Multimedication in Family Doctor Practices: The German Evidence-Based Guidelines on Multimedication

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this article. My general comment would be to reduce the number of abbreviations, especially those that are not frequently used in the article. In addition, a number of sentences are very long and complex hence the message may not come across to the reader. Please rephrase. Some specific comments below:

Introduction

• It is unclear what the authors mean by “Multimedication is the rule rather than the exception in general practice.” (Pg 2, Line 52) Please elaborate.
• Pg 2, Line 58, abbreviation DEGAM would be preferred in brackets for uniformity throughout the document.
• Line 61-65 – very long complicated sentence and hence meaning is lost. Could the authors rephrase and clarify what they mean.
• Lines 68-69, line 71 – what is the difference between updates and upgrades to the guideline?
• EVITA – for uniformity authors need to put abbreviations in brackets rather than full version of the abbreviation.
• The authors state that “For a structured care program for polypharmacy in multimorbidity, the guideline updates should support evidence-based decisions. (Line 73). Does this mean that the previous version was not supported by evidence-based decisions?

Methods – it would be useful to the reader if methods section was placed in a standard order.

Results

• Line 77-83 – very complex and long sentence leading to loss of clarity and meaning.
• Line 96 – “…with 5 or more drugs to be taken simultaneously.” Needs to be rephrased.
• Line 114-118 – very complex sentence. Authors have used very long sentences throughout which make it very difficult to interpret the main points of the article.
• Line 154 – “Underuse was included as an additional dimension of assessment to address frequent problems of undertreatment in multimedication.” Is this part of the guidelines or the instrument MAI?

Author Response

Point to Point letter: Manuscript 1653260

Review 1

Dear Editor, dear Reviewer

the authors would like to thank the reviewer for the thorough peer review and helpful comments that we addressed as follows. Changes in the manuscript are marked in bold letters.

Thank you for the opportunity to review this article. My general comment would be to reduce the number of abbreviations, especially those that are not frequently used in the article. In addition, a number of sentences are very long and complex hence the message may not come across to the reader. Please rephrase. Some specific comments below:

Answer. Thank you for this hint, we checked the manuscript carefully and changed the order (Abbreviation in brackets for DEGAM and EVITA). We kept the abbreviation in table 1, due to better readability of the table. We also kept the “names” of the drug list for elderly: PRISCUS and FORTA, as they are used in the literature. We explain PENS (insulin injections) and RCT (randomized controlled trial). We also shortened and rephrased several sentences.

Introduction

• It is unclear what the authors mean by “Multimedication is the rule rather than the exception in general practice.” (Pg 2, Line 52) Please elaborate
  
  Answer: It means, that most patients of a GP suffer from multimorbidity and hence need several drugs. Therefore, multimedication is something commonplace in the doctor's office. We rephrased the sentence as follows and includes some studies.

“Multimedication is something commonplace in the doctor's office, especially in the elderly [5-7].”

 

• Pg 2, Line 58, abbreviation DEGAM would be preferred in brackets for uniformity throughout the document.
  Answer: We changed the order and put DEGAM in brackets.

 

• Line 61-65 – very long complicated sentence and hence meaning is lost. Could the authors rephrase and clarify what they mean.

Answer: We explained the process of update an upgrade further (line 63-67).

“Recently, a new version of the GP Guidelines on Multimedication (2021) was published, which has not only been updated with new evidence, but also upgraded in accordance with the classification of the Association of the Scientific Medical Societies, Germany. The first version of the guideline was evidence-based (classified as “S2e”). In addition, the new version was formally consented with 15 medical societies, a patient representative, and supplementary experts (according to the classification “S3”).”

 

• Lines 68-69, line 71 – what is the difference between updates and upgrades to the guideline?
  
  This is now explained in the lines 63-67 (see above). Update = new literature, upgrade: systematic literature search and a structured consensus process with medical societies and other representatives.

