older patients: a synthesis of qualitative studies. Drugs Aging. 2016;33:249–66. https://doi.org/10.1007/s40266-016-0354-5.CrossRefPubMed

Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3:383–9.CrossRefPubMedPubMedCentral

Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230. https://doi.org/10.1186/s12877-017-0621-2.CrossRefPubMedPubMedCentral

Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol. 2007;63:187–95. https://doi.org/10.1111/j.1365-2125.2006.02744.x.CrossRefPubMed

Rollason V, Vogt N. Reduction of polypharmacy in the elderly. Drugs Aging. 2003;20:817–32. https://doi.org/10.2165/00002512-200320110-00003.CrossRefPubMed

Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA division of geriatric medicine. Arch Intern Med. 1991;151:1825–32.CrossRefPubMed

10.

Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.CrossRefPubMed

11.

Basger BJ, Chen TF, Moles RJ. Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool. Drugs Aging. 2008;25:777–93.CrossRefPubMed

12.

Kaufmann CP, Tremp R, Hersberger KE, Lampert ML. Inappropriate prescribing: a systematic overview of published assessment tools. Eur J Clin Pharmacol. 2014;70:1–11. https://doi.org/10.1007/s00228-013-1575-8

13.

Cooper JA, Cadogan CA, Patterson SM, Kerse N, Bradley MC, Ryan C, Hughes CM. Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open. 2015;5:e009235. https://doi.org/10.1136/bmjopen-2015-009235.CrossRefPubMedPubMedCentral

14.

Riordan DO, Walsh KA, Galvin R, Sinnott C, Kearney PM, Byrne S. The effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review. SAGE Open Med. 2016;4:2050312116652568. https://doi.org/10.1177/2050312116652568

15.

Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2016;3:CD006560. https://doi.org/10.1002/14651858.CD006560.pub3

16.

Johansson T, Abuzahra ME, Keller S, Mann E, Faller B, Sommerauer C, et al. Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82:532–48. https://doi.org/10.1111/bcp.12959.CrossRefPubMedPubMedCentral

17.

Anthierens S, Tansens A, Petrovic M, Christiaens T. Qualitative insights into general practitioners views on polypharmacy. BMC Fam Pract. 2010;11:65. https://doi.org/10.1186/1471-2296-11-65 .CrossRefPubMedPubMedCentral

18.

Schuling J, Gebben H, Veehof LJG, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56. https://doi.org/10.1186/1471-2296-13-56.CrossRefPubMedPubMedCentral

19.

Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4:e006544. https://doi.org/10.1136/bmjopen-2014-006544.CrossRefPubMedPubMedCentral

20.

Varonen H, Kortteisto T, Kaila M. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract. 2008;25:162–7. https://doi.org/10.1093/fampra/cmn020.CrossRefPubMed

21.

Beeler PE, Bates DW, Hug BL. Clinical decision support systems. Swiss Med Wkly. 2014;144:w14073. https://doi.org/10.4414/smw.2014.14073 .PubMedCrossRef

22.

Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson S-A. Computerized clinical decision support for prescribing: provision does not guarantee uptake. J Am Med Inform Assoc. 2010;17:25–33. https://doi.org/10.1197/jamia.M3170.CrossRefPubMedPubMedCentral

23.

Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Appropriateness in health care: application to prescribing. Soc Sci Med. 1997;45:261–71.CrossRefPubMed

24.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–2.CrossRefPubMedPubMedCentral

25.

Sönnichsen A, Trampisch US, Rieckert A, Piccoliori G, Vögele A, Flamm M, et al. Polypharmacy in chronic diseases–reduction of inappropriate medication and adverse drug events in older populations by electronic decision support (PRIMA-eDS): study protocol for a randomized controlled trial. Trials. 2016;17:1–9. https://doi.org/10.1186/s13063-016-1177-8

26.

Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489–95. https://doi.org/10.1503/cmaj.050051.CrossRefPubMedPubMedCentral

27.

Renom-Guiteras A, Meyer G, Thürmann PA. The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries. Eur J Clin Pharmacol. 2015;71:861–75. https://doi.org/10.1007/s00228-015-1860-9.CrossRefPubMedPubMedCentral

28.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. https://doi.org/10.1093/intqhc/mzm042.CrossRefPubMed

29.

Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016:1753–60. https://doi.org/10.1177/1049732315617444.

30.

Kuckartz U. Qualitative text analysis: a guide to methods, practice and using software. London: SAGE Publications; 2014.CrossRef

31.

Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80:1254–68. https://doi.org/10.1111/bcp.12732.CrossRefPubMedPubMedCentral

32.

Verdoorn S, Kwint H-F, Faber A, Gussekloo J, Bouvy ML. Majority of drug-related problems identified during medication review are not associated with STOPP/START criteria. Eur J Clin Pharmacol. 2015;71:1255–62. https://doi.org/10.1007/s00228-015-1908-x.CrossRefPubMedPubMedCentral

33.

Bolmsjo BB, Palagyi A, Keay L, Potter J, Lindley RI. Factors influencing deprescribing for residents in advanced care facilities: insights from general practitioners in Australia and Sweden. BMC Fam Pract. 2016;17:152. https://doi.org/10.1186/s12875-016-0551-7.CrossRefPubMedPubMedCentral

34.

Moen J, Norrgard S, Antonov K, Nilsson JLG, Ring L. GPs’ perceptions of multiple-medicine use in older patients. J Eval Clin Pract. 2010;16:69–75. https://doi.org/10.1111/j.1365-2753.2008.01116.x.CrossRefPubMed

35.

Short D, Frischer M, Bashford J. Barriers to the adoption of computerised decision support systems in general practice consultations: a qualitative study of GPs’ perspectives. Int J Med Inform. 2004;73:357–62. https://doi.org/10.1016/j.ijmedinf.2004.02.001.CrossRefPubMed

36.

Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10:38–43.PubMedPubMedCentral

37.

Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017;38:3–11. https://doi.org/10.1016/j.ejim.2016.12.021

38.

Toth-Pal E, Wardh I, Strender L-E, Nilsson G. Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners. Inform Health Soc Care. 2008;33:39–54. https://doi.org/10.1080/17538150801956754.CrossRefPubMed

39.

Sittig DF, Krall MA, Dykstra RH, Russell A, Chin HL. A survey of factors affecting clinician acceptance of clinical decision support. BMC Med Inform Decis Mak. 2006;6:6. https://doi.org/10.1186/1472-6947-6-6.CrossRefPubMedPubMedCentral

40.

Lugtenberg M, Weenink J-W, van der Weijden T, Westert GP, Kool RB. Implementation of multiple-domain covering computerized decision support systems in primary care: a focus group study on perceived barriers. BMC Med Inform Decis Mak. 2015;15:82. https://doi.org/10.1186/s12911-015-0205-z.CrossRefPubMedPubMedCentral

41.

Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330:765. https://doi.org/10.1136/bmj.38398.500764.8F.CrossRefPubMedPubMedCentral

42.

Koskela T, Sandstrom S, Makinen J, Liira H. User perspectives on an electronic decision-support tool performing comprehensive medication reviews - a focus group study with physicians and nurses. BMC Med Inform Decis Mak. 2016;16:6. https://doi.org/10.1186/s12911-016-0245-z.CrossRefPubMedPubMedCentral

43.

Evidence-Based Medicine Guidelines. https://www.duodecim.fi/english/products/ebmg/. Accessed 30 Apr 2018.

44.

Evidence-Based Medicine electronic Decision Support. http://www.ebmeds.org/web/guest/home?p_id=129190&b_id=129273&s_id=129273&lang=en. Accessed 30 Apr 2018.

45.

Martinez YV, Renom-Guiteras A, Reeves D, Erandie Ediriweera de Silva R, Esmail A, Kunnamo I, et al. A set of systematic reviews to help reduce inappropriate prescribing to older people: study protocol. BMC Geriatr. 2017;17:231. https://doi.org/10.1186/s12877-017-0570-9

46.

Renbase - Analysis of adverse drug reactions. http://www.medbase.fi/en/professionals/renbase. Accessed 30 Apr 2018.

47.

INXBASE Interaction Database http://www.medbase.fi/en/professionals/inxbase/. Accessed 30 Apr 2018.

48.

European Medicines Agency. http://www.ema.europa.eu/ema/. Accessed 30 Apr 2018.

49.

RISKBASE – Analysis of adverse drug reactions. http://www.medbase.fi/en/professionals/riskbase/. Accessed 30 Apr 2018.

Title: Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS study): a qualitative study of practical implementation in primary care
Authors: Anja Rieckert
Christina Sommerauer
Anja Krumeich
Andreas Sönnichsen
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: BMC Primary Care / Issue 1/2018
Electronic ISSN: 2731-4553
DOI: https://doi.org/10.1186/s12875-018-0789-3

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS study): a qualitative study of practical implementation in primary care

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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