When patients with a complex medication regime are identified, appropriate management is necessary. However, this is not easy. To a great extent prescribing of medications relies on the GP’s approach because patients with multimorbidity often visit their GP and GPs turn out to be reluctant in consulting a pharmacist or medical specialist when facing a difficult medication regime, as mentioned in chapter 5[9, 15]. GPs seem to adhere to the clinical practice guidelines (CPG) when possible, but also (highly) rely on their own previous experience and preferences for a therapy. For decades, GPs are encouraged and educated to adhere to the rapidly increasing collection of CPGs[44], but to date adhering strictly to the disease-specific guidelines is inappropriate when managing patients with multiple diseases with a complex medication regime. This resembles the findings that guidelines do not fit when providing appropriate care to patients during the final stages of life[45]. For this patient group, there is a movement that guidelines should be directed not only at ‘action’ but also at ‘inaction (alternative action)’, that shared-decision making is one of the most important basic principles for ensuring appropriate care, and that a multidisciplinary consultative team should be in place that can assist with complex treatment decisions[45]. What should treatment look like for patients with a complex medication management?
Most importantly, management should be highly tailored to the person, and focused on maintaining or improving patient’s abilities, and patient’s capacity to cope and participate in social activities, in line with the concept of positive health defined by Huber et al[46]. Asking the patient ‘what he wants’ and ‘what is bothering him most’ can help to prioritize management to the aspects that will have the highest impact on patients[16, 18, 47]. To elucidate what the patient wants and what he needs to manage his life independently to the very best of his abilities, clear communication is essential. More specifically, it means clear communication from the GP towards the patient, but also from the patient towards the GP. The patient should be adequately informed by the GP about the expected benefits and harms of different medications and treatment options, by also taking into account the patient’s level of health literacy[48, 49]. On the other hand, the patient
Chapter 7
124
should have the opportunity, but also take the opportunity and responsibility, to share his concerns about current treatment. For instance about (potential) medication side effects, the complexity of the medication regime, or about non-adherence. This seems a challenge, since patients nowadays still find it hard to express their concerns openly or spontaneously[50, 51]. To create an environment where both parties can actively discuss their concerns and preferences about current treatment, GPs and patients might profit from training or support. For patients, one could think of a patient information leaflet describing patient’s ‘rights’ during a consultation with the GP, or with possible ‘example questions’ to ask to the GP. An individualized care plan can be used to report the agreed management approach with patient’s treatment priorities and abilities. It is necessary to evaluate this plan frequently because of the changes in conditions of life (due to treatment), changing treatment priorities, and to pay attention to possible future problems. Generally, such kind of approach is visualized by the Ariadne principles, see Figure 1[18].
Figure 1. Schematic overview of the management approach based on the Ariadne principles (Muth et al, 2014)[18]
Two promising treatment programs for older patients with a complex medication regime are a clinical medication review, and the integrated care program for frail elderly. Clinical medication reviews have proven to decrease the number of medication related problems and improve patient satisfaction with the medication regime, which seem valuable goals for a patient[52-54]. Embedding a structural medication review as a component of the medication management approach of GPs (and pharmacists) seems therefore promising. However, detecting (potentially) inappropriate medications is only the first step. It should
General discussion
125
also result in appropriate action (e.g. adjusting medications, stopping medications, maintaining the current strategy), and GPs sometimes turn out to be indecisive about the best approach, as described in chapter 5. So, it is necessary to support GPs in their decision-making process, by providing evidence on appropriate medication combinations and the experience of other health professionals when facing a difficult regime, as described earlier. Future research on medication reviews should still focus on examining clinical outcomes, such as decreased hospital admission rates or improved quality of life, and should investigate potential solutions around organizational issues, for instance the issue around the target group who will benefit most from a medication review.
Integrated care programs for (frail) elderly which are currently only offered on regional level can improve the integrated approach of pharmacists and GPs in the management of patients with -most likely- multiple diagnosed chronic diseases and prescribed medications[26, 55-57]. In line with GPs’ and pharmacists’ preferences, (Chapter 6), case- finding for eligible older patients in these programs also relies on signals of the care providers in general practice, and on signals of caregivers from patients’ neighbourhood. In addition, attention for appropriate prescribing is a main element of these programs. Hence, nationwide use of such a care program is suggested to facilitate the medication management process. Future research should investigate its feasibility and effectiveness.