Increased Patient-Physician Dialogue in EDs May Reduce Polypharmacy in Older Patients

As the global population ages, polypharmacy among individuals with multiple long-term conditions is a growing issue that can make older patients more susceptible to medication-related adverse events. A recent study conducted in Denmark identified both barriers and enabling factors to including patients in emergency department (ED) decision-making, a practice that may help optimize the treatment of older patients with polypharmacy.

“More than 1,000,000 out of 1,300,000 yearly hospital admissions in Denmark are acute admissions in emergency departments, and more than 70% of these admissions are older patients (65+ years) with comorbidity conditions and polypharmacy, defined as taking 5 or more medications,” the authors wrote.

Their earlier research has shown that potentially inappropriate use of medicine in patients 65 years and older was very common in their ED, affecting 85% of those patients.

According to the World Health Organization, patient symptom reporting can play a crucial role in early detection of inappropriate polypharmacy. However, it can be challenging to implement shared decision-making (SDM) consistently if existing workflows and health care systems do not make it a standard.

This qualitative ethnographic study focused on health care professionals in the ED to explore the factors that go into patient involvement in decision-making. The research is part of a program called OPTICARE, which aims to create a “Medication Conversation Guide” for EDs that will include SDM tailored to polymedicated patients aged 75 and older.

The study included 48 health care professionals at 2 EDs within a university hospital system in Denmark. Researchers followed a 3-step process to gather data, first conducting field observations for 58 days. Observations included several focal points:

• What is going on, and who is participating in the medication process?
• What do people do and say about medication?
• Who makes decisions regarding medication?
• What or who is involved in those decisions?
• What do the patients say about medication?
• What role do patients, or their relatives, have?

They then developed a semistructured interview guide before interviewing 10 health care professionals who participated in the study and 10 who were not followed in the study to elaborate on the observations.

Four factors impeding patient involvement in medication decisions were identified: blurred roles among multidisciplinary health care professionals, increased complexity in treating older patients with polypharmacy, time pressure, and faulty IT systems.

One issue within multidisciplinary ED teams was unclear roles. Nurses, for example, reported having little to do with medication decisions although observations showed that nurses typically spoke to patients about medications and that their discussions with physicians significantly influenced medication decisions.

There was also inconsistency among physicians when it came to discussing older patients’ complex medication regimens with them. Most physicians assumed they could take the patients’ Shared Medication Cards (SMCs) at face value, but observations showed that very few older patients were aware of what medications were on their SMCs—which were often not regularly updated. Additionally, the widespread assumption that older patients were not trustworthy when it came to discussing their medication led to less dialogue about medication with them.

Time pressure in the form of short admission periods and fast patient flow also meant that many health care professionals perceived lengthy discussions with patients as a challenge to fit into their care.

Where technology is concerned, physicians typically spent more time on computers than with patients, further fragmenting the medication and communication processes. Different medications registered in different systems made it difficult to get an overview of medication regimens, several providers reported. Medications were often decided upon in front of a computer without a discussion with the patient beforehand.

One potential solution was also identified: Using patients’ printed medication lists from electronic health systems and SMCs consistently during ward rounds and discharge may help create dialogue around medication regimens and allow for more patient involvement.

“The observations showed that the few times a printed medicine list was used to support medication conversations, the patient had several specific questions about the medications, resulting in more dialogue about medications, which is a prerequisite for patient involvement,” the authors wrote.

In the long run, the researchers hope their findings will provide valuable insight to improve future patient pathways in the ED. Ideally, a tailored guide for discussions with older polymedicated patients could become standard for the physicians reviewing their medication regimens.

“Patient-centered health care builds on the ideology that patients should become active partners in health care,” they wrote. “Furthermore, health care policies demand that health care professionals involve patients in their medical treatment. Therefore, it is essential for our society (and patients) that vulnerable patients with multimorbidity and polypharmacy be empowered to better care for themselves.”

Reference

Fabricius PK, Andersen O, Steffensen KD, Kirk JW. The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study. PLoS One. Published online December 30, 2021. doi:10.1371/journal.pone.0261525