Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Mailed reminders to outpatient care providers reduced polypharmacy in the short term

ACP J Club. 1991 July-Aug;115:30. doi:10.7326/ACPJC-1991-115-1-030


Source Citation

Meyer TJ, Van Kooten D, Marsh S, Prochazka AV. Reduction of polypharmacy by feedback to clinicians. J Gen Intern Med. 1991 Mar-Apr;6:133-6.


Abstract

Objective

To reduce, through physician education, the number of active prescriptions for patients with ≥ 10.

Design

Randomized controlled trial of up to 12 months duration.

Setting

Veterans Affairs Medical Center outpatient clinics.

Patients

292 patients (mean age 62 y, 96% men) who had ≥ 10 active prescriptions (excluding topical preparations and eye medications) during May 1988 and who were alive on 1 June 1988 were randomized. In the next year, 20 patients (6.8%) left the center.

Intervention

Patients were randomized into 3 groups. Group 1 patients (control, n = 88) and their care providers received no intervention. In group 2 (n = 102), providers were notified of the patients' names and of the dangers of overmedication and were asked to reduce the number of medications. In group 3, providers for patients in the intensive group (n = 104) received an initial letter as for group 2, followed by a personal letter about the patient, estimating the patient's compliance with the drug regimen and giving specific recommendations for altering the patient's regimen.

Main outcome measures

Number of active prescriptions 4, 6, and 12 months after the first letters were sent out, and mortality.

Main results

62% of patients had cardiovascular disease; 47% had hypertension; 29% had psychiatric illness; 28% had emphysema; 27% had arthritis; 25% had diabetes; and 12% had chronic pain syndromes. Overall, there was a positive relationship between psychiatric prescriptions and total number of medications (11.4 for patients not receiving psychiatric medications, 12.0 for those receiving psychiatric medications, P = 0.014) and between number of providers (mean, 2.97) and number of active prescriptions (P < 0.001). Numbers of active prescriptions declined in all groups through the year (P = 0.001). There was no difference in reduction of prescriptions between the 2 intervention groups (P = 0.189), but the combined intervention groups had a reduction at 4 months compared with the control group (P = 0.028). This difference had disappeared by 12 months (P = 0.230). 24 patients died and 20 left the Denver VA system but mortality and drop-out rates did not differ among the groups.

Conclusions

A mailed reminder to outpatient care providers was effective in reducing polypharmacy in the short-term. A more intensive intervention was no more effective.

Sources of funding: Denver Veterans Affairs Medical Center and the University of Colorado Health Sciences Center.

Address for article reprint: Dr. T.J. Meyer, Denver Veterans Affairs Medical Center, 1055 Clermont, Denver, CO 80220, USA.


Commentary

This is the first study using a randomized controlled design to evaluate the effectiveness of educational interventions in reducing polypharmacy. The results include a reduction in polypharmacy in the control group, underscoring the importance of using a randomized controlled study design.

The study also highlights the value of extended observation after educational interventions (1). If the authors had stopped this study at 4 months, we would have concluded that the educational interventions were effective. However, the intervention and control groups were not substantially different at 6 and 12 months, showing that the effect was transient.

The authors suggest 3 possible explanations for this finding. If patients with an extreme number (≥ 10) of active medications are selected, they will have fewer active medications on follow-up because of random variation (regression to the mean). This could explain the reductions in medications in all groups, but not the difference at 4 months between intervention and control groups. Second, many of the patients in the control group were followed by providers who had patients in the intervention groups. Providers might also reduce medications in the control group because of information they received for intervention patients, a crossover or contamination effect. Third, other efforts to reduce polypharmacy might have influenced providers. Unfortunately, we cannot rule out any of these explanations. Therefore, we cannot draw firm conclusions about the interventions, particularly at 6 and 12 months.

Finally, it should be noted that these interventions are feasible only in practices having accurate, easily retrievable records of patients' medications and are probably applicable only to patients taking an extreme number of medications.

Martha Gerrity, MD
University of North CarolinaChapel Hill, North Carolina, USA.


Reference

1. Siu AL, Mayer-Oakes A, Brooks RI. Innovations in medical curricula: templates for change? Health Affairs. 1985;4:60-71.