gms | German Medical Science

Background: Since several years, the development of single disease guidelines that do not take into account patients with multimorbidity and respective polypharmacy has been criticised, especially by those involved in the care of the elderly. The publication of Boyd et al. (2005) [1] that addresses the problems arising in the treatment of multiple diseases of the elderly according to the respective single disease guidelines, has been discussed intensively. In Germany, the German council of experts in the health sector (Sachverständigenrat im Gesundheitswesen) claimed in his report 2009 the development of guidelines considering multimorbidity and prioritising the Treatment [2]. In 2010, Garfinkel and Mangin [3] demonstrated possibilities to reduce medication use. Their study population comprises eldery with relatively high average age. Furthermore, the framework of medication review applied in the study of Garfinkel and Mangin is not transferable to the situation of general practitioners (GPs) in Germany. Despite of these challenges, the GP guideline group of Hesse (Germany) developed a GP guideline on polypharmacy [4].

Materials and Methods: A systematic guideline and literature search was conducted (partly by ÄZQ). No guideline addressing polypharmacy could be identified. (Meanwhile a Dutch guideline has been published in 2012 [5]). No convincing studies could be identified to recommend GPs to conduct a medication review and to apply a special instrument for this task. In most of the studies, medication reviews were done by professional groups other than GPs in settings that are not comparable to the working environment of GPs. The guideline group of Hesse decided by consent to recommend the Medication Appropriateness Index [6] as a tool to review and evaluate the medication of a patient. The guideline recommendations are partly based on study results and/or consent of the authors of the guideline.

Results: The guideline introduces the topic of polypharmacy using epidemiological data that demonstrates the relevance of this issue. The so called “key questions for GPs” address all problems related to polypharmacy from the perspective of GPs. The core of the guideline is formed by the so called “medication process” which has been developed according the concept of Bain et al. (2008) [7] and consists of the following steps: assessment - medication review - reconcilement with the patient – prescribing recommendation – communication with patients – dispensing of drug in the pharmacy – drug use by patient – monitoring. The last step “monitoring” forms the starting point for the next passage of the medication process visualized as a circle. The guideline provides information for each step of the process. Special attention is paid to the task to set preferences in cases where all drugs are indicated but the situation requires a reduction of the number of drugs.

Conclusion: Besides dissemination of the guideline via internet or print media implementation strategies and a further development of tools for the medication review are indispensable. First steps of this process are the discussion of the guidelines combined with the analysis of prescribing data in quality circles and the integration of the guideline in special contracts between physician associations and sickness funds. Besides, the co-operation with other health professionals, pharmacists in the first place, has to be improved.