 

• EVITA – for uniformity authors need to put abbreviations in brackets rather than full version of the abbreviation.
  
  Answer: Thank you for the hint – we changed this in the new version.

 

• The authors state that “For a structured care program for polypharmacy in multimorbidity, the guideline updates should support evidence-based decisions. (Line 73). Does this mean that the previous version was not supported by evidence-based decisions?
  
  Answer: ‘We have clarified the text of the manuscript as follows:

“The guidelines were updated as part of the Evidence-Based Polypharmacy Program with Implementation in Health Care (EVITA) project. For this structured care program for polypharmacy in multimorbidity, the guideline will provide evidence-based decisions support”.”

Methods – it would be useful to the reader if methods section was placed in a standard order.

Answers: We highly appreciate the reviewer’s amendment. However, we adhered to the journal’s guidelines, which specified the presented order.

Results

• Line 77-83 – very complex and long sentence leading to loss of clarity and meaning.

Answer: We rephrased the sentences and hope that they are now better understandable.

“In a stepwise discussion process, it was adapted to the medication process by the guidelines group, with the aim to include dispensing and application of medication. The resulting medication process is divided into the following six steps in the guidelines (cf. Figure 1). In long-term primary care, monitoring represents a renewed medication assessment (step 1) and the process is, thus, run through again. The medication process is designed for both, prescribing and discontinuing medication.”

 

• Line 96 – “…with 5 or more drugs to be taken simultaneously.” Needs to be rephrased.
  
  Answer: we added the information “on a daily basis”

 

• Line 114-118 – very complex sentence. Authors have used very long sentences throughout which make it very difficult to interpret the main points of the article.

Answer: Thank you for the hint, we re-edited the sentence as follows.

“The inventory is an essential and central component of the medication process, which involves the assessment of all conditions of the patient (e.g. disease severity, quality of life, and functionality). Further, it includes a survey of current medication, as well as the evaluation of clinical and context-related parameters (e.g., family support, care situation, migration and social status).”

• Line 154 – “Underuse was included as an additional dimension of assessment to address frequent problems of undertreatment in multimedication.” Is this part of the guidelines or the instrument MAI?

Answer: The original MAI developed by Hanlon did not cover underuse. Therefore, it was added by the guideline group and highlighted as added dimension in the table.

 

 

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Dear authors, congratulations for these extensive guidelines and practical hints on multimedication, in Germany. Still, these guidelines are specific and contextual based. So, can you affirm that these guidelines can be implemented in each family doctor practices in Germany?
In the other hand, I wonder if these guidelines and hints could be adopted in the rest of european countries... 

Although these practical hints are valuable, do you think the family doctor will adopt them in each consultation? As they are so much time consumer? I think this should be taken in consideration and weighing in the discussion section. 

Other minor comments:

• when you refer to "overuse and undertreatment", you should write "adherence", as this concept refers to the process by which patients take their medications as prescribed in three iterrelated distinct phases - initiation, implementation and persistence.
•  when you say that Medication Appropriateness Index has been adapted, i not see any adaptation process. In table 1 you just presented a modification after Hanlon (!) This not represent a adpation. You should rectified this statement in the abstract or present the process and the results of the adaptation of the scale. 
• I wonder if you can provide a resume of the material and methods in order to facilitate the reading process.
• Why did you opted for practical tips for checking kidney function? (line 179) I miss the point here.

 Thank you for considering my opinion. 

 

Author Response

Point to Point letter: Manuscript 1653260

Review 2

 

Dear Editor, dear Reviewer

the authors would like to thank the reviewer for the time and helpful comments that we addressed as follows. Changes in the manuscript are marked in bold letters.

 

Comments and Suggestions for Authors

Dear authors, congratulations for these extensive guidelines and practical hints on multimedication, in Germany. Still, these guidelines are specific and contextual based. So, can you affirm that these guidelines can be implemented in each family doctor practices in Germany?

