Ri-Medi: a pilot implementation of a medication review and deprescribing service in primary care for elderly patients with polypharmacy in Rome

Introduction

In Italy, the population is progressively ageing, with an estimated life expectancy of 83.4 years.¹ Population ageing is one of the main drivers of polypharmacy; the latest national report on medicines use in Italy² shows that people over 65 years on average take 7.6 different medications per year. Polypharmacy is a major concern because it is associated with several risks, such as drug-drug interactions, adverse events, emergency room accesses, hospitalizations, falls, administration errors, and decreased adherence.^3,4 To address this issue, medication review and deprescribing (MRDP) are key interventions to avoid potentially inappropriate or unnecessary drug use. Beyond suspension of a drug, this includes also dose adjustments or switching to alternative medications based on scientific evidence. At the international level, several initiatives have been developed, such as the Canadian project ‘deprescribing.org’ and the Australian Deprescribing Network (available from australiandeprescribingnetwork.com.au). In Italy, some projects are currently emerging and guidelines have been published to implement MRDP in different healthcare settings.^5,6 In this context, the ‘Ri-Medi’ service was launched to empower General Practitioners (GPs) to implement MRDP for selected therapeutic areas. The service is currently in its pilot phase, carried out at the Local Health Authority ASL Roma 1, implementing MRDP in primary care with a group of volunteer GPs. This service targets elderly patients who are exposed to hyper-polypharmacy. This criterion, i.e., exposure to more than 10 drugs, was selected to focus on subjects with higher clinical complexity and to restrict the target population to a manageable number of patients per GP avoiding major disruptions in the routine clinical practice. These cases are supposed to serve as ‘learning examples’ which will empower GPs to acquire specific knowledge and apply it to their entire patient population. GPs are supported by a multidisciplinary team consisting of epidemiologists, pharmacists, statisticians, clinical pharmacologists, geriatricians, internists, and healthcare managers of the involved districts. The multidisciplinary team, in agreement with GPs, identifies specific therapeutic areas of interest that will be the focus of a series of educational campaigns. For each campaign, a literature review is performed including national guidelines, criteria for potentially inappropriate prescribing in older people like START/STOPP⁷, Beers Criteria⁸, summaries of product characteristics (SmPCs), and online tools such as INTERCheck WEB⁹ and Drugs.com¹⁰. On the basis of the literature review, updated evidence-based materials will be produced in both paper and electronic formats. These materials will be developed with the support of graphic designers specialized in the creation of materials for dissemination and educational purpose. The updated evidence-based materials will be provided to GPs and will be part of scheduled training sessions delivered both in person and online, in order to ensure the involvement of the largest possible number of GPs. Moreover, GPs will be supported by a facilitator, a non-medical figure like a pharmacist or a nurse, who will assist them during the process of medication review through educational outreach visits. This approach has been reported to increase the effectiveness of MRDP.¹¹ Another element to support GPs is the identification of the target population for each therapeutic area, based on administrative healthcare data. This target population is defined as patients associated to potentially inappropriate drug prescriptions and for whom MRDP is expected to be most favourable. Based on the list of potential candidates, GPs make their decision whether or not to adjust therapies, based on their knowledge of the clinical condition of each patient. The impact of the intervention will be evaluated through analyses of administrative data, including pre-post approaches and comparison among areas with and without the intervention. Moreover, physicians experience will be evaluated through an audit&feedback activity.¹² This service is designed to improve appropriate drug prescribing in the elderly (≥65 years) in hyper-polypharmacy (10+ drugs) through evidence-based campaigns for selected drug classes. The pilot phase of the service focuses on statin use in patients aged 80 years or older and is currently being implemented in two health districts of the Local Health Authority ASL RM 1, districts 1 and 14, in a sample of volunteer GPs. Before starting the implementation, a survey was conducted among the GPs adhering to the pilot phase to gather information to improve the service.

Objectives

The specific objective of this pilot phase is to understand the feasibility of ‘Ri-Medi’ through a dedicated survey and to estimate the number of eligible patients aged 80 years or older for medication review, with a particular focus on statin use.

Methods

The multidisciplinary team represents one of the main strengths of this project (figure 1); this team is supposed to have a positive impact on the implementation of this service. The steering committee is composed by the Department of Epidemiology of the Lazio Regional Health Service, the Catholic University Medical School, and Districts 1 and 14 of the Local Health Authority ASL RM 1 (all located in Rome). These organizations contribute at different levels:

• The Department of Epidemiology of the Lazio Regional Health Service is the supervisor of the entire project. Specifically, collaborators conduct literature research and prepare evidence-based educational materials for GPs, such as the SWOT (strength, weaknesses, opportunities and threads) analysis on statin therapy in the elderly (figure 2). They also define the target population for each educational campaign and, in collaboration with GPs, implements audit&feedback activities;
• Districts 1 and 14 of ASL RM 1 are responsible for coordinating GPs and for organizing training courses on the specific therapeutic area of each MRDP campaigns;
• The Catholic University Medical School is responsible for training activities of facilitators and provides pharmacological consulting.

