Drugs Aging DOI 10.1007/s40266-016-0354-5

REVIEW ARTICLE

Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies Beate Bokhof1 • Ulrike Junius-Walker1

 Springer International Publishing Switzerland 2016

Abstract Background Polypharmacy, common in elderly multimorbid adults, leads to increased iatrogenic health risks. Yet, no consistent approach to stopping medicines exists in primary healthcare. Objectives Our objective was to synthesize qualitative studies exploring the perspectives and experiences of general practitioners (GPs) and older patients in reducing polypharmacy and to discover approaches already being practiced. Methods We conducted a search in the PubMed, Cochrane Library, Web of Science Core Collection, and Scopus databases to identify qualitative studies in the primary care setting addressing multimorbid older patients and polypharmacy reduction. The seven-step model of meta-ethnography allowed for cross-interpretation between studies considering their original context and developing theories. Results A total of 14 studies from the perspectives of patients (n = 6) and providers (n = 8) were included, although discontinuing medicines only occurred as a subtheme in patient studies. Emerging key concepts for patients were experimenting with medicines, attitudes and experiences towards medicines, necessity of prioritizing treatments, relationship to GP, and system-related contributors. For GPs, they covered assumptions about elderly patients, interface prescribing problems, evidence-based

Electronic supplementary material The online version of this article (doi:10.1007/s40266-016-0354-5) contains supplementary material, which is available to authorized users. & Beate Bokhof [email protected] 1

Institute of General Practice, Hannover, Lower Saxony, Germany

guidelines, failure to meet the challenge of complex decision-making, and solutions. Discussion Complex medication regimens and uncertainties in decision making are challenges for both GPs and patients. For patients, symptom experiences with medicines, relationship with their prescriber, and fragmented care are at the forefront; for GPs, it is the decision-making responsibility in the context of unsuitable guidelines, time constraints, and deficient multidisciplinary co-operation. Heuristics such as prioritizing and individualizing treatments and relaxation of guidelines emerged. These strategies require professional awareness of the problem and establishing a trusting, patient-centered consultation style and supportive work conditions.

Key Points General practitioners and older patients perceive reducing polypharmacy as a challenge because they experience uncertainty in the decision-making process. A patient-centered consultation style and a certain level of patient health literacy are key heuristics facing this issue.

1 Introduction As the incidence of chronic diseases increases in aging people, so does the use of medicines. To date, definitions for polypharmacy vary from the intake of at least two to six medicines to the unnecessary use of multiple medicines [1,

B. Bokhof, U. Junius-Walker

2]. In our review, we maintain the definition in its widest terms to account for the varying definitions used by the original studies. Several factors facilitate polypharmacy: traditional consultation formats promote a single disease approach whereby patients seek medical advice in consecutive appointments. Doctors respond by applying disease-specific evidencebased treatments in an additive way [3–5]. Additional prescriptions by specialists and during hospital stays, and further medicines that ameliorate drug-induced side effects, result in a prescription cascade [6]. Further aspects of increasing polypharmacy use are ‘disease mongering’; medicalizing aspects of ordinary life, such as menopause; portraying mild problems as serious illnesses; and framing risk factors, such as high cholesterol and osteoporosis, as diseases [7]. In terms of patients, demographic characteristics like low education [8], increased age, White race, and poor health status are associated with polypharmacy [9]. Moreover, patient self-medication is rarely addressed and accounts for further substantial polypharmacy. Polypharmacy is of growing concern, as there is considerable evidence that it entails serious health risks and additional costs to health systems [10]. It is associated with an increased intake of inappropriate medications [11], leads to diminished patient adherence [12], and triggers adverse drug events, leading to hospital admissions with potentially lethal outcomes [13, 14]. ‘Deprescribing’ is the process of reducing or discontinuing medicines to minimize inappropriate use and to prevent adverse patient outcomes [15]. Although deprescribing is seen as a part of competent prescribing [16], to date there is little evidence and no consistent professional approach on how to stop medicines in older multimorbid patients. Currently, Australian research groups in particular are engaged in developing concepts for stepwise discontinuation of medicines [17–22]. Yet, effectiveness, suitability, and transferability of these concepts for daily use in older, multimorbid patients have yet to be proven. Explicit criteria [e.g., Beers, PRISCUS, STOPP (Screening Tool of Older Person’s Prescriptions), FORTA] targeting specific medications [23–27], and further algorithms [Good Palliative Geriatric Practice (GPGP) and the Medication Appropriateness Index (MAI)], have been developed for generic use [28, 29], but they are not yet fully accepted and implemented in practice [30]. Thus, attention has been directed towards knowledge gains, resulting in innovative guidelines on drug appropriateness and compatibility. However, this investigation intends to complement these findings by exploring cultures and processes in the context of polypharmacy management in daily practice. We expect to uncover barriers and promoters in this field as well as valuable heuristics and solutions. The aim of this review is therefore to retrieve and synthesize the perspectives and

experiences of general practitioners (GPs) and patients on reducing polypharmacy. We also want to identify practicable approaches that may be useful for polypharmacy management in primary care.

2 Methods We applied the seven-step model of meta-ethnography developed by Noblit and Hare and colleagues [31–33]. It facilitates a synthesis of findings from qualitative studies on which more comprehensive theories can be developed. Step 1 entailed a ‘‘clear statement of the specific research question and its potential benefit for the research field’’. In step 2, we defined the focus of the synthesis, located relevant studies, made decisions on inclusion, and assessed reporting quality. We designed a search strategy to retrieve articles relevant to the topic. Four databases were searched without time limit: PubMed, The Cochrane Library, Web of Science Core Collection, and Scopus. The following terms belonging to five subjects were applied via Boolean operators: (1) methods: ‘‘qualitative, qualitative research, qualitative research methods’’; (2) age: ‘‘aged, old, over 80; 80 and over’’; (3) medication: ‘‘polypharmacy, polypharmacy management, (de)prescribing, stopping medication, discontinuation medication’’; (4) doctor–patient relations: ‘‘doctor-patient-relation, medication attitudes, shared decision-making, health knowledge attitudes general practitioners, primary health care’’; and (5) multimorbidity management: ‘‘multimorbidity, multimorbidity management’’. We augmented this systematic search by a manual search of reference lists. We identified records, removed duplicates, and screened titles and abstracts for relevance. We excluded titles if they did not target our topic, study population, or setting; had a quantitative design; or used a language other than English or German. We then assessed the remaining titles for eligibility by reading the abstract and/or full text and excluded them accordingly. Finally, studies meeting the following eligibility criteria were included in the synthesis: • • • • •

Qualitative study (focus groups, semi-structured or indepth interviews, Delphi approach). Older patients (C65 years, multimorbidity, community dwelling). Primary care or GPs. Polypharmacy. Discontinuing or deprescribing medication across medicines.

