Skip to main content

Advertisement

Log in

Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care

  • Conference Report
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

To evaluate the effect of a combined or a single educational intervention on the prescribing behaviour of general practitioners (GPs). The primary endpoint was effect on inappropriate prescribing according to the Medication Appropriateness Index (MAI).

Methods

General practitioners were randomised to either (1) a combined intervention consisting of an interactive educational meeting plus feedback on participating patients’ medication, (2) a single intervention with an interactive educational meeting or (3) a control group (no intervention). Elderly (>65 years) patients exposed to polypharmacy (≥5 medications) were identified and approached for inclusion. Data on medications prescribed over a 3-month period were collected, and the GPs provided detailed information on their patients before and after the intervention. A pre- and post-MAI were scored for all medications.

Results

Of the 277 GPs invited to participate; 41 (14.8%) volunteered. Data were obtained from 166 patients before and after the intervention. Medication appropriateness improved in the combined intervention group but not in the single intervention group. The mean change in MAI and number of medications was −5 [95% confidence interval (CI) −7.3 to −2.6] and −1.03 (95% CI −1.7 to −0.30) in the combined intervention group compared with the group with the educational meeting only and the no intervention group.

Conclusions

A combined intervention consisting of an interactive educational meeting plus recommendations given by clinical pharmacologists/pharmacists concerning specific patients can improve the appropriateness of prescribing among elderly patients exposed to polypharmacy. This study adds to the limited number of well-controlled, randomised studies on overall medication appropriateness among elderly patients in primary care. Important limitations to the study include variability in data provided by participating GPs and a low number of GPs volunteering for the study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bjerrum L, Sogaard J, Hallas J, Kragstrup J (1998) Polypharmacy: correlations with sex, age and drug regimen. A prescription database study. Eur J Clin Pharmacol 54:197–202

    Article  PubMed  CAS  Google Scholar 

  2. Hajjar ER, Cafiero AC, Hanlon JT (2007) Polypharmacy in elderly patients. Am J Geriatr Pharmacother 5(4):345–351

    Article  PubMed  Google Scholar 

  3. Astrand E, Astrand B, Antonov K, Petersson G (2007) Potential drug interactions during a three-decade study period: a cross-sectional study of a prescription register. Eur J Clin Pharmacol 63(11):1095

    Article  Google Scholar 

  4. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA et al (1997) The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277:307–311

    Article  PubMed  CAS  Google Scholar 

  5. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP (1997) Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 277:301–306

    Article  PubMed  CAS  Google Scholar 

  6. Ebbesen J, Buajordet I, Erikssen J, Brørs O, Hilberg T, Svaar H, Sandvik L (2001) Drug-related deaths in a department of internal medicine. Arch Intern Med 161(19):2317–2323

    Article  PubMed  CAS  Google Scholar 

  7. Hohl CM, Dankoff J, Colacone A, Afilalo M (2001) Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 38:666–371

    Article  PubMed  CAS  Google Scholar 

  8. Routledge PA, O’Mahoney MS, Woodhouse KW (2004) Adverse drug reactions in elderly patients. Br J Clin Pharmacol 57(2):121–126

    Article  PubMed  CAS  Google Scholar 

  9. Schneeweiss S, Hasford J, Gottler M, Hoffmann A, Riethling AK, Avorn J (2002) Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol 58:285–291

    Article  PubMed  Google Scholar 

  10. Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M et al (2000) Incidence and preventability of adverse drug events in nursing homes. Am J Med 109:87–94

    Article  PubMed  CAS  Google Scholar 

  11. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC et al (2003) Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107–1116

    Article  PubMed  Google Scholar 

  12. Kanjanarat P, Winterstein AG, Johns TE, Hatton RC, Gonzalez-Rothi R, Segal R (2003) Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 60:1750–1759

    PubMed  Google Scholar 

  13. Lindley CM, Tully MP, Paramsothy V, Tallis RC (1992) Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 21:294–300

    Article  PubMed  CAS  Google Scholar 

  14. Patel P, Zed PJ (2002) Drug-related visits to the emergency department: how big is the problem? Pharmacotherapy 22:915–923

    Article  PubMed  Google Scholar 

  15. Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R (2002) Identifying clinically significant preventable adverse drug events through a hospital’s database of adverse drug reaction reports. Am J Health Syst Pharm 59:1742–1749

