There is also room for improvement in prescribing medication to people in the final phase of life in 2021

Healthcare professionals and policy makers have a growing focus on improving the quality of palliative care, which involves the use of quality indicators. Four such indicators, specifically aimed at medication, were measured in 2017 and 2021 in a sample of people who died from a condition associated with a possible need for palliative care and who were registered with a general practice until their death. Desirable outcomes were not measured for all these indicators, neither in 2017 nor in 2021. This suggests that there is still room for improvement among general practitioners in prescribing medication in the final phase of life. This research is the fourth within the collaborative project Learning and Improvement in Palliative Care (LeVePZ), of which Nivel is a part.

The quality indicators concerned the percentages of patients with prescriptions in the last 3 months of life of (1) opioids (for pain relief), (2) laxatives in combination with opioids, (3) possibly inappropriate medication in the final phase of life and (4) medication of questionable value at the end of life.

Hardly any difference on three of the four indicators between 2017 and 2021

The prescribing behavior of general practitioners in 2021 hardly differs from that of 2017 on three of the four indicators mentioned. This is despite the fact that in 2017 it was concluded that improvement was desirable in the context of ‘good care’.

The table makes it clear that in 2021, general practitioners prescribed relatively fewer opioids to people in the last three months of life (48%) than in 2017 (55%). On the other three indicators, the prescribing behavior of general practitioners in 2021 hardly differs from that in 2017, while this may be desirable for these three indicators in the context of ‘good care’.

Decline in opioid prescribing doesn’t mean much without knowing context

A high percentage of people who are prescribed weak or strong opioids in the final phase of life can be an indicator of good care. This is because people in this phase are believed to often be in pain and therefore need this medication. In that sense, the decline in 2021 compared to 2017 is undesirable. But pain can also be treated in other, more multidimensional ways than with opioids, and people may experience less pain through other treatment methods. This means that no firm conclusion can be drawn about the decline in opioid prescriptions.

A third do not receive a prescription for laxatives with their prescribed opioids

Constipation is a common side effect of opioids. Therefore, standard laxatives should be prescribed in addition to opioids. However, in 2017, not all people (68%) who were prescribed opioids also received a prescription for laxatives. We see no improvement in this in 2021 (66%). Improvement in this area is therefore desirable.

Two-thirds are incorrectly given repeat prescriptions in the final phase of life

Good pharmacological care for people in the last 3 months of life also means that the percentage of potentially undesirable repeat prescriptions is low. We investigated this for two categories of medicines:

• Firstly, these are medications that were useful previously but may be inappropriate in the final phase of life (indicator 3). Examples of this are Vitamin D and calcium supplements and cholesterol lowering agents. Our research shows that approximately a third of the target group indeed no longer received repeat prescriptions for (now) inappropriate medication. This suggests that general practitioners do indeed proactively consider the suitability of medication. This does not alter the fact that more than two thirds of the target group in 2021 (68%), just like in 2017 (70%), received these prescriptions (possibly) incorrectly.
• Secondly, this concerns medication that may no longer have any clinical value in the final phase of life (indicator 4). Examples of this are certain heart medications (cardiac glycosides) and antacids. Here too, there are indications that general practitioners pay attention to stopping prescribing this medication in the final phase of life. However, in 2021, the percentage of people with a repeat prescription for medication of questionable clinical value is high (77%), and this percentage is comparable to 2017 (79%).

In conclusion, we can conclude from this that general practitioners for this target group would be well advised to periodically evaluate whether certain medications can be stopped in the final phase of life. Prescribing laxatives in combination with opioids also remains a point of attention.

About the research

The Learning and Improvement in Palliative Care (LeVePZ) project is a collaboration between Nivel, the Netherlands Palliative Care Foundation (PZNL), the Netherlands Integral Cancer Center (IKNL), the National Consultation Consortia (LOCo) and the Netherlands Palliative Care Research Foundation (PALZON). with funding from ZonMw’s Palliance programme.

For this report, data were used from the population registrations of the Central Bureau of Statistics and the registrations of general practitioners of Nivel Zorgregistries Eerste Lijn. The figures have been calculated on a sample of 6993 people. The publications with figures from 2017, with which we compared these 2021 figures, can be found in the research project Integrated Information System Palliative Care – development and first use (2018-2020).