Medication Review for the 10-Minute Consultation: The NO TEARS Tool
The NO TEARS structure can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style:
Need/indication
Open questions
Tests
Evidence
Adverse effects
Risk reduction
Simplification/switches
Key words: medication review, NO TEARS, primary care, older adults, polypharmacy.
The importance of an effective medication review cannot be understated. An annual or semi-annual review could reduce the risk of iatrogenic harm, medico-legal issues, and waste. It can empower patients and improve their satisfaction. The NO TEARS structure (Table 1)1 can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style.
Mounting recognition of the importance of medication review is reflected in various British documents such as the New GMS Contract,1 the Older People’s National Service Framework,2 and the National Sentinel Clinical Audit of Epilepsy Related Death.3 Medication review has been recognized as an important component in the Multifactorial Falls Risk Assessment in Older People.4
The physiological decline associated with aging is well documented.5 While this may not be a problem when the patient is at rest or unchallenged, it reduces capacity to cope with both disease and treatment. Increasing complexity of illness may be associated with larger numbers of medical professionals. This can increase the risk of potentially inappropriate drug combinations.6 Inappropriate medication prescribing (both overuse of inappropriate medications and underuse of appropriate medications) is an important issue in the older population, and with the popularity of preventative therapy, it is unlikely to diminish. Adverse reactions are implicated in 5-17% of hospital admissions.7 With the dictum primum non nocere in mind, doctors need to be able to critically assess medication.
Re-authorizing and reviewing medication can take many forms,4 and some issues may be better addressed by other members of the primary health care team, such as pharmacists. However, practitioners must remember that they take ultimate responsibility for every script signed. If they know the patient, they will be more aware of what has been tried previously and of what changes will be acceptable. In the United Kingdom, the Task Force on Medicines Partnership has described various levels of medication review (Table 2).
The chosen method of review has often become a local tradition that can be difficult to challenge. It is important that a review system is agreed upon that includes all medications prescribed by different professionals and is clearly understood by all staff involved. Such a system should be equally transparent to the patient. It is suggested that practitioners keep the NO TEARS structure in mind when performing a six-month or annual review of treatments to maximize the potential of the 10-minute consultation.
Need
Is the treatment still indicated or has the diagnosis been refuted? For example, a putative diagnosis of angina may have subsequently been disproved. Treatments may have been inappropriately repeated or the dose may require adjusting. Non-pharmacological interventions may now be better. Does the patient know what the treatments were for and which were “as required” rather than essential?
Open Questions
This is an important opportunity to find out what medications the patient actually takes on a regular basis and his/her understanding of the treatments. Each physician will have his/her own way of asking such questions. It can be useful to show the patient or caregiver that you recognize some