Department of General Practice, University College Cork, Cork, Ireland.
Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
Age Ageing. 2024 Jun 1;53(6). doi: 10.1093/ageing/afae116.
Problematic polypharmacy is the prescribing of five or more medications potentially inappropriately. Unintentional prescribing cascades represent an under-researched aspect of problematic polypharmacy and occur when an adverse drug reaction (ADR) is misinterpreted as a new symptom resulting in the initiation of a new medication. The aim of this study was to elicit key stakeholders' perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades.
qualitative one-to-one semi-structured interviews were conducted with predefined key stakeholder groups. Inductive thematic analysis was employed.
Thirty-one stakeholders were interviewed: six patients, two carers, seven general practitioners, eight pharmacists, four hospital doctors, two professional organisation representatives and two policymakers. Three main themes were identified: (i) ADRs and prescribing cascades-a necessary evil. Healthcare professionals (HCPs) expressed concern that experiencing an ADR would negatively impact patients' confidence in their doctor. However, patients viewed ADRs pragmatically as an unpredictable risk. (ii) Balancing the risk/benefit tipping point. The complexity of prescribing decisions in the context of polypharmacy made balancing this tipping point challenging. Consequently, HCPs avoided medication changes. (iii) The minefield of medication reconciliation. Stakeholders, including patients and carers, viewed medication reconciliation as a perilous activity due to systemic communication deficits.
Stakeholders believed that at a certain depth of polypharmacy, the risk that a new symptom is being caused by an existing medication becomes incalculable. Therefore, in the absence of harm, medication changes were avoided. However, medication reconciliation post hospital discharge compelled prescribing decisions and was seen as a high-risk activity by stakeholders.
问题性多药治疗是指潜在不恰当地开具五种或更多种药物。非故意的处方级联反应是问题性多药治疗研究不足的一个方面，当药物不良反应（ADR）被误解为新症状导致开始使用新药物时就会发生。本研究旨在了解关键利益相关者对问题性多药治疗的看法和态度，重点关注处方级联反应。
采用预定的关键利益相关者小组进行了定性一对一半结构化访谈。采用归纳主题分析。
共访谈了 31 位利益相关者：6 位患者、2 位护理人员、7 位全科医生、8 位药剂师、4 位医院医生、2 位专业组织代表和 2 位政策制定者。确定了三个主要主题：（i）ADR 和处方级联反应-必要的邪恶。医疗保健专业人员（HCPs）担心经历 ADR 会对患者对医生的信心产生负面影响。然而，患者从实际出发看待 ADR，认为这是一种不可预测的风险。（ii）平衡风险/效益转折点。在多药治疗的背景下，开处方决策的复杂性使得平衡这个转折点变得具有挑战性。因此，HCPs 避免改变药物。（iii）药物调整的雷区。利益相关者，包括患者和护理人员，认为药物调整是一项危险的活动，因为系统存在沟通缺陷。
利益相关者认为，在多药治疗达到一定深度时，新症状是由现有药物引起的风险变得无法估量。因此，在没有造成伤害的情况下，避免改变药物。然而，出院后的药物调整迫使做出开处方的决策，并且被利益相关者视为高风险的活动。
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