Medication regimen complexity and the care of the chronically ill patient
AbstractAs the population in developed countries ages, patients with multiple chronic conditions are becoming more common. These patients are increasingly being managed with multiple concurrent medications and their medication regimens are frequently described as complex. Despite the significant challenges that complexity poses for clinical decision-making, the adherence of patients to their medication regimens and patient health and wellbeing, a robust understanding of this term in the context of medication regimens, is lacking. Here, it is shown that the essential feature of complex medication regimens is the multiplicity of rules that constitute their basic structure, rather than their intrinsic comprehensibility. Medication regimen complexity is a measure of the size of the consolidated medication script, or the shortest possible list of rules, for that medication regimen. A protocol is suggested for the consolidation of a medication regimen and the measurement and reduction of regimen complexity. This involves simplifying dosing instructions, consolidating the rules for taking medications, determining the number of rules in the consolidated medication script and eliminating or modifying rules towards a more parsimonious treatment plan. Following this protocolmay reduce the burden on the patient associated with adhering to the treatment regimen and thus promote patient-centred outcomes, such as improved health and quality of life, key components of the general move towards person-centered medicine.
Smirnova, A., Bell, S.H., Tracy, C.S. & Upshur, R.E. (2011). Still dizzy after all these years: a 90-year-old woman with a 54-year history of dizziness. BMJ Case Reports [Epub ahead of print]. doi:10.1136/bcr.05.2011.4247.
Centers for Disease Control and Prevention. (2003). Trends in aging--United States and worldwide. Morbidity and Mortality Weekly Report 52 (6), 101-104,106.
Upshur, R.E. & Tracy, S. (2008). Chronicity and complexity: is what's good for the diseases always good for the patients? Canadian Family Physician 54 (12), 1655-1658.
Bajcar, J.M., Wang, L., Moineddin, R., Nie, J.X., Tracy, C.S. & Upshur, R.E. (2010). From pharmaco-therapy to pharmaco-prevention: trends in prescribing to older adults in Ontario, Canada, 1997-2006. BMC Family Practice 11 (75).
Cole, A. (2008). Over 60s' use of prescription drugs has doubled in past decade in England. British Medical Journal 337, a1132.
Qato, D.M., Alexander, G.C., Conti, R.M., Johnson, M., Schumm, P. & Lindau, S.T. (2008). Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States.Journal of the American Medical Association 300 (24), 2867-2878.
Boyd, C.M., Darer, J., Boult, C., Fried, L.P., Boult, L. & Wu, A.W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. Journal of the American Medical Association 294 (6), 716-724.
Tinetti, M.E., Bogardus, S.T. Jr. & Agostini, J.V. (2004). Potential pitfalls of specific disease guidelines for patients with multiple conditions.New England Journal of Medicine 351 (27), 2870-2874.
Upshur, R.E. (2005). Looking for rules in a world of exceptions: reflections on evidence-based practice.Perspectives in Biology and Medicine 48 (4), 477-489.
Zhao, Y., Clark, W.T., Mort, M., Cooper, D.N., Radivojac, P. & Mooney, S.D. (2011). Prediction of Functional Regulatory SNPs in Monogenic and Complex Disease. Human Mutation 32 (10), 1183-90.
Lyon, G.J., Jiang, T., Van Wijk, R., et al. (2011). Exome sequencing and unrelated findings in the context of complex disease research: ethical and clinical implications. Discovery Medicine 12 (62), 41-55.
Naik, A.D. & Singh, H. (2010). Electronic health records to coordinate decision making for complex patients: what can we learn from wiki? Medical Decision Making 30 (6), 722-731.
Petersen, L.A., Woodard, L.D., Henderson, L.M., Urech, T.H. & Pietz, K. (2009). Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients? Circulation 119 (23), 2978-2985.
George, J., Phun, Y.T., Bailey, M.J., Kong, D.C. & Stewart, K. (2004). Development and validation of the medication regimen complexity index. Annals of Pharmacotherapy 38 (9), 1369-1376.
Martin, S., Wolters, P.L., Calabrese, S.K., Toledo-Tamula, M.A., Wood, L.V., Roby, G. & Elliott-De Sorbo, D.K. (2007). The Antiretroviral Regimen Complexity Index.A novel method of quantifying regimen complexity. Journal of Acquired Immune Deficiency Syndromes 45 (5), 535-544.
DiIorio, C., Yeager, K., Shafer, P.O., Letz, R., Henry, T., Schomer, D.L. & McCarty, F. (2003). The epilepsy medication and treatment complexity index: reliability and validity testing. Journal of Neuroscience Nursing 35 (3), 155-162.
Muir, A.J., Sanders, L.L., Wilkinson, W.E. & Schmader, K. (2001). Reducing medication regimen complexity: a controlled trial. Journal of General Internal Medicine 16 (2), 77-82.
Corsonello, A., Pedone, C., Lattanzio, F., Lucchetti, M., Garasto, S., Carbone, C., Greco, C., Fabbietti, P. & Incalzi, R.A. (2009). Regimen complexity and medication nonadherence in elderly patients. Journal of Therapeutics and Clinical Risk Management 5 (1), 209-216.
Mutasingwa, D.R., Ge, H. & Upshur, R.E. (2011). How applicable are clinical practice guidelines to elderly patients with comorbidities? Canadian Family Physician 57 (7), e253-262.
Cox, L., Kloseck, M., Crilly, R., McWilliam, C. &
Diachun, L. (2011). Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines. Canadian Family Physician 57 (7), e263-269.
World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.
Oxford Dictionaries. (2010). Definition of complex from Oxford Universities Online. Available at: http://oxforddictionaries.com/definition/complex (last accessed 16 August 2011).
Einstein, A. (1994). Ideas and Opinions. New York: Random House, Inc.
Chaitin, G. (2002). On the intelligibility of the universe and the notions of simplicity, complexity and irreducibility. Available at: http://www.umcs.maine.edu/~chaitin/bonn.html (last accessed 16 March 2011).
Wolf, M.S., Curtis, L.M., Waite, K., Bailey, S.C., Hedlund, L.A., Davis, T.C., Shrank, W.H., Parker, R.M. & Wood, A.J. (2011). Helping patients simplify and safely use complex prescription regimens. Archives of Internal Medicine 171 (4), 300-305.
Garfinkel, D., Zur-Gil, S. & Ben-Israel, J. (2007). The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Israel Medical Association Journal 9 (6), 430-434.
Garfinkel, D. & Mangin, D. (2010). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Archives of Internal Medicine 170 (18), 1648-1654.