Barriers and facilitators to deprescribing in primary care: a systematic review

Background Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented. Aim To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care. Design and setting Systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy (PROSPERO: CRD42019121848). Method A search of electronic databases: Medline, Embase, CINHAL, Cochrane and HMIC (26.02.19) using an agreed search strategy; supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies. Results Forty studies from 14 countries were identified. Cultural and organisational barriers included a culture of diagnosis and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools and resources. Interpersonal and individual-level barriers included professional etiquette; fragmented care; prescribers’ and patients’ uncertainties; and gaps in tailored support. Facilitators included prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge and understanding; patient-centred care; and shared decision-making. Conclusion A whole systems patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients and carers

Health-related preferences of older patients with multimorbidity: An evidence map

Objectives To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.Design Evidence map (systematic review variant).Data sources MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.Study selection Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).Data extraction Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.Results The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9–9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.Conclusion Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.Trial registration number Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ

Nurses\u27 experience of managing adults living with multimorbidity: A qualitative study

Background: The number of adults living with two or more chronic conditions is increasing worldwide. Adults living with multimorbidity have complex physical, psychosocial and self-management care needs. Aim: This study aimed to describe Australian nurses\u27 experience of care provision for adults living with multimorbidity, their perceived education needs and future opportunities for nurses in the management of multimorbidity. Design: Qualitative exploratory. Methods: Nurses providing care to adults living with multimorbidity in any setting were invited to take part in a semi-structured interview in August 2020. Twenty-four registered nurses took part in a semi-structured telephone interview. Results: Three main themes were developed: (1) The care of adults living with multimorbidity requires skilled collaborative and holistic care; (2) nurses\u27 practice in multimorbidity care is evolving; and (3) nurses value education and training in multimorbidity care. Conclusion: Nurses recognize the challenge and the need for change in the system to support them to respond to the increasing demands they face. Impact: The complexity and prevalence of multimorbidity creates challenges for a healthcare system configured to treat individual disease. Nurses are key in providing care for this population, but little is known about nurses\u27 experiences and perceptions of their role. Nurses believe a person-centred approach is important to address the complex needs of adults living with multimorbidity. Nurses described their role as evolving in response to the growing demand for quality care and believed inter-professional approaches achieve the best outcomes for adults living with multimorbidity. The research has relevance for all healthcare providers seeking to provide effective care for adults living with multimorbidity. Understanding how best to equip and support the workforce to meet the issues and demands of managing the care of adults living with multimorbidity has the potential to improve patient outcomes. Patient or Public Contribution: There was no patient or public contribution. The study only concerned the providers of the service

Perspectives on wider integration of the health-assistive smart home

Most older adults desire to be as independent as possible and remain living in their ancestral home as they age. Aging-in-place maximizes the independence of older adults, enhancing their wellbeing and quality of life while decreasing the financial burden of residential care costs. However, due to chronic disease, multimorbidity, and age-related changes, appropriate conditions are required to make aging-in-place possible. Remote monitoring with smart home technologies could provide the infrastructure that enables older adults to remain living independently in their own homes safely. The health-assistive smart home shows great promise, but there are challenges to integrating smart homes on a larger scale. The purpose of this discussion paper is to propose a Design Thinking (DT) process to improve the possibility of integrating a smart home for health monitoring more widely and making it more accessible to all older adults wishing to continue living independently in their ancestral homes. From a nursing perspective, we discuss the necessary stakeholder groups and describe how these stakeholders should engage to accelerate the integration of health smart homes into real-world settings

Aging in place among home-dwelling older adults in Canton Basel-Landschaft: the INSPIRE Population Survey

