LAUSR

Based on our recently published systematic review [1], the authors of a letter to the editor [2] state that physician-led interventions have some positive impact on all-cause mortality (3/4 studies). In the following we would like to explain why this conclusion has to be interpreted with caution. In our review we aimed to explore the impact of strategies to assess and reduce inappropriate polypharmacy in elderly patients on relevant clinical outcome measures such as mortality and hospitalization. As we stated in the paper, the included studies providing data on mortality have serious limitations in design and implementation. The quality of evidence was downgraded by imprecise results, small numbers of events and wide confidence intervals. Moreover, only seven studies defined mortality as an outcome measure and the included studies were highly heterogeneous. Due to the above mentioned limitations, it was not justifiable to perform any subgroup analysis based on type of interventions (e.g. physician-led, pharmacist-led, or multidisciplinary team-led intervention). Apart from that, the results of subgroup analysis and post hoc analyses should always be interpreted with caution and carry the risk of multiple testing. Nevertheless, we believe that educational interventions can have an impact on reducing inappropriate polypharmacy in elderly patients. However, such interventions should be evaluated within a long-term randomized controlled trial (RCT) following the CONSORT statement [3]. Gaviria-Mendoza et al. [2] stated that various medical education interventions have improved rationalizing the use of drugs and it is of great importance to strengthen this kind of research. The question is how to best implement medical educational interventions to reduce inappropriate polypharmacy? Are there any best practice models? To our knowledge very few RCTs have evaluated medical education interventions with the aim of reducing inappropriate polypharmacy. Specific educational interventions could support primary care physicians regarding their growing challenge of medication management due to increasing multimorbidity and demographic changes. Furthermore, patient education, implementation of shared decision-making strategies and involvement of relatives may improve the awareness of the risks and benefits of polypharmacy.