Structured Polypharmacy Management Before Elective Non-cardiac Surgery in Frail and Elderly People: a Pilot for a Randomized Control Trial

The population is aging rapidly, and elderly people have surgery at a higher rate than any other age group. Advanced age is independently associated with a 2- to 4-fold increase in adverse event rates after surgery, as well as increased rates of postoperative healthcare resource use such as costs and prolonged hospital length of stay. Polypharmacy (defined by the World Health Organization as taking >5 medications concurrently), and potentially inappropriate medications (PIM; i.e., taking medications that are likely to produce more harm than benefit given an individual's risk profile) are increasingly common in older people.

In the perioperative setting, the epidemiology of polypharmacy and inappropriate prescribing is poorly described. Single center studies of general surgery patients suggest that inappropriate prescriptions are independently associated with a 3- to 4- fold increase in the odds of serious complications, while hip fracture patients with polypharmacy have an increased risk of readmission and are often discharged on the same PIMs which may have caused the fracture.

Strategies to address polypharmacy and medication appropriateness have been synthesized in two recent systematic reviews. In general, interventions resulted in decreases in the number of medications taken, and overall medication appropriateness. However, substantial gaps in this knowledge base were also identified. First, no perioperative interventions were identified. Second, overall methodological quality of identified studies was low to very low, with significant issues identified related to study design and inadequate power, poor allocation concealment, and lack of appropriate analytic techniques. Finally, although decreasing the number and inappropriateness of medications are worthwhile outcomes, most studies did not report the impact of these interventions on patient-centered or system-level outcomes.

The preoperative anesthesiology clinic encounter may represent an optimal time to initiate polypharmacy management strategies, as the surgical encounter with the healthcare team is a teachable moment where patients demonstrate extra motivation to make positive changes in their health behaviors. Therefore, the hypothesized positive impact of preoperative polypharmacy management could extend not only into the postoperative period, but also on a longitudinal basis beyond the transition from acute postoperative care.

The preoperative polypharmacy management intervention will be based on a pragmatic, evidence-based, CIHR-funded tool developed by our coinvestigators from McGill for use in elderly inpatients. It has recently been field tested in a 600-patient inpatient study at the Universities of Ottawa, Toronto, and McGill. The tool is a web-based platform developed by experts in internal and geriatric medicine and is based on best-practice guidelines, Choosing Wisely Canada's declarative statements, and evolving issues (such as narcotic and benzodiazepine co-administration). It contains rules that identify PIMs, prioritizes them in terms of risk of harm, and provides deprescribing opportunities for safely stopping medications using the current evidence as well as incorporating patient comorbidities in the analyses.