The pilot phase

The first evidence-based campaign of ‘Ri-Medi’ focuses on the use of statins in primary prevention in patients aged 80 years or older in hyper-polypharmacy, given that there is no evidence that the benefits outweigh the risks in this population. For each GP of the two health districts, the target population was defined as those patients with potentially inappropriate statin prescriptions in 2023, in particular patients for whom there were no signals of secondary prevention. Hyper-polypharmacy was defined as the concurrent use of 10 or more medications during the year 2023, using the fourth level of the Anatomical Therapeutic Chemical (ATC) Classification. The target population was identified using regional healthcare databases. Statin users were defined as patients with at least 2 prescriptions of any statin (ATC: C10AA, C10BA, C10BX) in 2023. On this cohort, the following exclusion criteria were applied to obtain only candidates for the MRDP campaign, i.e., older patients in primary prevention:

• ages below 80 years on 01.01.2023;
• patients not alive on 31.12.2023;
• patients not enrolled in the regional healthcare system in 2023;
• patients assisted by GPs who discontinued their service during 2023;
• patients in secondary prevention. Secondary prevention was defined as not having a history of diabetes or cardiovascular events.

Information was retrieved from hospital discharge records using specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (diagnostic codes: 250, 410-414, 433.X1, 434.X1, 435, 436, 438; procedure codes: 00.66, 36.0, 36.1, 38.10, 38.11, 38.12, 00.61, 00.62, 00.63) and, for diabetes, disease specific co-payment exemptions (code 013) and use of specific drug classes (oral antidiabetics and insulin, ATC codes A10) in the preceding 6 years. 

The survey

The survey explored several aspects:

• prior knowledge of MRDP;
• GP’s willingness to participate in the pilot phase;
• general interest of the GPs in this activity.

In addition, GPs were asked to identify therapeutic areas in terms of pharmacological classes to be prioritized in future campaigns and to collect their opinions about added value of the facilitators and their expected competences. The GPs involved in the survey were the same involved in the first phase of the project. They had been invited to a presentation of ‘Ri-Medi’ and were aware of the first statin campaign. The survey, developed using Google Forms, was designed to evaluate the feasibility and acceptability of the project and, before being distributed, was tested among a sample of collaborators of the Department of Epidemiology of the Lazio Region to ensure its comprehensibility and functionality. It comprised 13 questions, with an estimated completion time of about five minutes; most questions were mandatory.

Results

The pilot phase

In 2023, in district 1 based on a selection of 11,386 patients over the age of 65 in hyper-polypharmacy, 5,020 statin users were identified; 618 (12.3%) over the age of 80 were in primary prevention and assisted by 132 GPs, average of 4.7 potential candidates for medication review per GP. In district 14, based on a selection of 12,220 patients over the age of 65 in hyper-polypharmacy, 6,747 statin users were identified, with 868 (12.8%) over the age of 80 in primary prevention, assisted by 118 GPs (mean 7.4 patients per GP). The majority of eligible patients were female (67.8%), with a median age of 84 years. 

The survey

Twenty responses were collected, with a response rate of 52.6%. The survey showed that 12 GPs (60%) already had some knowledge of medication review, but only 3 GPs (15%) reported frequently receiving materials on this topic. Moreover, 85% of GPs (17/20) considered the launch of a medication review/deprescribing service very useful (dashed square in figure 3).

The majority of GPs (19/20, 95%) confirmed their interest to participate in the pilot implementation of the MRDP service. Regarding feasibility, 60% of GPs (12/20) considered the project truly feasible (dashed square in figure 4), 40% moderately feasible (figure 4). The pharmacological classes considered most important for future MRDP therapeutic campaigns were proton pump inhibitors (PPI, 90%) and non-steroidal anti-inflammatory drugs (NSAIDs, 70%). The facilitator was considered useful by 80% of GPs (16/20).

Regarding the competences, facilitators should have deep knowledge of pharmacology and drug interactions, the ability to remain updated on literature and scientific evidence, and the ability to listen and collaborate (figure 5).