The authors (BB and UJW) reviewed the studies independently according to inclusion criteria. As discontinuing medicines was not a key subject in any of the studies of older

Physician and Patient Views on Reducing Polypharmacy

patients’ views or in most of the studies that assessed GPs’ views, studies were still included in our analysis if they dealt with medication management and decision making but also included discontinuation of medicines as a sub-theme. Table 1 lists the characteristics of included participants and corresponding definitions of polypharmacy. In step 3, we applied the Consolidated Criteria for Reporting Qualitative Research (COREQ) to explicitly and comprehensively report the important aspects of our included studies. Each study included was assessed in terms of three domains for reporting qualitative research: (1) research team and reflexivity, (2) study design, and (3) analysis and findings [34]. We read the studies several times, and identified and listed the main findings and concepts. Study findings included both the first-order constructs (study participants’ views) and second-order constructs (study authors’ views). In step 4, we compared and searched individual study findings for common and recurring concepts to determine ‘‘how the studies were related to each other.’’ In step 5, studies were translated into each other by examining how each study contributed to a key concept [35]. In step 6, the translations of each key concept were synthesized to develop third-order interpretations (authors’ interpretations). These third-order interpretations were linked by a ‘line of argument,’ which represented the overarching perspective of study participants. In the final step, step 7, the results of the synthesis were expressed in text and tables. Ethical approval was not required, as the study was a literature review that did not directly involve human subjects, medical records, or human tissues.

3 Results 3.1 Step 1 ‘Clear Statement of the Specific Research Question’/Step 2 ‘Search Strategy’ Electronic database search results are presented in Fig. 1. The authors (BB and UJW) agreed on the inclusion or exclusion of 91 % of the 124 studies assessed for eligibility. One [36] of the remaining studies was included; nine were excluded (design [37], not targeting the patient age [38–40], focusing on specific medicines [41–44], not targeting a primary healthcare setting [45], or healthcare setting and ethnic patient group not comparable with the included studies [46]). 3.2 Step 3 ‘Reading the Studies’ The 14 studies included were conducted in eight countries (Table 2). In six studies, the interviewees were patients

(total n = 245), in eight studies they were GPs/further healthcare providers (total 244 GPs, 46 pharmacists, ten nurse practitioners, one social scientist) (Table 2). Study characteristics are presented in Table 1. The completeness of reporting varied across the studies, with an average of 23 (range 20–25) of 32 items from the COREQ Checklist, but, overall, revealed good quality of reporting [Electronic Supplementary Material (ESM) Table S1]. Further details on study methods are shown in the ESM Table S2. 3.3 Step 4 ‘Determining How the Studies are Related’ Three studies primarily focused on discontinuing medicines from a GP’s perspective [47–49]. The remaining 11 studies dealt with stopping medicines as a sub-theme and referred to the key topics ‘‘patients’ multiple medication management’’ [36, 50–53], ‘‘physician prescribing for multimorbid patients’’ [54–58], and ‘‘competing outcomes and clinical decision making’’ [59]. 3.4 Step 5 ‘Translation of Included Studies’ We identified and determined 11 key concepts with subthemes, reported below and presented in Tables 3 and 4. 3.4.1 Patients’ Views 3.4.1.1 Experimenting with Multiple Medicines to Get to Know Them ‘Trial and error’ was a common way for patients to become familiar with and to feel safe about their complex medical regimens. The participants tended to experiment with their medicines in different ways, ranging from stopping all medicines [50] to stopping some medicines to test their efficacy [50, 52, 53] or determine the cause of adverse effects [36, 50]. Some patients took regular breaks [50], tried individual medicines in a complex new regimen [50], and reduced or changed drug doses [36, 50]. 3.4.1.2 Attitudes and Beliefs about Medicines The way medicines are generally regarded Participants often held a positive and accepting attitude about the need to take medicines and trusted their GP [36], whereas others expressed dislike but took them: ‘‘I don’t like taking it but I have to and that’s all there is to it. It’s just one of those things you put up with’’ [51]. Further participants even felt a general resistance to taking certain medicines, especially regarding mental health [50, 51] and did not want to take more medicine than they already did [50]. The fear of becoming dependent on medicines was another factor for patients to resist taking them. This was the case for antidepressants, analgesics, sleeping pills, and non-

B. Bokhof, U. Junius-Walker Table 1 Characteristics of included studies Study

Objective

Participants, definition of polypharmacy

Methods

Results

Conclusions

Elliott et al. (2007) [50]

Older, multimorbid adults’ real medicine choices in the past (‘historical’) and hypothetical (‘future’) choices in terms of adherence

20 (8 male) communitydwelling seniors with health insurance, aged 67–90 years, 4–12 medicines, 3–9 comorbidities

Semi-structured interviews

Prioritizing of medicines (future choices): effectiveness and future risk of the disease. Key factors leading to nonadherence (historical choices): costs, side effects. No evidence of ‘adherent’ personalities

Prescribing a new medicine, a change in provider or copayment can provoke new choices about both new and existing medications in older adults with multiple morbidities

Fried et al. (2008) [59]

Views of older adults if their illnesses and tx interacted, tx goals, decisions to change or stop tx

66 participants, C65 years, median of 5 (range 3–8) chronic conditions; median of 7 (range 5–14) daily drugs

Focus groups

Context of decision making: from diseasespecific to global, cross-disease health outcomes. Preferred tx is the one that would achieve the most desired outcome

Prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors faced with complex healthcare decisions

Moen et al. (2009) [53]

Multiple medicine use from elderly pt’s perspective

59 (29 male) older adults, C65 years, mean age 76 years, using C5 medicines

Focus groups

Positive attitudes: grateful towards medicines. Negative attitudes: experiencing AEs and harm for the body. Medicine perception depended on trustful pt-doctor relation

Practice implications: importance of the pt– doctor relationship and the need for appropriate consultation length for tx success

Tordoff et al. (2010) [36]

How pts C65 years manage their medicines

20 (10 male), aged C65 years; at least one prescription medicine

In-depth semistructured interviews

Good, affordable access to medicines, good recall routines for medicine intake. Occasional missing doses due to change in routine. Practical problems in swallowing or halving tablets. Experiences with AEs when changing dose or drugs

Positive beliefs about medicines. Concerns about medicine taking should be routinely addressed and prescribing optimized to minimize AEs

Bagge et al. (2013) [51]

Experiences of medicines over lifetime and of medicine changes after hospital discharge

60 (30 male) older adults aged C75 years and older taking C4 drugs

Semi-structured interviews

Pt disliked having to take medicines, but perceived them as necessary. They trusted in their GPs’ expertise, took their medicine regularly, had no fear of possible side effects and were reluctant to take analgesics and non-prescription medicines

Acceptance of necessary medicines as part of everyday routine. Higher willingness of older people to take their medicines than studies on adherence have indicated

