How to reduce polypharmacy in the multimorbid elderly

How to reduce polypharmacy in the multimorbid elderly

Choosing Wisely – Lugano, 15th September 2017

Prof. Nicolas Rodondi, Director of BIHAM & Head of Ambulatory Care, University of Bern

Berner Institut für Hausarztmedizin

(BIHAM), University of Bern

Department of General Internal

Medicine, Inselspital

University of Bern

2 Prof. N. Rodondi

Universitätsklinik und Poliklinik für Allgemeine Innere Medizin

Plan

• The 3 main challenges of the health care system: - Increase of multimborbid patients

- Overmedicalization

- Shortage of family doctors

• Multimorbidity & polypharmacy

• How to reduce polypharmacy and

overmedicalization?

• Role of family medicine in multimorbidity

• Role of research in multimorbid patients

• Polypharmacy/overmedicalization: critical issues

in Switzerland

3 Prof. N. Rodondi

Universitätsklinik und Poliklinik für Allgemeine Innere Medizin P

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1 C Aubert, S Streit & N Rodondi. Eur J Intern Med 2016; 2 Brulhart MI. Int J Clin Pharm 2011

Multimorbidity & Polypharmacy1

None 1 - 4

5 - 9

≥ 10

0 1 2 3-4 5-6 ≥ 7

Number of diseases

Nb of medic.

10 elderly nursing homes in JU 2: avg. 13 (2-27) medicaments per day

N=1000 randomly selected ambulatory patients (40-70 y. old)

4 Prof. N. Rodondi


Multimorbidity induces overmedicalisation1

• 60% of the adult population 65 y. have

2 diseases

• Multimorbid patients are excluded from clinical

trials2:

− randomized studies published these 15 last years:

• 63% have excluded multimorbid patients

• Only 2 % have explicitly included those

• Recommendations («guidelines») applicable

to patients with 1 disease

1 Rodondi N & Héritier F, Rev Med Suisse 2014; 2 Jadad AR et al., JAMA 2011

5 Prof. N. Rodondi


Inappropriate prescribing & consequences

Inappropriate prescribing using STOPP criteria - Primary care

- Hospital

- Nursery home care

21%

35%

60%

Inappropriate prescribing using START criteria - Primary care

- Hospital

- Nursery home care

23%

58%

42%

Annual drug-related hospital readmissions for patients aged ≥80 years 32%

Potentially preventable drug-related hospital admissions (DRAs) in the

elderly 47%

Deaths due to inappropriate prescription and adverse drug events (ADEs) 3%

Drug-related fatalities in hospitalised patients 5%

Unjustified overt costs caused by overtreatment 21%

Leendertse AJ, et al. Arch Intern Med 2008;168:1890-96; O'Mahony D, et al. Age Ageing 2014 Gillespie U, et al. Arch Intern Med 2009;169:894-900; Berwick DM, et al. JAMA 2012;307:1513-16

6 Prof. N. Rodondi


Methods to optimize drug prescription

• Training / continuing medical education

(“Choosing Wisely”/“Smarter Medicine” 1,2)

• Computer-based decision system

• Interventions by pharmacists

• Multidisciplinary interventions

• Best method: unclear

• Unclear if the prognosis of patients will be

improved with the reduction of inappropriate

medication

1 N Rodondi, Schw Med Forum, 2013; 2 C Rieben & N Rodondi, Primary Care, 2014

7 Prof. N. Rodondi


Past trials to reduce inappropriate prescribing

RCT Population Intervention Outcomes Study limitations

Gillespie et al; Arch Intern Med 2009

400 inpatients ≥80 years in 1 hospital in Sweden

Mean number of drugs: 8

Medication review vs. usual care.

Follow-up: 12 months

Reduction of DRAs: 80% (95%CI 59-90%)

Single site; contamination bias (no cluster randomisation), no adjudication of DRAs by a committee (physician judgment)

Schnipper et al; Arch Intern Med 2006

178 discharged US patients (mean age 58 years)

Mean number of drugs: 8

Medication review vs. usual care.