Discussion

‘Ri-Medi’ is an innovative service of MRDP in primary care which may be complementary to similar initiatives in different healthcare settings. This service involves different healthcare professionals working together with GPs, leveraging the value of a multidisciplinary approach, favoured by previous experiences at international level.¹³ GPs frequently face time constraints that limit their ability to remain up-to-date on a wide range of therapies. Concise, updated evidence-based materials and support by a multidisciplinary team offer GPs the opportunity to exchange knowledge and seek consultation where needed. Identifying the target population showed that the overall number of patients who are potential candidates for the MRDP activity requires a limited workload. Focusing on these small groups, facilitates GPs in the activity and serves as a learning example. The results of the survey are promising and indicate a potential for a good uptake of the service by GPs. Yet, GPs also express their concerns about the feasibility. At the time of writing, the survey had received a high response rate. The planned audit&feedback activity, moreover, will contribute to address these challenges and find workable solutions. There are several limitations to be mentioned. The project currently addresses only one side of appropriate drug prescribing (i.e., deprescribing in the absence of evidence-based clinical indication or in the presence of contraindications). The other side of the same coin, namely lack of prescribing or adherence to evidence-based drug therapies, is not part of the initiative. The sample of GPs is small and composed of volunteers who had already received a presentation of the activity and were aware of the first statin campaign. This may limit the generalizability of the results to all GPs. Furthermore, the role of the facilitator has not yet been tested in an Italian primary care setting. Although GP survey responses were generally encouraging, it remains to be defined to which degree the facilitator should proactively reach out to GPs. One challenge will be to assess the impact of the service on population health outcomes, such as a potential reduction in emergency room access associated with reduced hyper-polypharmacy related risks, including decreased medication adherence and clinically significant drug-drug interactions. Previous studies have not provided clear evidence to this regard, but authors warrant the need of large studies to increase evidence.8,10 The results of the pilot phase will help define and develop the most appropriate therapeutic approaches and analytical methods to be implemented in the next phase of ‘Ri-Medi’. Audit&feedback techniques will be implemented to ensure a continuous monitoring of aspects related to the feasibility and efficiency of the service in primary care. Results will be used to steadily improve the service.

Conclusions

The preliminary data on the first statin campaign are useful to encourage GPs to participate, given the limited workload. At the same time, numbers give evidence of the potential positive impact of this public health intervention. The results of the survey underpin the interest in the activity by GPs and the added value by offering educational outreach visits with trained facilitators. As the survey is still open, additional responses are expected. The next steps of the activity are to implement the first campaign about statins use in primary prevention with updated data and to develop other campaigns focusing primarily on PPI and NSAIDs. If the pilot implementation proves successful, the service may be proposed to other health districts and local health units in the Lazio Region, involving also citizen representatives.

Conflicts of interest: none declared.

Acknowledgements: the Authors would like to thank the ‘Ri-Medi’ working group (Acampora Anna, Antonio Addis, Nera Agabiti, Silvia Alessio, Laura Angelici, Caterina Magnani, Consuelo Cefalo, Claudio Consoli, Cinzia Dello Russo, Rosella Di Rita, Leonardo F. Difrancesco, Paola Giannantonio, Elisa Gullino, Ursula Kirchmayer, Laura Macculi, Pierluigi Navarra, Graziano Onder, Rosanna Petrangeli, Daniela Ricciardulli, Alessandro Cesare Rosa, Maria Rosaria Russo, Michela Servadio, Valentina Ungari) and all the GPs volunteering participating in the project.

References

1. Istat. Demographic Indicators. Available from: https://esploradati.istat.it/databrowser/#/it/dw/categories/IT1,POP,1.0/POP_POPULATION/DCIS_INDDEMOG1/IT1,22_293_DF_DCIS_INDDEMOG1_1,1.0
2. Italian Medicines Agency. National Report on Medicines use in Italy. Year 2023. Rome: AIFA; 2024. Available from: https://www.aifa.gov.it/en/-/l-uso-dei-farmaci-in-italia-rapporto-osmed-2023
3. Xu Q, Ou X, Li J. The risk of falls among the aging population: A systematic review and meta-analysis. Front Public health 2022;10:902599. doi: 10.3389/fpubh.2022.902599
4. Marcum ZA, Gellad WF. Medication adherence to multidrug regimens. Clin Geriatr Med 2012;28(2):287-300. doi: 10.1016/j.cger.2012.01.008
5. Documento inter-societario sull’implementazione del servizio di medication review e deprescribing nei vari setting assistenziali. Rome: Academy of Geriatrics, FADOI, SICP et al.; 2023.
6. Pasina L, Azab M, Elli C, Nobili A. Revisione della terapia farmacologica e deprescrizione nel paziente anziano. Milan: Mario Negri Institute for Pharmacological Research IRCCS; 2025.
7. O’Mahony D, Cherubini A, Guiteras AR et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med 2023;14(4):625-32. doi: 10.1007/s41999-023-00777-y
8. The 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71(7):2052-81. doi: 10.1111/jgs.18372
9. INTERCheck Web. Available from: https://intercheckweb.marionegri.it/
10. Drugs.com. Drug Interactions Checker. Available from: https://www.drugs.com/drug_interactions.html
11. O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2007;2007(4):CD000409. doi: 10.1002/14651858.CD000409.pub2
12. Angelici L, Angioletti C, Pinnarelli L, et al. EASY-NET Program: Effectiveness of an Audit and Feedback Intervention in the Emergency Care for Acute Conditions in the Lazio Region. Healthcare (Basel) 2024;12(7):733. doi: 10.3390/healthcare12070733
13. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Netw Open 2025;8(6):e2517965. doi: 10.1001/jamanetworkopen.2025.17965