Older adults

Physician and Patient Views on Reducing Polypharmacy Table 1 continued Study

Objective

Participants, definition of polypharmacy

Methods

Results

Conclusions

Meranius and Hammar (2015) [52]

How older adults with multimorbidity experience medication selfmanagement and how this is affected by the healthcare system

20 older adults (11 male) aged C75 years, living in private homes, at least 3 diagnoses

In-depth interviews

Lack of communication hindered adherence, safety, led to health risk-taking. Healthcare organization as a system of repairing ‘parts’ but not enabling selfmanagement and the experience of health

Healthcare system enables tx of individual symptoms, but is not supportive in achieving and promoting good function and health

GPs and further healthcare providers Marx et al. (2009) [54]

GPs’ perception of polypharmacy

21 GPs and researchers, definition of polypharmacy: intake of C5 drugs

Group discussion

3 core aspects of polypharmacy: overview of prescribed medicines, communication between pts and health care providers and evidence for managing multimorbidity. GPs are torn between medical care and guidelines stipulation. Pt expectations, adherence, multiple prescribers, advertisements and cost influence pharmacotherapy

Simply improving evidence for the care of multimorbid pts via meta-guidelines is not enough to get over many other influencing factors

Moen et al. (2010) [55]

GPs’ perspectives of treating older pts with multiple medicines

31 GPs; definition of polypharmacy: use of more medicines than clinically indicated

Focus groups

Guidelines as ‘medicine generators’ with ambiguous effect on GPs. Lack of communication between GPs and hospital specialists, leading to reduced tx quality. Pt pressure leads to multiple medicine use

GP empowerment by policy makers to handle the increasing proportion of older pts with polypharmacy, receiving care from multiple specialists

Anthierens et al. (2010) [56]

GPs’ views on polypharmacy and their role in relation to improving prescribing behavior

65 (40 male) GPs, average age 50 years; definition of polypharmacy: multiple drug use; use of more medicines than clinically indicated

Semi-structured interviews

Polypharmacy leads to ADRs, interactions, and lowered adherence; lack of overview for exact medication intake; reducing drugs is hampered by pts’ strong belief in (self-) medication. Lack of regular medication reviews by GPs, several prescribers. Prevention and EBM guidelines induce polypharmacy

GPs feel responsible for optimizing drug regimens, yet, limited options for addressing polypharmacy leave GPs feeling helpless; simple GP-friendly tools and pharmacotherapeutic advice are needed

B. Bokhof, U. Junius-Walker Table 1 continued Study

Objective

Participants, definition of polypharmacy

Methods

Results

Conclusions

Schuling et al. (2012) [48]

How GPs feel about deprescribing medication in older pts with multimorbidity and how they involve pts in these decisions

29 (27 male) GPs, aged 39–65 years; definition of polypharmacy: multiple drug use; use of more medicines than clinically indicated

Focus groups

GPs perceived deprescribing preventive drugs as difficult due to lack of benefit/risk information. Barriers to GPs’ deprescribing: beliefs that pts have accepted polypharmacy; pts interpret stopping preventive medicines as professional resignation; discussing life expectancy vs. QOL with pts as taboo, guidelines compelling to prescribe, collaboration with specialists and dispensing pharmacists

Support and training in shared decision making will help GPs to deal with several guidelines and elicit pt preferences. Explicit rules for collaborating with medical specialists are required

Herrmann et al. (2015) [49]

How GPs prioritize and reduce medicines in multimorbid elderly pts at the transition between inpatient and home care

44 (14 male) GPs, aged 35–69 years; definition of polypharmacy: intake of C5 drugs

Focus group discussions and semistructured interviews. Development of case vignettes for daily routine with respect to drug optimization

Factors that influence deprescribing decisions: pt safety, pt wishes and QOL, pt health literacy, GPs’ competence in the healthcare system, evidence base, communication between secondary and primary care

GPs prioritise drug regimens according to rational criteria. Representative investigations and further education of care issues of drug therapy in elderly pts with multiple morbidities are necessary

Sinnott et al. (2015) [57]

How GPs make decisions when prescribing for multimorbid pts

Interview of 20 GPs about 51 multimorbid pts, mean age 75 years, 55 % female; definition of polypharmacy: intake of C5 drugs

In-depth interviews

If pts were stable, GPs preferred to ‘maintain the status quo’ than rationalize medications. Changes in medications were allowed by continuity of care, sufficient consultation time, open communication with pt, other healthcare professionals

GPs make compromises between pt-centered and evidence-based care

Physician and Patient Views on Reducing Polypharmacy Table 1 continued Study

Objective

Participants, definition of polypharmacy

Methods

Results

Conclusions

Smith et al. (2010) [58]

GPs’ and pharmacists’ views of managing multimorbid pts

13 GPs and 7 pharmacists; definition of polypharmacy: multiple drug use

Focus groups

Elements of an intervention are highlighted that could be designed and tested to improve multimorbidity management

Farrell et al. (2015) [47]

To identify and prioritize medication classes where evidencebased deprescribing guidelines would be of benefit

Panel: 3 pharmacists, 2 GPs, 1 social scientist. Survey: 65 geriatrics experts (36 pharmacists, 19 physicians, 10 NPs); definition of polypharmacy: intake of 2–9 drugs

Modified Delphi approach, 3 rounds

Predominant themes: multimorbidity and the link to polypharmacy and aging; health system issues relating to lack of time, interprofessional communication, fragmentation of care; professional roles, clinical uncertainty, avoidance; pt issues; management solutions Deprescribing guidelines are needed for mental health, cardiovascular, gastroenterological, and neurological conditions

Evidence-based deprescribing guidelines are a priority in the care of the elderly

ADR adverse drug reaction, AE adverse event, EBM evidence-based medicine, GP general practitioner, NP nurse practitioner, pt(s) patient(s), QOL quality of life, tx treatment

prescription medicines [51], whereas long-term users of sleeping tablets were unwilling to stop [51]. Evaluating a drug as beneficial or harmful Many patients perceived their medicines as beneficial because they were prescribed by their GP [53]. They were not concerned about adverse effects and trusted in their GP’s advice: ‘‘If I get them I would ring the doctor and know what it was’’ [51]. To their mind, medicines were the only way to reduce their symptoms and their use made participants feel safer in terms of their disease. Otherwise, the benefits of medicines did not seem to outweigh risks such as adverse effects [53]. Several participants doubted their medicines’ benefit due to adverse effects [36, 50, 53, 59] or perceived adverse effects as ‘‘competing, unintended outcomes’’ [59] that would influence their treatment decisions; others worried whether the use of multiple medicines ‘‘is good for the body’’ [53]. Some participants used dietary supplements because they believed them to be as beneficial as prescription medicines but without side effects [51]. 3.4.1.3 Personal experiences with medicines Participants experienced several situations and sentiments with respect to their complex medication regimens. These included practical issues, efficiency and side effects of medicines, and costs.

