Sophie Jouaville, PhD

Multimorbidity and associated polypharmacy, including use of potentially inappropriate medication (PIM), are an increasing challenge for European health systems. A lack of cross-national studies using standardized methodology and comparable study populations makes it difficult to determine the prevalence of polypharmacy and PIM use in primary care across Europe.

In a recent study, “The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing,”

 real-world evidence (RWE) provided researchers with information about the prevalence of polypharmacy in older people (65 years and older) in six European countries, including their patient characteristics and the types of medications they were prescribed. The findings emphasized the critical need for strategies to help manage polypharmacy to reduce medication-related harm, as well as challenges and solutions for cross-national drug utilization studies.

Potential issues of polypharmacy for the elderly patient population

In the study, more than half of the older population in four of the six European countries had been prescribed more than five medications in six months by their general practitioners. While polypharmacy may be appropriate in many cases, it also presents risks:

 Older adults are more susceptible to adverse drug reactions due to changes in drug metabolism and elimination as they age.

 The likelihood of drug interactions increases with the number of medications taken. These interactions can reduce the effectiveness of medications or cause harmful side effects.

 Polypharmacy can contribute to confusion, memory problems, and other cognitive impairments, which can further complicate patients’ medication management.

 Certain medications, especially those affecting the central nervous system, can increase the risk of falls and accidents.

PIM use associated with polypharmacy is concerning because certain drugs, including antipsychotics and benzodiazepines, as well as proton pump inhibitors and opioids, pose an unfavorable risk/benefit balance in many older adults. PIM use can result in a decline in physical and cognitive function, falls, frailty, hospitalizations and mortality.

Challenges of cross-national studies—and the benefits of RWE

While the need to improve patient safety supports efforts to improve polypharmacy management across Europe, isolating and interpreting country-to-country differences is a challenge for cross-national studies. Data must be analyzed from various and often disparate sources, which may also include differences in data formatting, quality and completeness, collection method, and coverage, in terms of population or settings. Specific cultural, socioeconomic ,and healthcare-related differences between countries also need to be considered.

The study approached standardization challenges by using six electronic medical record databases of similar construction and setting across six European countries. All databases represented primary care and reflected routine clinical practice in the participating countries. The same methods and definitions were used, applying a systematic approach to assess cross-national drug utilization. Country-specific knowledge of each nation’s healthcare system, prescribing practices, and policies to complement prescribing data were also included. These were systematically documented and reported to determine their potential influence on polypharmacy.

This methodology provided valuable insights when interpreting results. For example, from a review of national prescribing practices of specialists, researchers recognized possible underestimation of use for some drug classes, like benzodiazepines. This emphasizes the importance of systematic inclusion of national experts in cross-national studies and illustrates how this intelligence can be more robustly collated and reported to support contextualization of findings.

A framework for polypharmacy management strategies

The high prevalence of polypharmacy emphasizes the urgent need to develop and implement strategies to manage polypharmacy and RWE studies to evaluate drug utilization.

The framework provided in the study integrates key factors, such as the characterization of real-world data sources, healthcare infrastructures, and policies to support the analysis, reporting and interpretation of cross-national studies. When conducting cross-national drug utilization studies using databases, the recommendation for researchers is to systematically collate and document health system practices and policies with the potential to impact the interpretation of findings.

The use of all available data plays a key role—a central prerequisite for drug therapy safety is up-to-date medication information for each patient. Insight into other routine data, such as from various countries’ sickness funds, further reduces the information deficit regarding prescriptions from other physicians. The use of available data as a tool for surveillance and to monitor improvement strategies can support changes in practice.

Using this foundation, detailed drug utilization studies can compare the prescribing practices and selected medications known for overuse among different countries to help improve patient safety.

Sophie Jouaville, PhD, is an associate principal, consulting services at IQVIA.

1. Bennie M, Santa-Ana-Tellez Y, Fungie Galistiani G, Trehony J, Despres J, Laurence Jouaville S, Poluzzi E, Morin L, Schubert I, MacBride-Stewart S, Elseviers M, Nasuti P, Taxis K. The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing. British Journal of Clinical Pharmacology [Internet]. Available from: 

https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.16113

Articles

A multi-national study reveals over half of older adults in several European countries are prescribed five or more medications—spotlighting the urgent need for better data-driven prescribing strategies.