We are delighted to see others look for ways to improve and broaden the use of the Garfinkel GP-GP model.1,2 Avoiding adverse events is a major motivator for reducing polypharmacy. Incorporation of risk assessment tools into the GP-GP model might improve the ability of physicians to identify medications particularly likely to cause problems for elderly persons. Hospital admissions can be an opportune time to recommend drug discontinuation. This discharge advice is given to primary care providers who can then initiate and coordinate the withdrawal and monitoring. However, patients are usually discharged on more medication therapy than they were admitted on, and hospital physicians may be reluctant to stop or change medications given by the family physician and vice versa. Transfer between primary and secondary care settings is a time of pharmacological peril. Effective communication is required between primary and secondary care settings, with clear delineation of responsibility for follow-up. A better solution is the case manager approach: teams or experienced physicians, who are preferably geriatricians, with or without pharmacists who would have final responsibility for the patient, particularly for the polypharmacy aspect. The place of clinical judgment should not be understated though in relation to evidence-based medicine. Furthermore, special mention should be made of the need for in-depth consultation with the patient and family before and during the course of the new regime.
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