Practical issues affecting polypharmacy management For some participants, written memory aids [36, 50] or dosette boxes [36, 50, 53] helped them cope with complex drug regimens and to remember the correct drug intake. Some patients indicated that the intake of preventive medicines was harder to remember than that of symptom-specific medications because they did not feel its immediate impact on their physical condition [36]. Participants occasionally forgot to take medicines when their daily routine changed [36, 51, 53], and they stopped taking medicines when regimens were unpleasant or in unacceptable dosage forms. However, most of the patients reported that they took medicines according to instructions [36]. Perceived drug-related efficacy and side effects Participants reported that their choice of medicines had been influenced by experiences with side effects. One participant reported that he stopped taking a medicine that caused leg pain ‘‘because of the effect on my life. I couldn’t even go to the grocery store or anything’’ [59]. Doubts about the importance of disease also led to patients stopping medicines [50]. The desire for non-medical alternatives was triggered by the experience of side effects [50, 53], resistance to taking medicines [50], or ineffective treatment [52]. In some cases, alternative treatment methods were perceived as lacking ‘‘I think the Zocor is doing me harm. But what’s the alternative here … death?’’ [59].

B. Bokhof, U. Junius-Walker Fig. 1 Flow chart of study inclusion

Table 2 Characterization of included papers by country and interviewee group Interviewee group and country

Published language

References

USA

English

Elliott et al. (2007) [50]

USA

English

Fried et al. (2008) [59]

Sweden

English

Moen et al. (2009) [53]

New Zealand

English

Tordoff et al. (2010) [36]

New Zealand

English

Bagge et al. (2013) [51]

Sweden

English

Meranius and Hammar (2015) [52]

Older, multimorbid community-dwelling adults

GPs Germany

German

Marx et al. (2009) [54]

Sweden

English

Moen et al. (2010) [55]

Belgium The Netherlands

English English

Anthierens et al. (2010) [56] Schuling et al. (2012) [48]

Germany

German

Herrmann et al. (2015) [49]

Ireland

English

Sinnott C et al. (2015) [57]

Ireland

English

Smith et al. (2010) [58]

Canada

English

Farrell et al. (2015) [47]

GPs and further healthcare providers

GP general practitioner

Physician and Patient Views on Reducing Polypharmacy Table 3 Contribution of each study to key concepts (‘translation of studies into each other’)—older adults Key concepts

Sub-themes/references

Illustrative quotations (extracts)

Experimenting with multiple medicines

[36, 50, 52, 53]

‘‘What if I discontinue treatment for a week and see how it goes!’’ [53]

Attitudes and beliefs about medicines

The way medicines are generally regarded [36, 50, 51, 53]

‘‘Yes, but obviously one has faith in them otherwise one would stop taking them. That’s how I reason anyway’’ [53] ‘‘I don’t like taking it but I have to and that’s all there is to it. It’s just one of those things you put up with’’ [36]

Personal experiences with medicines

Evaluating a drug as beneficial or harmful [36, 50, 51, 53, 59]

‘‘Yes, and then I take medicines for the heart; I am totally dependent on nitroglycerine. The constant worry is what I think is most difficult.[…] Well, everyday. You could say always, all the time my mind is on that (her heart problems). […] Yes, for me it’s like that. Although I use anxiety relieving medicine. But I don’t want to use them. Because … I don’t think that is good for you; to use anxiety relievers’’ [53]

Practical issues affecting polypharmacy management [36, 50, 51, 53]

‘‘It’s absolutely crazy, you cannot break it in four. Cos in the hospital they gave me little pink ones and I found them much more easier, I find this—this stupid, I’ve told him but he don’t take any notice’’ [36]

Perceived drug-related efficacy and side effects [36, 50, 52, 53, 59]

‘‘Okay, so I’ve—I’ve been taking these (terazosin) for about five or six years and they’ve got really bad effects in terms of drying up mouths. So I’ve got—now I’ve got dental problems. I had really good teeth. Anyway so I’ve had—just replaced (terazosin) with a different one called (prazosin).They’re not—maybe not so damaging in terms of drying up the saliva. I thought they were making me slightly constipated (prazosin).Yeah. I might go back to (terazosin) but I mean I—there’s—there’s a very slight improvement in the dryness of the mouth’’ [36] ‘‘She gave me some stretching exercises that seemed to help an awful lot. I was able, finally, not to take the [celecoxib] and still get along pretty well. I keep it here if I wake up someday with a really sharp pain’’ [50]

Uncertainties with managing acute symptoms [52]

‘‘I get pain in my chest sometimes and take nitroglycerin tablets. I should take three of them, waiting 15 min between the tablets for the chest pain to disappear. I don’t want to upset the emergency nurse by calling before I take all three tablets, but if I am still in pain it is okay to call. At the same time though, they tell you it is your call; the patient should decide’’ [52]

Drug-related financial expenses affect adherence [36, 50]

‘‘I said my God, what do they think I’m a bank here or what! I have a lot of pills. But if they [prices] jump like that I’ll have to start cutting them in half or stop taking them. So a few of them that I haven’t been taking I don’t take them anymore. Just can’t afford it’’ [50]

Necessity of priority-based treatment decisions in the face of multimorbidity

[50, 59]

‘‘I have a feeling the Beconase would strike me as more important [than the atenolol] for my comfort, for my noticing.’’ [50]

Relationship to GP affecting reasonable medication management

[50–53]

‘‘I’m not happy about it. But as I say, I trust my GP. And if she tells me I need something I take it’’ [51] ‘‘… but why doesn’t the doctor find the reason for my problems? Then I think that the drugs are unimportant, or else the doctor would have bothered more about it’’ [52] ‘‘The doctor has been in such a hurry, by the way, all of them are. He is not Swedish and has difficulty understanding. They do not trust people who have problems with speech; even my own doctor does not believe me because I say the wrong words. It’s weird; when you have difficulty talking they think you don’t get it. I still want to participate in a conversation’’ [52] ‘‘Yes, everything! What is this medicine for? What adverse effects can one encounter? And how should one take it? […] Information! One doesn’t know the benefit of the drug …’’ [53]

B. Bokhof, U. Junius-Walker Table 3 continued Key concepts

Sub-themes/references

Illustrative quotations (extracts)

System-related contributors to polypharmacy

Consultation time is limited [52, 53]

‘‘The doctor’s visit lasts only 20 min, which is too short a time to tell him about my problems’’ [52]

Patients distrust in the healthcare system due poor experiences [52, 53]

‘‘I had been to the family doctor the same week, and twice before that. I saw two different doctors. They should have checked me. At the hospital, they found out that I had water in my lungs. I could have died’’ [52]

Multiple prescribers and competency [52, 53]