Answer: We conducted a practice test, which was successful (cf. Dinh et al. Evidence-Based Decision Support for a Structured Care Program on Polypharmacy in Multimorbidity: A Guideline Upgrade Based on a Realist Synthesis. Journal of Personalized Medicine. 2022;12(1):69.) However, the implementation process may be difficult, as it is for all guidelines in all countries (to our knowledge). We expect a supportive effect implementing the guideline into a structured care programme, which itself needs to be evaluated. The guideline update and upgrade was conducted under the umbrella of a realist synthesis, which meant that the content, the recommendations and also the format and design of the guideline was developed together with general practitioners (Guideline Group of Hesse). Involving them and other stakeholders during the whole guideline upgrade process enabled us to develop a guideline that considers the daily general practice.

 

In the other hand, I wonder if these guidelines and hints could be adopted in the rest of european countries... 

Answer: We guess, that the recommendations have to be checked whether they are in line with the national guidelines and framework for GPs practice. The German guideline has in turn taken into account other (international) guidelines.

Although these practical hints are valuable, do you think the family doctor will adopt them in each consultation? As they are so much time consumer? I think this should be taken in consideration and weighing in the discussion section. 

Answer: The guideline for a structured medication review is recommended for those with three or more chronic diseases and five and more continuously prescribed drugs once a year or in special occasions. It is not expected in each consultation. We took up this aspect in the new section conclusion.

5. Conclusion

“The evidence-based guideline “multimedication” has been developed alongside a structured medication process in order to support the management of patients with multimorbidity and chronic multiple drug use and to ensure medication safety. The MAI can be considered as valuable tool for GPs. The medication plan can support both, patients and GPs to share decisions about the ongoing treatment. Recommendations and practical tips may support GPs in their prescribing and deprescribing activities. The application of the structured medication review requires time and resources. It is recommended regularly once a year and in special occasions. Other health professionals are also part of the process and have been addressed in the guideline as well.”

Other minor comments:

• when you refer to "overuse and undertreatment", you should write "adherence", as this concept refers to the process by which patients take their medications as prescribed in three iterrelated distinct phases - initiation, implementation and persistence.

Answer: According to our understanding, overuse and undertreatment are here related to the GP who might prescribe to much (drug not necessary) or missed to prescribe a drug in spite of an indication, Therefore, we did not change the sentence, but of course we share with you the understanding of adherence related to the patient.

 

• when you say that Medication Appropriateness Index has been adapted, i not see any adaptation process. In table 1 you just presented a modification after Hanlon (!) This not represent a adpation. You should rectified this statement in the abstract or present the process and the results of the adaptation of the scale. 

Answer: We changed the word adapted to modified in the abstract.

 

 

• I wonder if you can provide a resume of the material and methods in order to facilitate the reading process.

Answer: In the second last paragraph of the introduction section, we provided a brief summary of the update / upgrade process of the guideline. In the Material and Method section we allocated two references for further details: Dinh et al. Evidence-Based Decision Support for a Structured Care Program on Polypharmacy in Multimorbidity: A Guideline Upgrade Based on a Realist Synthesis. Journal of Personalized Medicine. 2022;12(1):69.) and the guideline report.

 

• Why did you opted for practical tips for checking kidney function? (line 179) I miss the point here.

Answer: The monitoring of the kidney function and the necessary dose adjustment in certain drugs should be common ground in drug treatment in general and not only in multimedication. However, studies report lack of control or inappropriate intervals and inappropriate dosages. Therefore, the guideline group addressed this issue explicitly. We have therefore added a sentence, which clarifies this point for the reader:

We changed the introducing sentence as follows.

“The monitoring of the kidney function and the necessary dose adjustment in certain drugs should be common ground in drug treatment in general and not only in multimedication. As studies report lack of control of the renal function or inappropriate dosages or inappropriate dosage intervals [21], the guideline group addressed this issue explicitly. Considering renal function, the following advice was given in the guideline:”

 

Author Response File: Author Response.docx