Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review

Introduction Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention. Objectives To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions. Design We performed a scoping review as defined by the Joanna Briggs Institute. Setting The focus was on primary care settings. Data sources Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024. Eligibility criteria We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded. Extraction and analysis We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions. Results In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention. Conclusions Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

• Meta-analysis found that the STOPP criteria reduced PIM rates in all four studies, but study heterogeneity (I2 = 86•7%) prevented the calculation of a meaningful statistical summary.• We found evidence that use of the criteria reduces falls, delirium episodes, hospital lengthof-stay, care visits (primary and emergency) and medication costs, but no evidence of improvements in quality of life or mortality.

Any intervention aimed at reducing inappropriate polypharmacy
• There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy • These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23 • In meta-analyses, no significant associations between medication reviews and fall outcomes were found in any of the settings.• There was a trend for a lower number of fallers in the meta-analysis assessing medication reviews in long-term care.• In a frail subgroup, medication review might be effective even as a single intervention.

Shrestha et al. 2021
Impact of deprescribing dual-purpose medications on patientrelated outcomes for older adults near endof-life: a systematic review and metaanalysis.

Australi a
Review & metaanalysis

Any deprescribing intervention
• The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44-0.79)and referral to acute care facilities (RR = 0.40, 95% CI = 0.22-0.73),but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits • Insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events.Interviews with 14 GPs • The primary barriers toward multimorbid patients with polypharmacy were the need for communication and teamwork with specialists • Often, GPs felt that the specialists were more concerned about following standards and guidelines regarding specific diseases instead of a more holistic patient approach.• To improve management of polypharmacy patients, the GPs suggest that a joint force is • Within the studied EU countries, polypharmacy management was not widely addressed.
• Results highlight the importance of change management and theory-based implementation strategies.

All Wales Medicines
Polypharmacy in older people: A guide for • The feasibility of the finder tool and intervention were assessed through GP feedback and analysis of use of the online material.Overall, the intervention was well received by the GPs and their patients many of whom reported feeling reassured that their medicines were being reviewed and rationalised.• When the higher prevalence, lower risk proton pump inhibitor PIP was excluded, 90% of patients had at least 1 PIP and the mean number of PIP per patient was 1.1.Identified instances of PIP were acted on in 44% of cases and 45% when the proton pump inhibitor PIP was excluded.• Identification (step 1) and implementation elements (Step 3) were perceived most helpful by GPs.Whereas, shared-decision making elements (step 2) revealed room for improvement.• Patients were satisfied with the deprescribing consultation (85%) and with their decision made regarding their medication (90%).• A clinical pharmacist found that 86% of participants had a drug therapy problem according to classification criteria.Seventy-nine percent of all drug therapy problems identified were resolved upon completion of the study.• A service model using remote pharmacist services may be an effective means of improving team-based primary care medication management for this population.• GPs rated patient involvement higher than did patients themselves.

Mangin et al. 2023
Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy.
Canada Feasibility BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

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GPs were satisfied tool and gave important hints for future development.
Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively.•TheMAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.•Forevery new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points.Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Understanding the medication use profile in primary health care allows identifying groups of people that are more likely to experience polypharmacy, and planning measures to mitigate potential polypharmacy-related problems.•Amajority of GPs perceive the CCs of the multimorbid patients correctly, but there is room for improvement.•Concordancebetween CCs and diagnosis was 53.6%.•Theyounger age and higher intake of drugs were significantly associated with an increased concordance between CCs and diagnosis.•Atotal of 20.3% of the older primary care attenders experienced polypharmacy (26.7%% in public and 11.0% in private practice).•Theadjusted odds ratio (OR) of polypharmacy were 6.37 times greater in public practices.BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) The total MRCI score had significant correlation with the number of drugs in the regimen, but not with the age and gender of the patients.No two groups had the same priorities.GPs ranked 'evidence for deprescribing' and BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Pharmacists ranked 'clinical appropriateness of therapy' and 'identifying residents' goals of care' as most important.• The multidisciplinary groups prioritised both 'adequacy of medical and medication history' and 'identifying goals of care'. BMJ