Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many

The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of ‘many’ drugs and ‘too many’ drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients’ clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients’ safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving ‘many’ medicines. It is now recognised that the prescribing of ‘many’ medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients’ clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term ‘appropriate polypharmacy’ in differentiating between the prescribing of ‘many’ drugs and ‘too many’ drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research

Theory-Based Interventions to Improve Medication Adherence in Older Adults Prescribed Polypharmacy: A Systematic Review

BACKGROUND: Previous interventions have shown limited success in improving medication adherence in older adults, and this may be due to the lack of a theoretical underpinning. OBJECTIVE: This review sought to determine the effectiveness of theory-based interventions aimed at improving medication adherence in older adults prescribed polypharmacy and to explore the extent to which psychological theory informed their development. DATA SOURCES: Eight electronic databases were searched from inception to March 2015, and extensive hand-searching was conducted. ELIGIBILITY CRITERIA: Interventions delivered to older adults (populations with a mean/median age of ≥65 years) prescribed polypharmacy (four or more regular oral/non-oral medicines) were eligible. Studies had to report an underpinning theory and measure at least one adherence and one clinical/humanistic outcome. REVIEW METHODS: Data were extracted independently by two reviewers and included details of intervention content, delivery, providers, participants, outcomes and theories used. The theory coding scheme (TCS) was used to assess the extent of theory use. RESULTS: Five studies cited theory as the basis for intervention development (social cognitive theory, health belief model, transtheoretical model, self-regulation model). The extent of theory use and intervention effectiveness in terms of adherence and clinical/humanistic outcomes varied across studies. No study made optimal use of theory as recommended in the TCS. CONCLUSIONS: The heterogeneity observed and inclusion of pilot designs mean conclusions regarding effectiveness of theory-based interventions targeting older adults prescribed polypharmacy could not be drawn. Further primary research involving theory as a central component of intervention development is required. The review findings will help inform the design of future theory-based adherence interventions. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s40266-016-0426-6) contains supplementary material, which is available to authorized users

Development of a European competency framework for health and other professionals to support behaviour change in persons self-managing chronic disease

Funding: This project has received funding from the Erasmus+ Programme of the European Union under the grant agreement no. 2019–1-PT01-KA203– 061389. The Funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The European Commission’s support for the production of this publication does not constitute an endorsement of the contents, which reflect the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.Background: Healthcare and other professionals are expected to support behaviour change in people living with chronic disease. However, effective behaviour change interventions are largely absent in routine encounters. The Train4Health project, a European strategic partnership for higher education, sought to address this problem. The primary aim of this study, which is part of an early work package, was to develop an interprofessional competency framework for health and other professions to support behaviour change for the self-management of chronic disease at a European level. A secondary aim was to derive a set of behaviour change techniques (BCTs) from an established taxonomy to link with framework competencies. Methods: The study comprised two interlinked parts. Part 1 involved a two-round e-Delphi study with an interprofessional panel of 48 experts across 12 European countries to develop the behaviour change competency framework. Preparatory work included drafting a list of competency statements based on seven existing frameworks. Part 2 involved an expert panel of six behavioural psychologists deriving a set of BCTs to link with framework competencies. Their feedback was based on preparatory work, which focused on seven high priority chronic diseases for self-management, identified through European projects on self-management and identifying five relevant target behaviours from key clinical guidelines. A literature search yielded 29 effective BCTs for the target behaviours in the selected chronic diseases. Results: Twenty-seven competency statements, were presented in Round 1 to the Delphi panel. Consensus was achieved for all statements. Based on comments, two statements were removed, one was added, and 14 were modified. All 15 statements subjected to Round 2 were consensus-approved, yielding a total of 12 foundational competencies for behaviour change in self-management of chronic disease and 14 behaviour change competencies. Four behaviour change competencies related to BCTs. Behavioural psychologists’ feedback led to a core set of 21 BCTs deemed applicable to the five target behaviours across the seven chronic diseases. Conclusions: A behaviour change competency framework comprising 26 statements for European health and other professionals to support self-management of chronic disease was developed, linked with a core set of 21 BCTs from an established taxonomy.publishersversionpublishe

Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review

OBJECTIVE: To summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people. DESIGN: Cochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation). SETTING: All healthcare settings. PARTICIPANTS: Older people (≥65 years) with ≥1 long-term condition who were receiving polypharmacy (≥4 regular medicines). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes. RESULTS: 12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers’ criteria and Screening Tool of Older Person's Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported. CONCLUSIONS: The included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice

How to write a successful grant application: guidance provided by the European Society of Clinical Pharmacy.