Due to medical and technological advancements, many individuals in countries around the world are living longer (1). In Switzerland between 2020 and 2050, a rise from 18% to 26% for those aged 65 years or older and from 5% to 11% for those aged 80 years and older is foreseen (2). The gains in life expectancy, although a positive outcome, are not always enjoyed in full health and free of limitations. As individuals age, many of them may suffer from the presence of multi-morbidity and frailty (3, 4). Functional limitations as well as isolation and loneliness are also frequently reported among this population (3, 5-7). Moreover, these individuals usually receive care from different providers across various settings which can lead to their care being fragmented (8). Fragmentation of care is characterized by gaps in provision of care which could cause confusion and distress for older adults and their caregivers, as well as higher costs associated with unnecessary use of services (9). Despite challenges associated with aging, many older individuals prefer to remain living in their own environments for as long as possible (10, 11), an objective known as aging in place (12). Aging in place is linked to the ability to maintain independence and live a thriving and highly qualitative life within an individual’s own environment (13). It can therefore be fostered by designing environments that facilitate the mobility and engagement in social activities, which are important components for the health and quality of life of older adults (14). There is also an opportunity for countries to exploit existing and new assistive technologies, another pertinent facilitator of aging in place (15). Assistive technologies are an umbrella term including any device, equipment, instrument or software whose purpose is to maintain or improve an individual’s functional status and independence (16). To assist older adults to age in place and address their complex needs, the World Health Organization (WHO) has proposed an integrated care approach to support older adults’ independence and make aging in place possible (8, 17). Integrated care models are complex, dynamic interventions targeting multiple levels of the healthcare system, which often entail behavior change in the way various health and social care providers provide joint care (18, 19). To successfully develop and implement an integrated model of care, not only the perspectives of the healthcare providers, social care professionals or policymakers are essential, but also the needs and preferences of older adults and their informal caregivers (15, 20). Understanding the demographic and social characteristics of a target population, is also fundamental in planning, developing and implementing integrated care for older people (21). In 2018, an opportunity for integrated care for home-dwelling older adults was put forward by a new care law in Canton Basel-Landschaft in Switzerland (22). The INSPIRE project is working together with the local policymakers to support the development, implementation and evaluation of an integrated care model for home-dwelling adults aged 75 and above living in this region (23). The INSPIRE project is an implementation science project, positioned within the three phases (development, feasibility and effectiveness evaluation) of the Medical Research Council (MRC) for developing and implementing complex interventions (18). The project incorporates the recommendations of the MRC framework with several implementation science components such as contextual analysis, stakeholder involvement, as well as using implementation strategies and implementation outcomes to ensure the successful implementation and sustainability of the care model in Canton BL. During the development phase, an understanding of the context aids in ensuring the suitability of the intervention components for the implementation setting (23, 24). Therefore, we conducted the INSPIRE Population Survey (25, 26) as part of the contextual analysis, with the aim to understand the needs and preferences of older adults, as well as the support and services they currently require and anticipate needing in the future to maintain their independence and make aging in place possible. The overall goals of this dissertation are threefold. First, we aimed to describe the development of the INSPIRE Population Survey and the marketing strategy we used to reach as many home-dwelling older adults as possible, a population that is known to be challenging to recruit in research (27). Second, we used an ecological approach to dive deeper into the health-related quality of life of this population, as one of the main goals of aging in place. Finally, we investigated factors associated with openness to use assistive technologies that can facilitate independence among home-dwelling older adults and support them to age in place. Chapter 1 provides a general overview of challenges associated with caring for an aging population as well as the opportunities for integrated care for aging in place among home-dwelling older adults. The current literature on the concepts of quality of life and health-related quality of life, as well as the current state of the art on assistive technologies facilitating the autonomy of older adults is also provided. Chapter 2 follows with the dissertation aims. Chapter 3 chronicles the research conducted to develop the INSPIRE Population Survey, as well as an outline of the variables and measurements used in the survey (25). The work also describes the marketing strategy used for disseminating the survey and briefly reports on the response rate and participant characteristics. This population-based survey achieved a response rate of 30.7%, which is considerably high for postal surveys (28), particularly in those involving older adults (27). This accomplishment can be credited to the ongoing stakeholder involvement strategies we used, including early engagement of all stakeholders during the development of the questionnaire as well as its marketing. In Chapter 4, we evaluated HRQoL and factors related to it using an ecological outlook. The participants of our survey reported a high HRQoL, similar to findings from previous research (29, 30). We specifically looked at multilevel factors at the micro, meso and macro level related to how home-dwelling older adults perceived their HRQoL. This ecological perspective permitted the investigation of variables associated not only with the individual, but also with the environment around the older adult. We confirmed that among home-dwelling older adults, having a higher income, supplementary insurance, better education and generally a greater socio-economic status were associated with a higher HRQoL (31, 32). Our findings also validated previous studies indicating that individuals who report to be more frequently involved in one or more social activities, correspondingly report a higher HRQoL (33, 34). We also confirmed factors that negatively impact home-dwelling older adults’ HRQOL, as previously researched, like being older and female, having multimorbidity and polypharmacy, and being lonely or socially isolated (35-46). Chapter 5 presents the results from our study aiming to describe the current and anticipated use of assistive technologies among our participants, namely telemedicine, phone/SMS, wearables and assistive robots; as well the factors associated with openness to use such assistive technologies. We showcased that the current use of assistive technologies was rather low amid participants, compared to findings from two other surveys conducted on this topic among Swiss older adults (47, 48). Our results highlight a new finding that compared to current use, a higher percentage of home-dwelling older adults were open to using wearables and telemedicine in the future. We also found that openness to use assistive technologies in this population was positively associated with their current use, and also with receiving support from a spouse or a partner. Similar to the two previous surveys in Switzerland, openness to use assistive technologies was negatively associated with older age and with being female (47, 48). Chapter 6 presents a summary of the findings from the three preceding chapters and interprets them in the context of the current literature. Furthermore, methodological strengths and limitations of these studies are discussed. At last, reflections on the implication of this thesis for future research, policy and practice are presented. In conclusion, this dissertation was part of the development phase of an implementation science project aiming to implement and sustain an integrated care model for home-dwelling older adults. Our findings provide some important insight into the areas requiring the attention of care professionals and policymakers. We brought forward the need for considering the role the environment and the social network surrounding home-dwelling older adults play in fostering care that augments their quality of life and supports them in maintaining their desired independence. We also showed the potential assistive technologies have in attaining this goal, possibly also alleviating some of the burden of informal caregivers who are providing care and support for home-dwelling older adults. From a research, practice and policy position, we believe our findings have the prospective to provide a better scientific and policy approach in assuring older adults are reaching their goal to age in place