Follow-up: 1 month

Preventable DRAs or emergency department visits: 1 vs. 8% (p=0.03)

Single-site; contamination bias (no cluster randomisation); small sample size; young population; short follow-up time

DRAs: drug-related hospital admissions

8 Prof. N. Rodondi


OPERAM1 EU consortium

on multimorbidity

• 40 researchers

from different

domains

• CHF 8 millions from

EU Horizon 2020

program and the

Swiss Government

• Coordination:

Prof. N. Rodondi

1 OPERAM: OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly

9 Prof. N. Rodondi


Expected impacts of OPERAM

• Development and assessment in a RCT of an intervention with the help of STRIP-assistant software to optimise pharmacotherapy

• Comparative evidence about most effective interventions in multimorbid patients through network meta-analyses

• For the elderly population, potential for: - Improving the quality of prescribing - Providing more accurate information to patients

and prescribers (assessment of their perspective/ preferences)

- Reducing hospitalisations and reducing costs of care

10 Prof. N. Rodondi


Role of family medicine in

dealing with multimorbidity

11 Prof. N. Rodondi


Risks with a weak family medicine: US example

1 chronic condition 4 physicians

5 chronic conditions 14 physicians

Ø Number of physicians involved for

a Medicare patient 1:

CARE FRAGMENTATION and costs because of uncoordinated care

US states: + family physicians

quality of care, hospitalizations, emergency, costs2,3

1 Vogeli C et al., J Gen Intern Med 2007; 2 Baicker K et al., Health Affairs 2017; 3 L Shi, Scientifica 2012

12 Prof. N. Rodondi


40% of the projected visits will not be ensured!

Age of family physicians2: 30% > 60 years old, 20% < 45 years old

1 Obsan 2008; 2 Commonwealth Fund 2015

Challenge in Switzerland: need for family physicians: number of visits vs. supply 1

13 Prof. N. Rodondi


A common example with

an important role for GPs:

management of dyslipidemia

14 Prof. N. Rodondi


0

10

20

30

40

50

60

70

80

90

100

Treated Poor control Near control In control

High

Intermediate

Low

Very low

Risk category (adapted PROCAM)

LDL-C therapy and control in Lausanne (n=2111 with dyslipidemia)

M. Firmann et al., EJCPR, 2010; Levels of control based on: N. Rodondi et al., Ann Intern Med 2006

15 Prof. N. Rodondi


US recommendations 1

• Start high-intensity statins therapy to lower LDL-cholesterol by ≥ 50% if :

1. Cardiovascular disease, aged < 76 years

2. Diabetes if aged 40-75 years, with complications or other risk factors

3. LDL ≥ 4.9 mmol/l without secondary cause: − only 2% with proven genetic disease2

4. Aged 40-75 years with 10-year risk of cardiovascular event ≥ 7.5% (new score)

> 1 billion of people taking statins3

1 Stone NJ et al., Circulation 2013; 2 Khera AV, JACC 2016; 3 Ioannidis JP, JAMA 2013

16 Prof. N. Rodondi


Overmedicalization: suggestions from OECD

• Data: - Variations in the interventions (10/35 countries) - Low-value care (0/35!)

• costs: - Health Technology Assessment (HTA, 19/35):

• value of new treatments? • Scientific quality, independence

- generic drugs (17/35)

• overmedicalization: - Strengthen family medicine (14/35)

- «Top 5» lists Choosing Wisely (1/3)

- E-health to share information ( duplication)

- Reimburse appropriate care instead of volume OECD, Tackling Wasteful Spending on Health, 2017

17 Prof. N. Rodondi


Generics market shares, OECD, 2005 - 2015

OECD, Tackling Wasteful Spending on Health, 2017

24.5%

UK 84.3%

18 Prof. N. Rodondi


Role of research: 1 example : thyroxine most

prescribed drug in US, 3rd in UK!

• Overt hypothyroidism: about 0·2–2·0%, stable incidence

• According to guidelines, 9/10 women with subclinical hypothyroidism (SHypo, TSH 5·5–10 mU/L) eligible

• Once started, 90% long term therapy

• Costs: > 1 billion/y only for drugs (+visits,…)

R Rodriguez-Gutierrez et al., Lancet Diabetes Endo, 2017

19 Prof. N. Rodondi


1st large study on thyroxin supplementation in

SHypo: no benefit on thyroid symptoms

D Stott, N Rodondi, et al., NEJM 2017

• Same for

tiredness

20 Prof. N. Rodondi


Who will pay for clinical trials on

overmedicalization?

• Pharma industry? Will not, not alone

• BAG / FOPH (Federal Office of Public Health)

Enough funding?

• SNSF? PNR 74, then what next?

• partnership pharmas – insurances - SNSF?

SCTO, June 18th 2014, 100 Mio/year? No decision yet

One solution?

• Italy: Fund for independent research (AIFA / Art. 48, law

326/2003)

• Pharmaceutical companies are obliged to devote 5% of their

promotional expenditure to a fund for independent research.

SCTO, Bern June 18 2014: Lorenzo Moja, Università degli Studi di Milano

21 Prof. N. Rodondi


Polypharmacy/overmedicalization: critical issues in Switzerland

• Better coordination of care: - Strengthen primary care (hospital/family physicians)

• Better data on health care system:

- Plan after PNR 74 (SNF)?