‘‘I think it’s a matter of prestige between the doctors. They don’t like to consult each other. The family doctor is not willing to make contact with the kidney specialist, nor is the cardiologist, who prescribed inappropriate tablets even though I asked him to consult the kidney specialist’’ [52]

The pharmaceutical industry influences prescribing [53]

‘‘Do you think the doctors know how many (medicines) one has? I don’t think so…Maybe they are treated with a trip here and there [by the drug industry]. One never knows …’’ [53]

GP general practitioner

Uncertainties with managing acute symptoms Some participants worried more about their present physiological functions and acute symptoms than about their medicines’ effect on their future health. Sometimes, when participants experienced acute symptoms of their illness, they became insecure and worried about deciding whether to take medicines or to seek professional assistance: ‘‘I get pain in my chest sometimes and take nitroglycerin tablets. I should take three of them, waiting 15 minutes between the tablets for the chest pain to disappear. I don’t want to upset the emergency nurse by calling before I take all three tablets, but if I am still in pain it is okay to call. At the same time though, they tell you it is your call; the patient should decide’’ [52]. Drug-related financial expenses affect adherence Generally, the access to medicines was thought uncomplicated, and patients did not perceive drug costs to be a problem [36]. However, for a substantial subgroup of the US elderly chronically ill population, changes in coverage, economic circumstances, or providers or initiation of a new medicine led to increased co-payments. Consequently, some participants modified their regimens or rejected medicines outright and felt unfairly treated and resentful [50]. Further participants weighed the potential or actual benefits of partfunded/unfunded medicines against the costs when deciding whether to start or stop taking medicines, ‘‘I’m not sure if we were prepared (to pay) ninety dollars a month um because the pain I have now is bearable’’ [36]. 3.4.1.4 Necessity of Priority-Based Treatment Decisions in the Face of Multimorbidity Living with complex medical regimens entailed prioritizing medicines for some participants [50]. They referred to cross-disease health outcomes such as survival, preservation of physical function, and

symptom relief and weighed them against one another in regard to their subjectively perceived relevance [59]. When questioned as to how one participant would decide between treating her arthritis or her heart disease, she expressed that if therapy for one had the potential to worsen the other, ‘‘I think I would go back to the thing that I fear most, being incapacitated and living, so I would choose whatever would prevent that’’ [59]. Patients with chronic diseases thought they had no other choice but to take additional, preventive medicine, although they did not believe them to be risk reducing. In the long run, they were afraid of stopping and believed that they avoided immediate death, ‘‘If you have a heart condition, you don’t want to cut [the medications for your heart] out or else you won’t be here’’ [59]. 3.4.1.5 Relationship to General Practitioner (GP) Affecting Reasonable Medication Management A trusting relationship with good communication [52] between the patient and their GP was a reoccurring concept for those coping with polypharmacy. Some patients saw the responsibility for medical decision making as lying with their doctors; others felt responsible for their own healthcare needs as their experience was that no-one else would do it for them [53]. Some participants were not sufficiently informed about the reasons for using medicines, about the kind and number of medications necessary to control disease, or about side effects [52]. ‘‘Alright … I take six medicines, of which five are for the blood pressure and the sixth is lipid-lowering. I don’t know how many of these are necessary’’ [53]. Also, not being able to stop treatment after symptom relief, e.g., if the blood pressure was ‘‘normal’’ again, caused frustration or confusion [53]. On the other hand, patients tended to not inform their GPs and pharmacists of medicine

Physician and Patient Views on Reducing Polypharmacy Table 4 Contribution of each study to key concepts (‘translation of studies into each other’)—GPs and further healthcare providers Key concepts

Sub-themes/references

Illustrative quotations (extracts)

Assumptions about old patients

Patients do not understand what medicines they are taking [48, 49, 54– 58]

‘‘The other problem with a percentage of these patients is that they are, you know, cognitively impaired and it’s very difficult to explain things to them and you have to explain things again and again, and in fact they still get muddled up with their tablets and all the rest of it.’’ [58] ‘‘They take a blood-diluting drug. Then they take another aspirin with another brand name because their neighbor told them that they should take one daily. They have no idea what they are taking …’’ [56]

Patients do not inform their GP about their medicine intake [48, 54–56, 58]

‘‘… sometimes the older people decide for themselves to reduce some of their medication or to adjust the doses without telling their GP. Therefore as their GP you can have the wrong impression about their medication intake…’’ [56]

GPs assumptions on patient reactions [48, 55–57]

‘‘A lot of medication that has once been prescribed is being taken daily. The patient feels fine and does not want to change the medication regime’’ [58] ‘‘What you are saying by stopping it [a statin] is ‘‘I’m stopping this now because really now you are so old so if you get a heart attack at this stage … whatever [55]

Interface prescribing problems contributing to polypharmacy

[48, 49, 54–58]

‘‘When people have three, four, five different illnesses and particularly where the care is kind of fragmented, under the care of a number of doctors, they’re often not sure what exactly is wrong with them, or what illnesses or diagnoses they have’’ [58] ‘‘Rather he (patient) was supposed to have it for five or six months, and at the time we discovered this he had been receiving it for several years. In these cases it sometimes feels like information doesn’t cross over’’ [55]

Evidence-based guidelines contribute to polypharmacy

[47–49, 54–58]

‘‘… If you look at the guidelines on what to prescribe post-infarct… Strictly speaking that is 6 additional drugs…You will have to draw a line between what is scientifically proven and what is realistic in daily practice…’’ [56] ‘‘It should be so that studies are presented that change the guidelines, so to speak, that they become related to age. It must depend a little on that guidelines are most often written by specialists. They’re not written for primary care medicine or general medicine’’ [55]

Failure to meet the challenge of complex decisionmaking

[48, 49, 54–58]

‘‘We do not always have an overview of the interactions, that is a big problem, firstly there is not much information available for us GPs, and secondly when there is information available to us it does not mean that we know it; it is not that simple …’’ [56] ‘‘You prescribe (a new medicine) then you think: ‘‘They already have five–six medicines. How will they interact? It may not give the desired effect at all, and it may interact with the other medicines. That one has no control over’’ [55] ‘‘The number of medications grows slowly. There is a complaint, we give new medication, it continues without really stopping it after a while …and it is our responsibility to try and withdraw it from the patient…’’ [56]

Proposals for solutions

Relaxing treatment targets and prioritization [48, 49, 54–58]

‘‘Well it wouldn’t be ‘‘my way or the highway’’; you need to negotiate it, because as you know people have all sorts of kind of fixed ideas about things really and it can be difficult to dislodge them’’ [57] ‘‘I’m not aiming for very tight control—I’m happy if his sugars are running a little higher than normal. I mean he has got cardiac failure as well, his life expectancy isn’t brilliant—so long term I think, I don’t think it’s his type 2 diabetes that’s going to kill him’’ [57]