    PubMed  Google Scholar 

  16. Buetow SA, Sibbald B, Cantrill JA, Halliwell S (1996) Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, 1980–95: systematic literature review. Br Med J 313:1371–1374

    CAS  Google Scholar 

  17. Curtis LH, Ostbye T, Sendersky V, Hutchison S, Dans PE, Wright A et al (2004) Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med 164:1621–1625

    Article  PubMed  Google Scholar 

  18. Liu GG, Christensen DB (2002) The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash) 42:847–857

    Article  Google Scholar 

  19. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. Br Med J 317:465–468

    CAS  Google Scholar 

  20. Gill PS, Makela M, Vermeulen KM, Freemantle N, Ryan G, Bond C et al (1999) Changing doctor prescribing behaviour. Pharm World Sci 21:158–167

    Article  PubMed  CAS  Google Scholar 

  21. Hanlon JT, Schmader KE, Ruby CM, Weinberger M (2001) Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 49:200–209

    Article  PubMed  CAS  Google Scholar 

  22. Freudenstein U, Howe A (1999) Recommendations for future studies: a systematic review of educational interventions in primary care settings. Br J Gen Pract 49:995–1001

    PubMed  CAS  Google Scholar 

  23. Hansten PD, Horn JR (2004) The Top 100 drug interactions—a guide to patient management. H&H Publ, Edmonds

  24. Allard J, Hebert R, Rioux M, Asselin J, Voyer L (2001) Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. Can Med Assoc J 164:1291–1296

    CAS  Google Scholar 

  25. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. Br Med J 317:465–468

    CAS  Google Scholar 

  26. Gill PS, Makela M, Vermeulen KM, Freemantle N, Ryan G, Bond C et al (1999) Changing doctor prescribing behaviour. Pharm World Sci 21:158–167

    Article  PubMed  CAS  Google Scholar 

  27. Hanlon JT, Schmader KE, Ruby CM, Weinberger M (2001) Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 49:200–209

    Article  PubMed  CAS  Google Scholar 

  28. Lipton HL, Bird JA (1993) Drug utilization review in ambulatory settings: state of the science and directions for outcomes research. Med Care 31:1069–1082

    Article  PubMed  CAS  Google Scholar 

  29. Raisch DW (1990) A model of methods for influencing prescribing: Part II. A review of educational methods, theories of human inference, and delineation of the model. DICP 24:537–542

    PubMed  CAS  Google Scholar 

  30. Soumerai SB, McLaughlin TJ, Avorn J (1989) Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q 67:268–317

    Article  PubMed  CAS  Google Scholar 

  31. Fitzgerald LS, Hanlon JT, Shelton PS, Landsman PB, Schmader KE, Pulliam CC et al (1997) Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother 31:543–548

    PubMed  CAS  Google Scholar 

  32. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK et al (1992) A method for assessing drug therapy appropriateness. J Clin Epidemiol 45:1045–1051

    Article  PubMed  CAS  Google Scholar 

  33. Schmader K, Hanlon JT, Weinberger M, Landsman PB, Samsa GP, Lewis I et al (1994) Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 42:1241–1247

    PubMed  CAS  Google Scholar 

Download references

Ethics approval

Due to an exception to the ‘Act on Patients’ legal rights and entitlements in Denmark’, the Danish National Board of Health instead of the ethics committee approved the protocol.

Funding

This study was financially supported by the Hørslev Foundation, The Danish Research Foundation for General Practice, The Health Insurance Foundation, and The Copenhagen County Health Administration. All of the researchers contributing to this manuscript are independent of the funders.

Conflict of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to L. Bregnhøj.

Additional information

The trial is not registered in a publicly available database of clinical trials. The trial was conducted in a period prior to June 1, 2007.

Appendix

Appendix

In rating the Medication Appropriateness Index, weights of 3 were given to inappropriate ratings for indication and effectiveness, 2 for dosage, direction correctness, drug-–rug interactions and drug–disease interactions and 1 for direction practicality, therapeutic duplication, duration and cost. The weighted MAI score can range from 0, which indicates no prescribing problems, to 18 if all criteria are rated as inappropriate. A score of 0 was given for all criteria rated as appropriate or marginally appropriate. For more information on the MAI, other references should be consulted [3133].

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bregnhøj, L., Thirstrup, S., Kristensen, M.B. et al. Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care. Eur J Clin Pharmacol 65, 199–207 (2009). https://doi.org/10.1007/s00228-008-0558-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00228-008-0558-7

Keywords

Navigation