• Invest in research - SNSF to identify those1:

- "Pr. Trump - NIH" (18%)

• Promote «high-value care»1 instead of quantity

or rationing of care

1 «High-value health care», Right Care Series, Lancet 2016-17

22 Prof. N. Rodondi


Contact:

Prof. N. Rodondi

Director of Berner Institut für Hausarztmedizin (BIHAM)

& Head of Ambulatory Care, Inselspital

University of Bern; Email: [email protected]

Thank you for your attention!

References:

• Où en sommes-nous avec la surmédicalisation en Suisse

en 2017? Rodondi N & Gaspoz JM, Swiss Med Forum 2017

• OECD, Tackling Wasteful Spending on Health, 2017

• How to prevent overdiagnosis. A Chiolero & N Rodondi;

Swiss Med Wkly 2015

• Right Care Series, Lancet 2016-17

23 Prof. N. Rodondi


Ungeeignete Verordnungen &

Arzneimittelneben-wirkungen (ADE’s)

• Ca 3% aller Todesfälle1

• 5. häufigste Todesursache in den USA

• Anstieg von Spitalaufnahmen wegen ADEs seit

1980: - 5-6% aller akuten Aufnahmen2

• Mittleres Alter: bei Männern 81 J, bei Frauen 83 J

• Kosten: > $200 Milliarden pro Jahr in den USA

1 Schweden: Wester et al., Br J Clin Pharmacol. 2008 Apr;65(4):573-9 2 Leenderstse et al., Arch Intern Med. 2008 Sep 22;168

24 Prof. N. Rodondi


Possible to reduce inappropriate medications?

• Swedish experience: national indicators for quality of drug

therapy

• Inappropriate drug use decreased by 36% in persons

aged 80 years and older

• Extensively used for : - Drug utilisation reviews: Implemented in some computerised

systems

- National benchmarking, including levels of inappropriate

medication, in different geographical areas

- Pay for performance, including for drugs that should be

avoided

- Many educational initiatives for healthcare personnel and for

older persons and their relatives

Fastbom J et al., Drugs Aging 2015;32:189-199

25 Prof. N. Rodondi


Recommandations de l’AGLA/GSLA1

pour la prise en charge des dyslipidémies

• Patients à haut risque: LDL > 2,6 mmol/l - Affections coronariennes ou maladies similaires (AVC,

artériopathie périphérique)

- Diabète

- Risque à 10 ans 20% (PROCAM-AGLA)

• Patients à risque intermédiaire: LDL > 3,4 mmol/l - Risque à 10 ans entre 10 et 20%

• Patients à faible risque: LDL > 4,1 mmol/l - Risque à 10 ans < 10 %

• Patients sans facteurs de risque: LDL > 4,9 mmol/l

AGLA 2014: faible risque: mesures de style de vie

Pour la prévention primaire: toujours recommander des mesures de style de vie de quelques semaines à plusieurs mois!

1 Groupe de travail Lipides et Athérosclérose, GSLA, www.agla.ch

Nombreuses

données

Quelques

études

Très peu de

données

Aucune

donnée

26 Prof. N. Rodondi


Recommandations américaines: position de l’AGLA 1,2

• Surestimation du risque CV avec ce score et les

scores américains pour la Suisse:

- Risque doublé par rapport au risque actuel aux USA3

• Approche très agressive de l’hypercholestérolémie

familiale avec statines systématiques dès l'âge de

12 ans

• Limite le choix des statines

• Hautes doses de statines: - Facteur de risque pour les effets secondaires

1 Moser M & Rodondi N, Rev Med Suisse 2014; 2 Nanchen D & Rodondi N, Forum Médical Suisse 2014; 3 Ridker PM et al., Lancet 2013;382:1762-5

27 Prof. N. Rodondi


Seule exception: dyslipidémie familiale • Antécédents personnels ou familiaux de maladies

cardiovasculaires précoces

• Signes cliniques: gérontoxon précoce, xanthomes

tandineux et cutanés

• Le + simple au cabinet: LDL-cholestérol ou triglycérides >

5 mmol/l

• 2 maladies les plus fréquentes: - Hypercholestérolémie familiale

- Hyperlipidémie familiale combinée

• Prise en charge spécifique1,2 - Score de risque faux, 1er infarctus entre 20-60 ans

- USA: statines pour tous dès 12 ans

- Berne: estimation individualisée du ESC risque dès 8 ans

(anamnèse familiale, taux de LDL, mesure de l’IMT, …) 1 C Aubert & N Rodondi, Primary Hospital Care 2017; 2 NICE 2008 Guidelines on familial hypercholesterolemia

28 Prof. N. Rodondi


Neue Kriterien zur Erkennung ungeeigneter Verordnungen

• (A) Screening Tool of Older Persons’ potentially

inappropriate Prescriptions (acronym, STOPP):