Considering a rejection rate of 80–90%, the preparation of a research grant is often considered a daunting task since it is resource intensive and there is no guarantee of success, even for seasoned researchers. This commentary provides a summary of the key points a researcher needs to consider when writing a research grant proposal, outlining: (1) how to conceptualise the research idea; (2) how to find the right funding call; (3) the importance of planning; (4) how to write; (5) what to write, and (6) key questions for reflection during preparation. It attempts to explain the difficulties associated with finding calls in clinical pharmacy and advanced pharmacy practice, and how to overcome them. The commentary aims to assist all pharmacy practice and health services research colleagues new to the grant application process, as well as experienced researchers striving to improve their grant review scores. The guidance in this paper is part of ESCP’s commitment to stimulate "innovative and high-quality research in all areas of clinical pharmacy"

Writing a manuscript for publication in a peer-reviewed scientific journal:Guidance from the European Society of Clinical Pharmacy

Publishing in reputable peer-reviewed journals is an integral step of the clinical pharmacy research process, allowing for knowledge transfer and advancement in clinical pharmacy practice. Writing a manuscript for publication in a journal requires several careful considerations to ensure that research findings are communicated to the satisfaction of editors and reviewers, and effectively to the readers. This commentary provides a summary of the main points to consider, outlining how to: (1) select a suitable journal, (2) tailor the manuscript for the journal readership, (3) organise the content of the manuscript in line with the journal’s guidelines, and (4) manage feedback from the peer review process. This commentary reviews the steps of the writing process, identifies common pitfalls, and proposes ways to overcome them. It aims to assist both novice and established researchers in the field of clinical pharmacy to enhance the quality of writing in a research paper to maximise impact

The Future Direction of Inter-Professional Education in Ireland: Insights From Focus Groups With Key Stakeholders

Rationale: An inter-professional education (IPE) masterclass symposium titled, ‘The journey to team-based healthcare’, was jointly hosted by the School of Pharmacy, Royal College of Surgeons in Ireland (RCSI), the Irish Institute of Pharmacy and the Bill Gatton College of Pharmacy in East Tennessee State University in May 2017. The masterclass provided a comprehensive overview of IPE initiatives based on the extensive experience of senior academics from the host institutions, which included staff from pharmacy, nursing and medicine. The masterclass was attended by healthcare professionals, policy makers and educationalists working in Ireland. As part of the symposium, focus groups were conducted with a sample of symposium attendees to determine their opinions and perceptions, as key stakeholders, regarding the development, implementation and future direction of IPE in Ireland. Methods: Focus groups were conducted with symposium attendees using a topic guide that was developed based on previous literature. Questions explored participants’ views and experiences on a range of topics including development and implementation of IPE activities, and key priorities for developing future IPE initiatives. Thematic analysis was conducted to identify key themes. Findings: Three focus groups were conducted each involving five to six participants (total 16 participants: nine female). Preliminary themes have been identified and further analysis is ongoing. Discussion/conclusion: The research findings will help to inform the future development and direction of IPE initiatives at both undergraduate and postgraduate level within the host institutions and could help in the development of an IPE strategy for undergraduate and post-graduate teaching across Ireland

Scope, content and quality of clinical pharmacy practice guidelines:a systematic review

Background Guidelines for pharmacy practitioners regarding various clinical pharmacy activities have been published ina number of countries. There is a need to review the guidelines and identify the scope of activities covered as a prelude todeveloping internationally acceptable common guidelines.Aim To review the scope of clinical pharmacy guidelines and assess the extent to which these guidelines conform to qualitystandards as per the AGREE II instrument.Method Medline, Embase, Guideline Central, International Pharmaceutical Abstracts, Google Scholar and Google (for greyliterature) were searched for the period 2010 to January 2023. Guidelines which focused on any health care setting and anyclinical pharmacy activity were included. Data were extracted and quality assessed independently by two reviewers usingthe English version of the AGREE II instrument.Results Thirty-eight guidelines were included, mostly originating from Australia (n = 10), Ireland (n = 8), UK (n = 7) andUSA (n = 5). Areas covered included medication reconciliation, medicines optimisation, medication management and transi-tion of care. As per the AGREE II assessment, the highest score was obtained for the scope and purpose domain and the low-est score for rigour of development, mainly due to non-consideration of literature/evidence to inform guideline development.Conclusion Clinical pharmacy guidelines development processes need to focus on all quality domains and should take asystematic approach to guideline development. Guidelines need to further emphasise person-centred care and clinical com-munication. There is a scope to harmonise the guidelines internationally considering the diverse practices, standards and legislations across different geographie