Living with multimorbidity: medical and lay healthcare approaches

Multimorbidity is rapidly becoming the norm rather than the exception in healthcare. Research on this issue is increasing and this review discusses a selection of clinical and social science literature. The focus is on understanding the complexity of the lived experience of multimorbidity and how this is presented in clinical encounters, drawing on examples of arthritis within a multimorbidity context. Taking into account the biophysical, psychological, social and cultural factors that shape multimorbidity this paper calls for a re-conceptualization of the concept, allowing a more dynamic and holistic approach

Home-based Digital Health Technologies for Older Adults to Self-Manage Multiple Chronic Conditions: A Data-Informed Analysis of User Engagement from a Longitudinal Trial

BACKGROUND: Ageing populations are resulting in higher prevalence of people with multiple chronic conditions (multimorbidity). Digital health platforms have great potential to support self-management of multimorbidity, increasing a person's awareness of their health and well-being, supporting a better understanding of diseases and encouraging behaviour change. However, little research has explored the long-term engagement of older adults with such digital interventions. METHODS: The aim of this study is to analyse how 60 older adults with multimorbidity engaged with digital symptom and well-being monitoring through a digital health platform over a period of approximately 12 months. Data analysis focused on user retention, frequency of monitoring, intervals in monitoring and patterns of daily engagement. RESULTS: Our findings show that the overall engagement with the digital health platform was high, with more than 80% of participants using the technology devices for over 200 days. The submission frequency for symptom parameters (e.g. blood glucose (BG), blood pressure (BP), etc.) was between three and four times per week which was higher than that of self-report (2.24) and weight (2.84). Submissions of exercise (6.12) and sleep (5.67) were more frequent. The majority of interactions happened in the morning time. The most common time of submission for symptom parameters was 10 am, whereas 8 am was the most common time for weight measurements. CONCLUSIONS: The findings indicate the patterns of engagement of older adults with complex chronic diseases with digital home-based self-management systems

What does it take to make integrated care work? A ‘cookbook’ for large-scale deployment of coordinated care and telehealth

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care coordination and telehealth (CC&TH) services on a large scale. A number of insights and conclusions were identified by the ACT programme. These will prove useful and valuable in supporting the large-scale deployment of CC&TH. Targeted at populations of chronic patients and elderly people, these insights and conclusions are a useful benchmark for implementing and exchanging best practices across the EU. Examples are: Perceptions between managers, frontline staff and patients do not always match; Organisational structure does influence the views and experiences of patients: a dedicated contact person is considered both important and helpful; Successful patient adherence happens when staff are engaged; There is a willingness by patients to participate in healthcare programmes; Patients overestimate their level of knowledge and adherence behaviour; The responsibility for adherence must be shared between patients and health care providers; Awareness of the adherence concept is an important factor for adherence promotion; The ability to track the use of resources is a useful feature of a stratification strategy, however, current regional case finding tools are difficult to benchmark and evaluate; Data availability and homogeneity are the biggest challenges when evaluating the performance of the programmes

The impact on health-related quality of life of mixed mental and physical multimorbidity in adults aged 60 years and older: secondary analysis of primary care data

Introduction Given the number of patients with mental conditions who receive treatment within the primary care (PC) context, and the high prevalence of multimorbidity (especially in older people), there is a need to study mental-physical multimorbidity (MPM) in this population and context. This study sought to identify the impact on health-related quality of life (QoL) of MPM in adults aged 60 years and older. Material and methods Secondary analysis of data derived from 251 primary health individuals. Data were collected via a sociodemographic and clinical questionnaire. Health-related QoL was assessed using the SF-12 instrument. Multiple linear regressions were performed for physical and mental health in MPM patients and in patients with physical-only multimorbidity. Results Mean age of participants was 70.6 years; 57.8% were female. Quali¬ty of life was lower in MPM patients than in those with physical-only multimorbidity. Regarding MPM patients, female sex, 75 years and over, and low income were associated with worse physical health. Female sex was also associated with worse mental health. Conclusions This study contributes to the global knowledge of MPM in older people, illuminates health-related QoL differences among MPM and physical- only multimorbidity patients, and highlights the importance of non-modi-fiable characteristics associated with deterioration of health-related QoL. Team collaboration between primary care physicians, psychiatrists (and other mental health providers), and social workers may be necessary to assess psychiatric and physical symptoms and provide for the care needs of older people with MPM.info:eu-repo/semantics/acceptedVersio