B. Bokhof, U. Junius-Walker Table 4 continued Key concepts

Sub-themes/references

Illustrative quotations (extracts)

Informing, training and involving patients [48, 54–58]

‘‘Above all you should provide sufficient information to enable people to make a choice. Honest and good information. Let people choose for themselves however. Not based on emotions but numbers. Explain it with percentages’’ [48] ‘‘An elderly person stands up, feels dizzy as hell, but he may live a little longer. Well, these matters I discuss’’ [48] ‘‘You have to go ‘‘this is your life, your decision’’ and then give them my advice but they have to make the decision for themselves’’ [57]

Using system support [54, 58]

‘‘… if we had time to have longer consultations with them they would consult us less.’’ [58] ‘‘We need a multimorbidity rehab scheme where we can send all these people, I’m not joking, like post-MI [myocardial infarction]’’ [58]

Developing deprescribing guidelines considering multimorbidity and old age [47]

‘‘Deprescribing should like be a component of all treatment guidelines. To date it has not been given the attention it deserves. I feel focusing in on a few drugs, developing the methods for deprescribing guidelines and getting a few guidelines into play is what is needed to catalyze a larger deprescribing movement’’ [47]

Improving interface cooperation [57, 58]

‘‘One could decide to, say for good practice to actually, to ask a patient to nominate a GP for their chronic conditions, which ideally should be seen on a planned basis’’ [58] ‘‘to bounce [ideas] off your colleagues just helps, even if it is just something like ‘‘what in the name of God am I going to do about this’’, it’s really important.’’ [57]

GP general practitioner

changes they made [53]. Consequently, neither GPs nor pharmacists were aware of the actual doses and medication regimen of many of their patients [50]. 3.4.1.6 System-Related Contributors to Polypharmacy Consultation time is limited Generally, consultation time was perceived as too short [52, 53]. When contacting their GPs proactively for regular checkups or because of side effects, several participants experienced resistance on the part of the healthcare system [53]. Patients’ distrust in the healthcare system due to poor experiences Several patients even felt they were a burden on the healthcare system [52] and as such they exposed themselves to hazardous situations by seeking professional care too late: ‘‘I saw two different doctors. They should have checked me. At the hospital, they found out that I had water in my lungs. I could have died’’ [52]. Further patients distrusted the healthcare system after having poor experiences such as no follow-up, not being heard, conflicting advice given by different doctors, or doctors perceiving themselves as superior or backing each other up [53]. Multiple prescribers and competency Specialists were perceived as having too little general knowledge, resulting in medicines being prescribed that interacted with other medicines or that caused adverse effects [53]. Patients felt

the lack of professional co-operation was a matter of reputation between specialists [52]. Participants generally viewed pharmacists positively, but as only playing a minor role. Only a few talked to pharmacists about medicine concerns, and then only sought advice on adverse effects and minor problems [36, 51]. Nurses were not explicitly mentioned in the context of medication decisions. The pharmaceutical industry influences prescribing Some patients also expressed concerns about the pharmaceutical industry influencing GPs to over-prescribe [53]. They perceived the pharmaceutical industry as putting profits before safety and withholding negative information. They wondered how medicines with many adverse effects could be allowed on the market. ‘‘Maybe they are treated with a trip here and there (by the drug industry). One never knows.’’ [53]. 3.4.2 Views of GPs and Other Healthcare Providers 3.4.2.1 Assumptions About Elderly Patients Patients don’t understand what medicines they are taking GPs saw patients’ health literacy as important for successful treatment. They indicated that patient characteristics such as old age, impaired cognitive function, and lack of adherence and education hampered effective communication and participation in decisions about appropriate medicines [48, 58].

Physician and Patient Views on Reducing Polypharmacy

Patients do not inform their GP about their medicine intake GPs felt they were not completely aware of the difficulties their patients experienced. Patients tended to under-report adverse effects and rationalized them as ‘old age’ [48]. Other patients would unilaterally decide to reduce their medication, adjust the doses, or take nonprescription medicines [54–56, 58]. GPs perceived patient self-medication [55, 56], pressure from patients, and expectations from patients’ next of kin as contributing to multiple medicine use [55, 56]. GPs’ assumptions about patient reactions GPs appeared to perceive the issue of deprescribing as difficult, feeling that many patients expected them to prescribe [55, 56], valued their medication [48], or had no problem with polypharmacy [48]. Patients even showed off: ‘‘You know what a mass I have to take each day?’’. Moreover, GPs avoided discussing stopping preventive medicines because they were concerned that patients might interpret this as a sign of being given up on ‘‘Don’t I count anymore, am I not important?’’ [48], which had the potential to damage the doctor–patient relationship [57]. Several GPs were also reluctant to talk about life expectancy versus quality of life, ‘‘I think it’s tricky to discuss life expectancy with a patient’’. Others perceived such a discussion as positive for their relationship, ‘‘Well doc, when it’s over tomorrow, that’s OK with me’’ [48]. 3.4.2.2 Interface Prescribing Problems Contribute to Polypharmacy A good relationship between patients, specialists, hospitals, and GPs was considered essential for polypharmacy management; however, GPs believed there to be ‘‘[A] collusion of anonymity, … this is not my patient’’, poor inter-professional communication [58] leading to unnecessary prescriptions by multiple physicians, and consequently adverse clinical outcomes [49, 54, 55]. Additionally, dissent between prescribers each insisting on their own relevant guidelines [58] hampered the coordination and overview of medication. Some GPs felt responsible towards overseeing patients’ medicines [54, 56]. Others were insecure about their task and desired ‘‘a clear line of responsibility’’ [58]. GPs felt frustrated when interacting with junior hospital doctors who changed regularly and were inexperienced [58]. Instead, they perceived themselves as ‘gatekeepers’ with a broader view of their patient, whereas ‘‘specialists narrowed the things down’’ [56]. GPs rarely contacted specialists to explore their motivation for prescriptions [55]. Despite these reservations, GPs viewed an exchange of knowledge with colleagues as desirable in achieving a ‘‘balance of equals’’ and to improve their awareness of the complexity of multimorbidity [54, 57, 58]. Thus, all prescribers involved