= Screening-Instrument für die Erkennung von

ungeeigneten Verordnungen bei älteren Personen:

68 Kriterien

• (B) Screening Tool to Alert doctors to Right (i.e.

indicated, appropriate) Treatment (acronym, START):

= Screening-Instrument für Ärzte, um die richtige

(indizierte, geeignete) Behandlung zu wählen:

22 Kriterien

29 Prof. N. Rodondi


STOPP: ungeeignete Verordnungen und Auswirkungen

• Häufigste ungeeigente Verordnungen 1:

- PPI mit voller Dosis > 8 Wochen

- NSAR > 3 Monate

- Lange Halbwertszeit Benzodiazepine > 4 Monate

- Duplikate Medikamentenklasse (z.B. ACE-Hemmer &

AT2-Antagonist 2)

• Polypharmazie: grösster Risikofaktor

• 30 von 65 STOPP-Kriterien = Prävalenz von 36%

• Totaler Kostenaufwand für STOPP-Medikamente:

- € 45.6 Million = 9% des totalen Kostenaufwands für

Medikamente für Personen im Alter von ≥ 70 Jahre in Irland

1 Cahir et al. Br J Clin Pharmacol 2010; 2 Makani H et al. Meta-analysis of RCTs. BMJ 2013

30 Prof. N. Rodondi


Häufige, vermeidbare Arzneimittelnebenwirkungen, die zu einer Spitaleinweisung führen oder dazu beisteuern

• Schädliche Stürze und:

- Benzodiazepine oder Schlafmittel

- Psychopharmaka

- Opiate

• Orthostatische Hypotonie und Therapie für Hypertonie

• Elektrolyten-Störung und Diuretika

• Akute Nierenfunktionsstörungen und Diuretika /

nephrotoxische Medikamente

• Gastritis / Magengeschwür und NSARs

• Symptomatische Bradykardie und Betablocker

31 Prof. N. Rodondi


Remboursement selon la qualité?

• UK:25% du salaire des MFs dès 2004

• Impact 1: - qualité à court terme; peu 1x objectifs atteints

- qualité des soins pour les autres conditions!

- Ecosse: "QOF" remplacé par cercles de qualité dès 2016

• Patients complexes "exclus" si hors des objectifs (USA)

• Défis : - Charge "administrative"

- Effet sur coûts? 1 indicateur si haut risque cardiaque: LDL-cholestérol < 1.8 mmol/l? Inhibiteurs du PCSK9 en + ?

1 QOF; Campbell SM, et al., NEJM 2017

32 Prof. N. Rodondi


“Smarter Medicine”- SGAIM: 5 interventions à éviter en médecine interne générale ambulatoire

• Un bilan radiologique en cas de douleurs lombaires

non-spécifiques depuis < 6 semaines

• Le dosage du PSA pour dépister le cancer de la prostate

sans discuter des risques et bénéfices avec le patient

• La prescription d’antibiotiques en cas d’infection des

voies aériennes supérieures sans signe de gravité

• Une radiographie du thorax dans le bilan préopératoire,

en l’absence de suspicion de pathologie thoracique

• La poursuite à long terme d’un traitement d’inhibiteurs de

la pompe à proton (IPP) pour des symptômes gastro-

intestinaux sans utiliser la plus faible dose efficace

1 K Selby et al., JAMA Intern Med, 2015; www.smartermedicine.ch

33 Prof. N. Rodondi


Rôle de la formation des médecins

• Décisions complexes et individuelles

• Rôle crucial dans la réduction de la surmédicalisation

pour améliorer la qualité des soins:

- Campagne «Smarter Medicine», SGAIM

- Journaux de la FMH 1 distribués aux 39’000

médecins suisses chaque semaine

• Les spécialistes suisses devraient aussi élaborer

des listes «Top 5» :

> 60 sociétés de spécialités aux USA

1 Rodondi N, Schw. Med Forum (SMF) 2013: «Less is more: …»

34 Prof. N. Rodondi


Conséquences de cette fragmentation

Plus il y a de médecins différents impliqués, plus:

• Il est difficile pour les patients de comprendre le plan de

traitement

• Il y a de perte d’information

Explications inutiles, répétées

Recommandations contradictoires

• Médicaments – effets secondaires / Hospitalisations / Coûts

• Mouvement contraire aux USA: „Need for healthcare systems that promote continuity of care

and integration of services“ Renforcement de la médecine de

premier recours

• Mouvement contraire en Suisse: OFSP 2016: groupe de

travail sur «L’augmentation de la spécialisation en médecine

humaine & fragmentation»

Documents

How to reduce polypharmacy in the multimorbid elderly