Reducing medication problems – INTERPOLAR project launch | 5 Questions for… Prof. Dr. Petra Thürmann & Dr. Beate Mussawy

Especially older people often take several medications at the same time. However, there is a risk of undesirable drug interactions and side effects. Additional medical conditions and need for therapy can be the result. To address this problem, the cross-consortium Use Case POLAR addressed the identification of potentially inadequate medications during the past funding phase of the Medical Informatics Initiative (MII). The interdisciplinary project team worked to predict potential risks through the collection of medication data. The POLAR follow-up project INTERPOLAR has now started in January 2023. The aim is to improve medication safety via the existing MI-IT infrastructure.

On this occasion, we spoke with Prof. Dr. Petra Thürmann and Dr. Beate Mussawy. They are experts in the field of pharmacology and pharmacy and have been providing pharmacological support to POLAR since the start of the project. In the interview, they provide an insight into the INTERPOLAR Use Case and explain how data analyses can be used in the project to improve drug safety.

You have both been working on potentially inadequate medication (PIM) in older people for many years. How have physicians dealt with the prescription of a wide variety of drugs (polypharmacy) up to now?

Dr. Beate Mussawy: In everyday life, it is sometimes not easy to keep track of everything. A complete re-evaluation of the patient’s illness and the medication required for it would actually be necessary for a correct assessment. I have noticed that many physicians find it more difficult to discontinue medications than to start new ones. Often, several disciplines are involved in the treatment of patients. For this reason, doctors, particularly in the outpatient sector and to some extent also in the inpatient sector, sometimes do not even know the patient’s complete medication regimen. It is certainly important to have an aid here in order to identify drugs that could cause problems as quickly as possible.

Prof. Dr. Petra Thürmann: I would answer the question from two perspectives. One is from the outpatient area for physicians in private practice and the other is for hospital physicians. If we start with the former: General practitioners have usually known their patients for a very long time and therefore often have no problems with the previous medication. Rather, they have to find a way to deal with it when something changes, for example, after a hospital stay or due to specialist prescriptions. The problem that often arises here is that the general practitioners often did not have complete information beforehand. The patient then says something like, “I got a new painkiller from the orthopedist, but I can’t tell you exactly what it’s called right now.” Often the patient is the only source of information and the primary care physician has to somehow come to terms with that.
In the hospital, I see it somewhat differently again. There, the patient is often very “new.” Especially for a specialty like accident surgery, where the patient with polypharmacy has never been seen before and now arrives with a bone fracture. The accident surgeon is, of course, deeply grateful to find a written medication plan. The hospital physician has neither the intention, nor the time, nor the overview to re-sort the entire polypharmacy. That is also not the treatment mandate at all. That’s why I think a lot of support is urgently needed for both settings, outpatient and hospital.

How exactly did the POLAR project address the problem of polypharmacy and what are the findings?

Dr. Beate Mussawy: In the POLAR project, the first step was data analysis. The goal was to find out to what extent polymedication problems are relevant in everyday clinical practice and can be detected at all in routine clinical data. The pooled data set from 13 university hospitals can help to map a broad cross-section and thus derive the identification criteria for medication-related problems. There were a number of different subprojects in the POLAR project. In our subproject, potentially inadequate medication (PIM) was investigated in more detail. For example, after operationalizing the different PIM lists, it was possible to ask all university hospitals how many patients were taking the potentially inadequate medication amitriptyline and had fallen. In other words, it was possible to conduct initial association studies, although feasibility was the initial focus of the POLAR project.

Prof. Dr. Petra Thürmann: POLAR was the first opportunity in German university medicine to check: How common are certain drugs that shouldn’t be prescribed so often? How often do certain drug interactions also occur in Germany? We are asking ourselves the same questions with unfavorable drugs, disease combinations, etc. So far, we have had a lot of data on this from abroad. What is special about the MII and POLAR, is, that for the first time we have such data from the hospital sector in Germany and can compare them internationally.
We first have to see whether we can also find the correlations between adverse drugs and adverse events such as falls, which Ms. Mussawy just mentioned, with German routine data from German hospitals. Before we can wow the world with a few new findings, we first have to create the conditions for that, and that’s what we’ve done in POLAR.