would become empowered to ‘‘speak with one voice. Different stories provoke distrust’’ [48]. 3.4.2.3 Evidence-Based Guidelines Contribute to Polypharmacy Although GPs reported they generally agreed with guidelines, many felt torn between providing individual medical care and complying with stipulations [54]: ‘‘To me, the guidelines are kind of a hindrance. At the moment they do not cater for older patients’’ [48]. Guidelines focused on single diseases [48] and led to polypharmacy [54, 55]. ‘‘If you want to follow the evidence-based guidelines … then quickly you will come to six additional medications.’’ [56]. Participants stated they often felt guilty when they did not adhere to guidelines. Consequently, several GPs desired deprescribing guidelines that consider the age and multimorbidity of the patients [47]. Others relied on their own personal experience [54]. 3.4.2.4 Failure to Meet the Challenge of Complex Decision Making GPs felt poorly equipped for polypharmacy management Several GPs admitted that their prescribing was inappropriate due to their uncritical attitude towards initiating new medicines [56], too short consultation time, and lack of treatment plans [57]. GPs and pharmacists felt insecure, overwhelmed, and inadequately prepared to manage polypharmacy [48, 54, 58]. One reason for this lay in the susceptibility of older patients to harm [55]. Another reason was that older multimorbid adults are rarely included in clinical trials, so research results could not be easily transferred to this patient group [55]. Decision making for appropriate medicines was perceived as a challenge [49, 54–56, 58]. GPs found it difficult to weigh treatment risks against benefits in terms of the shorter life expectancy of older patients, preventive medicines and adverse effects, medical over- and undersupply, or other treatment options [49, 54]. Even if information about benefits and risks was available, some GPs felt unable to communicate such complex risks [55]: ‘‘We can’t predict the effect for the individual patient’’ [48]. They also feared legal consequences when deprescribing ‘‘… but if you stop something and something happens, you know, it gets very dodgy’’ [58]. Therefore, they tended to avoid regularly reviewing medicines: ‘‘To be honest, you often get that sense [of opening Pandora’s box].’’ [58]. Consequently, medicines were continued for longer than necessary [55]. 3.4.2.5 Proposals for Solutions Many GPs had already developed ideas or applied approaches to face polypharmacy. These included relaxing treatment targets, prioritizing treatments, and applying patient-centered and patient education strategies. They also sought to optimize medication management processes and relied on IT system support.

B. Bokhof, U. Junius-Walker

Relaxing treatment targets and prioritization Some GPs tended to relax their treatment targets, negotiate compromises, and focus on maintaining the status quo [57]. Others considered prioritization criteria for pharmaceutical treatment, including patient safety, quality of life, life expectancy, and patient will [49]. Informing, training, and involving patients A doctor’s medical expertise and communicative competence in terms of joint responsibility was recognized by providing information and focused education in face-to-face conversations [54]. For example, GPs suggested placing ‘‘ARR (absolute risk reduction) numbers on the package’’ [48] or advised patients about keeping a medication chart. They also informed patients about alternatives to medication (e.g., lifestyle changes [54]), motivational withdrawal strategies, or a list of priority medication [48, 56, 58]. When deprescribing, GPs assessed individual needs, treatment targets, and patients’ capacities and characteristics by involving the patients and caregivers in the process [54, 55]. A longstanding patient–GP relationship was perceived as essential for this sort of patient-centered care [48, 54, 56, 58]. Using system support GPs perceived software-assisted prescription analysis as helpful when managing and overviewing (self-)medication [54]. Developing deprescribing guidelines considering multimorbidity and old age GPs considered the development of evidence-based deprescribing guidelines for several drug classes, such as mental health, cardiovascular, gastroenterological, and neurological conditions, as necessary. The guidelines should carefully consider GPs’ appraisals and patients’ age and multimorbidity. They should also contain risk assessments on continuing versus stopping drugs and alternative treatment options: ‘‘Deprescribing should like be a component of all treatment guidelines. To date it has not been given the attention it deserves. I feel focusing in on a few drugs, developing the methods for deprescribing guidelines and getting a few guidelines into play is what is needed to catalyze a larger deprescribing movement’’ [47]. Improving interface cooperation Communication on an equal footing, joint therapy circles, and close cross-sectoral information exchange, including with pharmacists, were proposed to optimize interdisciplinary co-operation [54, 58], ‘‘Would be useful if we could phone a geriatrician, some sort of resource like that when we are feeling out of our depth’’ [58]. 3.5 Step 6 ‘Third-Order Interpretations’—‘Line of Argument’ In step 6, patients’ and GPs’ key concepts were interpreted on a third-order level and linked in a line of argument.

3.5.1 Patients’ Views Many older patients with polypharmacy struggle with the complexity of their medication regimens and therefore find it difficult to take responsibility for their medicines. Several patients meet this challenge by experimenting to become familiar with drug effects. Moreover, past drugrelated experiences with respect to manageability, adverse effects, and costs influence patients’ decisions on (dis)continuing medicines. Some patients attempt to prioritize treatments with respect to a best possible quality of life and autonomy. A trusting relationship is crucial for patients to feel comfortable with prescribers’ regimens. Key factors include information on the drugs and benefits and risks, a good communication style allowing for negotiation, patients’ individuality, and shared decision making. These require sufficient time resources. 3.5.2 GPs’ Views Apart from medically driven considerations influencing medication decisions, non-medical contributors to polypharmacy emerged. These derive from patients, prescribers, and the work environment. On the one hand, patients are perceived as putting pressure on their prescribers; on the other hand, GPs self-critically admit to easy-going medicine prescribing and a certain inertia towards reducing them. This is a consequence of insecurity and poorly developed solutions in polypharmacy management. Medication management takes place in the context of short consultation times and is sometimes influenced by fear of prosecution. Additionally, interface communication is lacking. GPs managing older patients face the dilemma of weighing the risks of side effects of medications against the risks of discontinuing them, measuring the benefits of life gains achieved by preventive medicines against the timely proximity of death in some cases, and finding the right balance between over- and undersupply. These decisions must be made on an individual basis; however, GPs were able to apply some solutions (Table 5).

4 Discussion Polypharmacy is a growing challenge to patient safety and effective care, and solutions are sorely needed. As evidence-based medicine does not offer ready-made solutions, this paper seeks direction and findings from routine care. To our knowledge, this is the first review to systematically synthesize the perspectives on reducing polypharmacy of

Physician and Patient Views on Reducing Polypharmacy

both older, multimorbid adults and primary healthcare providers. Patients felt insecure and rather unprepared to deal with complex medication regimens. Patients used several heuristics to arrive at medication-related decisions. They experimented with their drugs, considered past experiences, sought information on medicines, and desired a trusting doctor–patient relationship in which decisions could be shared or handed over to the doctor. General attitudes towards medications also played a role, although the use of new technology did not seem important to patients as yet. GPs often felt pressurized to prescribe in the first place due to patient expectations or the need to follow evidencebased guidelines. Deprescribing decisions were sensed as not easy, particularly when no guidance was available. As noted in Sect. 3.5.2, GPs are faced with difficult decisions concerning the risks and benefits of medications, particularly in terms of the role of preventive medicines in patients near the end of life. They also considered the reaction of the patients, who might have come to value their medicines or feel that deprescribing is a sign of abandonment. Decisions were further complicated by the fear of litigation. GPs also found it difficult to convey an understanding of complex drug issues in the absence of sufficient health literacy. They wished for patients to inform them when medication was not taken as prescribed. System factors, such as multiple prescribers, interface problems, and insufficient consultation time were mentioned by both patients and GPs. GPs and other healthcare providers also applied heuristics to handle the complexity of medication management. These mainly dealt with the decision-making process: relaxing treatment targets, prioritizing treatments, and negotiating compromises. Because these decisions were made on an individual basis, a patient-centered consultation style was regarded as essential. Standards of good medicine were also mentioned, such as regular medication reviews and technical support for determining drug–drug or

drug–disease interactions. Evidence-based deprescribing guidelines were recognized as providing useful assistance for the care of older, multimorbid patients. When comparing GP and patient statements, the relational aspect emerged as a prominent pattern when dealing with medication decisions. GPs often adopt a simultaneously critical and caring attitude towards their older patients, who are often viewed as barely health literate, as unpredictable in implementing medication plans, and sometimes as attempting to pressurize their doctors. Together with the fact that physicians feel responsible for medication regimens and patients tend to trustfully hand over their responsibility, the relational structure resembles the parent–child model in the transactional analysis. However, suggested solutions work on an adult–adult level and are built on individualizing decisions guided by a communication process undertaken on an equal basis [60]. 4.1 Relevance to Findings from Previous Research Four previous reviews of qualitative studies were partly comparable to our issue as they investigated aspects of multimorbidity and polypharmacy or deprescribing of certain drug classes. Three reviews aimed at doctors’ views [61–63] and one considered the patients’ perspective [64]. Altogether, only five of our original qualitative studies were also included in their reviews [48, 54–56, 58]. Reeve et al. [64] conducted a patient review and also found patient factors relating to certain drug classes. Experimenting with medicines, general attitudes towards medication, and experiences with effects and side effects were factors that influenced continuing or stopping medication use. Patients also expressed their views on the importance of a good doctor–patient relationship in which communication and trust is upheld and haste avoided. However, no age limits were applied to participants, and the medications involved were primarily psychotropic drugs. Our review adds some dimensions in that patients try to prioritize treatments in line with maintaining a

Table 5 General practitioners’ solutions to the challenges of reducing polypharmacy in older patients Trust in your own experience Consider non-pharmaceutical alternatives Apply routines in medication management and make use of technical support Relax current evidence-based treatment targets Rethink the treatment aims; maintain the status quo, i.e. stabilize the patient’s current state of health; put quality of life first Provide information; seek the patient’s view; apply shared decision-making and negotiate compromises Break the taboo against consulting with your colleagues and participate in cross-sectoral communication Participate in the development of age- and multimorbidity-specific deprescribing guidelines

B. Bokhof, U. Junius-Walker

reasonable quality of life. It also becomes apparent that patients are aware of and experience interface problems between prescribers. From the GPs’ point of view, previous reviews share findings with ours that address patient issues and the insecurity of making decisions. For example, it has been noted before that some of the drivers to polypharmacy are patient pressure [62] and multiple and interface prescribing [61, 63]. Decisional conflicts are also recognized due to drug complexity, failing guidelines, and a limited number of effective non-drug treatment options [61, 62]. Unsupportive working conditions also have a part to play [61, 62]. In combination, this leads to a ‘‘failure to act’’ [61]. Prescribers are able to offer heuristics that they either already apply or consider useful in solving the issue of inappropriate polypharmacy management. Only some of them have been mentioned earlier—IT support [62] and a patient-centered approach—which potentially resolve conflict and uncertainty but may increase the complexity of managing polypharmacy [63]. Some new approaches are being tested. Reeve et al. [65] developed a patient-centered deprescribing process based on patient knowledge and views on medication cessation. A further approach is a stepwise strategy of discontinuing medicines by GPs in a two-way consultation with a pharmacist to reduce clinically significant adverse events [8]. Algorithms, such as the GPCP [66], MAI, Beers criteria, and the STOPP/START (Screening Tool to Alert doctors to Right Treatment) [67] have shown some benefit with respect to reduction in inappropriate prescribing. The SIGN guideline has introduced a ‘7-step approach’ to medication review to distinguish appropriate from inappropriate polypharmacy [68]. 4.2 Strengths and Limitations We identified 11 key concepts and linked them in a line of argument accounting for both patients’ and GPs’ perspectives. Although there is some overlap with previous findings, this comprehensive review presents additional and solution-based concepts and a deeper understanding of the complex issue of managing polypharmacy in multimorbid older patients in the context of primary care. The broad approach of including studies in countries with different healthcare systems within a wide range of publication years using perspectives of 546 participants contributed to these findings. Relevant articles may have been missed as the database search was limited to four databases, exclusion of languages other than English and German, and exclusion of grey literature. Our findings are based on 14 qualitative studies, and we do not know whether all relevant issues were addressed. Also, meta-ethnography—a useful and inductive but not entirely objective technique for

qualitative research—is open to varying interpretations. Moreover, the qualitative studies included performed inductive, deductive, theory-developing, or theory-driven techniques. These different approaches might have influenced our interpretations. 4.3 Robustness of Findings Through a step-by-step approach, our analysis generated themes in a transparent and reproducible manner. The robustness of our findings was supported by quality checks. Potential reporting bias of the studies included was assessed via COREQ [34]. Theme identification and synthesis was validated by two researchers. 4.4 Implications for Practice To improve complex polypharmacy management, several key levers must be adjusted. These include, in particular, patients’ awareness of their complex multiple medication regimens and a better position to receive sufficient information about their drugs. Enhanced health literacy will empower patients to share treatment decisions, which are highly individual in the face of such complexity. A partnerlike relationship will also promote patient willingness to provide feedback and transparency as regards self-medication, unwanted effects, and non-adherence. Furthermore, GPs are in need of more support. Apart from medical IT support dealing with interactions and dosage adjustments, doctors require evidence-based (de)prescribing procedures. This again implies the urgent necessity of including older primary care patients in evidence-based studies. Apart from this, it seems that medication management for patients with multimorbidity first and foremost requires a comprehensive individual and not disease-oriented approach. To achieve this, a trusting relationship with receiving and giving information, negotiating and prioritizing treatments, and shared decision making approached on an equal basis is essential. Health system changes, such as protected consultation time for medication reviews, and clear prescribing roles and responsibilities for interface management will enhance progress.

5 Conclusions Collating the profound wealth of experience is one way to assemble solutions in the face of polypharmacy. This review shows that, apart from pharmacological and medical knowledge, wider communication with patients about their individual treatment goals and drugs are important

Physician and Patient Views on Reducing Polypharmacy

factors in handling polypharmacy successfully. More time is a prerequisite for such complex decisions. Compliance with Ethical Standards Funding No sources of funding were used to assist in the preparation of this article. Conflicts of interest Beate Bokhof and Ulrike Junius-Walker declare that they have no conflicts of interest relevant to the content of this review.

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