On Jan. 1, 2023, INTERPOLAR, the follow-up project to POLAR, was launched. What is new in INTERPOLAR?

Dr. Beate Mussawy: POLAR was a use case that primarily looked at data analysis and how common medication-related problems are in polypharmacy. INTERPOLAR is an intervention study. Here, we are investigating whether a risk analysis based on electronic patient data can reliably identify medication problems and reduce them in everyday clinical practice. The aim is to use the limited working time of physicians and clinical pharmacists more efficiently. In summary, POLAR was data analysis, INTERPOLAR is already about supporting the medical professionals and thus already concretely about the benefit for patients.

Prof. Dr. Petra Thürmann: In addition to what Ms. Mussawy said: You also have to see the whole thing in an international context. There have been very few large multicenter studies to date looking at reducing the number of adverse drug interactions in hospitalized patients. All previous approaches in the literature have dealt either only with potentially inappropriate medication or only with interactions, but then with all hospitalized patients above a certain age. We are trying to use an algorithm to identify in advance exactly those patients who are particularly at risk and thus could benefit most from the study. If this proves effective, then we have a real solution for practice and not just another theoretical approach.

As a pharmacologist or pharmacist, what motivated you to become involved in digitization in medicine?

Dr. Beate Mussawy: Since my first day at work at the University Medical Center Hamburg-Eppendorf (UKE), I have worked with electronic patient files and electronic prescribing. I have experienced the many advantages of a high level of digitization in a clinic and have been able to actively support the constant expansion and further development of the systems. I have noticed an incredible number of advantages: You no longer have to search for files, all the necessary data can be accessed at one workstation, and processes can be more structured and uniform. For example, if a patient is transferred from one ward to another, digital documentation can prevent information interruptions. The electronic patient file can always be accessed from anywhere. This makes the day-to-day work in the clinic much easier. I believe that digitization in hospitals should always be expanded and kept up to date. This is how patient safety can be effectively increased.

Prof. Dr. Petra Thürmann: I don’t come from a hospital that has been digitized for many years. The UKE was a real pioneer nationwide in terms of digitization. For me, it’s just appealing that the majority of hospitals are still not particularly digitized even today. Despite all the progress in medicine, about five percent of hospital admissions are still due to side effects. Around ten percent of patients in hospital, and even more if they are older, suffer a relevant side effect. This problem is growing because of the increasing complexity of drug therapy. I am firmly convinced that we can only deal with this if we really exploit all the opportunities offered by digitization without mercy. I find it almost unethical not to use the possibilities of digitization both to gain knowledge and to implement the findings for individual patients.

Please finish the following sentence: The work in the Medical Informatics Initiative can support in concrete clinical issues such as polymedication, because…

Dr. Beate Mussawy: Data analysis helps to identify medication-related problems in clinics. Through the collaboration of experts from clinics, medicine, pharmacy, biometrics and IT, the MII provides the uniform data infrastructure needed for this purpose.

Prof. Dr. Petra Thürmann: they bring new insights that can be immediately reflected in practice. This applies not only to findings on polymedication, but also to other common medication-related problems. In this way, patients can be helped directly.

About the interview partners:

Prof. Dr. Petra Thürmann is deputy medical director of Helios University Hospital in Wuppertal. At Witten/Herdecke University, she holds the Chair of Clinical Pharmacology in addition to her position as Vice President for Research. One of her most significant scientific contributions is the Priscus list, which doctors can use to find out whether drugs are associated with risks for elderly patients when prescribing them. Prof. Dr. Thürmann is represented on several committees, including the Drug Commission of the German Medical Association. She also chairs the coordination group of the Action Plan on Drug Therapy Safety (AMTS) of the German Federal Ministry of Health (BMG) and was a member of the German Council of Health Care Experts until January 2023. 

Dr. Beate Mussawy is a specialist pharmacist for clinical pharmacy, geriatric pharmacy and medication management in hospitals. She completed her doctorate on the topic of “Potentially inadequate medication for the elderly” at the University of Hamburg. Since 2011, Dr. Mussawy has been involved in increasing drug therapy safety as a pharmacist in the hospital pharmacy of theUniversity Medical Center Hamburg-Eppendorf. She also gives continuing education seminars in clinical pharmacy for the Hamburg Chamber of Pharmacists.