Medication safety in polypharmacy: technical report

As the population ages more people are likely to suffer from multiple long term illness and take multiple medications. It is essential to therefore take a person-centred approach to ensure that the medications are appropriate for the individual to gain the most benefits without any harm. This reports highlights importance of leadership in nurturing a culture that priorities safety and quality of prescribing, provides guidance on prioritising patients for medication review, the role of the patient and the importance of a multi-professional team across the health and care system, including policy makers. Included in the report are tools and case studies which illustrate a systematic approach that can be followed by all health care professionals and the patient, across the health and care system to ensure that patients are integral to the decisions about their medications and feel supported to do so

Polypharmacy.

The improvement topic series is a set of briefing papers about areas of quality and safety which general practice clusters could usefully focus improvement activity on. They summarise research, guideline and other evidence about areas of care which can be improved, and improvement methods and interventions. Multimorbidity and inappropriate polypharmacy impact patient care, with consequences of drug-drug interactions and adverse drug events, drug-related hospitalisations, non-adherence and higher health care costs. Decisions on starting and stopping medicines in older people are complex due to a number of factors including the plethora of single disease guidelines which are based on evidence from research that largely excludes most people with multimorbidity. This paper describes measures and improvement methods being implemented in the real-world in Scottish general practice

Optimizing polypharmacy management in the elderly: a comprehensive European benchmarking survey and the development of an innovative online benchmarking application

Background: Polypharmacy, defined as the simultaneous use of multiple medications by a patient, is a worldwide problem of rising prevalence. Paving the way for drug interactions, adverse drug reactions and non-adherence, it leads to negative health outcomes, increased use of healthcare services and rising costs. Since it is closely related to multimorbidity, it peaks in older adults. So far, not many polypharmacy management programs in the elderly have been introduced in practice. However, due to the rapid ageing of European societies, there is an urgent need to implement them more widely. Objective: The aim of this study was to benchmark polypharmacy management programs in the elderly available in Europe and creating a dedicated benchmarking application. Methods: It was a cross-sectional study based on an online survey targeting healthcare professionals and other stakeholders across European countries. Data collected in the survey were reused to design an online benchmarking application. Results: As many as 911 respondents from all but two EU countries took part in this study. Out of the survey participants, 496 (54.4%) reported availability of various activities or formal programs targeting polypharmacy in the elderly that were known to them. These programs had multiple goals, of which improved patient safety was indicated as the most common objective (65.1% of the cases). The most typical settings for such programs was primary care (49.4%), with pharmacists and primary care doctors being indicated most often as those providing the programs (61.7% and 35.5% of cases, respectively). Vast majority of programs applied diverse forms of drug reviews. The identified programs were assessed against four predefined dimensions of effectiveness, applicability, scalability and cost-effectiveness. The lowest scores were obtained within the last of these categories, due to unavailability of relevant data. Based on the survey results, a benchmarking application was constructed. It allows for comparing an individual polypharmacy management program targeting the elderly against the other ones, and particularly, against the national and European context. Conclusion: By providing strong evidence, the findings of this study, coupled with the benchmarking application, can prove valuable in aiding clinicians and policymakers in the implementation and expansion of polypharmacy management programs for the elderly

Polypharmacy and Adherence: Key Components of Integrated Care Findings from the SIMPATHY Project

Context, aims and objectives: As many as half of all patients with chronic conditions are using their medicines in a way that is not fully effective, resulting in sub-optimal treatment and subsequent increases in hospitalisations and emergency department visits. High levels of inappropriate prescribing further compound this problem. These issues are especially germane to older patients. Safe and effective pharmacotherapy remains one of the greatest challenges in this population, where models of healthcare delivery lag behind the enormous growth in single disease focused pharmacotherapy. The implications for safe, efficient, effective and sustainable deployment of healthcare resources are significant from both a healthcare systems and societal perspective.Integrated care models have the potential to mitigate inappropriate polypharmacy, while simultaneously diminishing problems related to poor adherence. Project SIMPATHY addresses both of these issues by aiming to stimulate and support innovation throughout the European Union regarding the management of polypharmacy and adherence in the older patient. The SIMPATHY Consortium has completed case studies in eight EU countries, providing useful insights into how different health care systems address this challenge. This workshop will present these findings, using them as a basis for discussion on the practicalities of integrating new practices into existing workflow, highlighting the opportunities that an integrated care model can provide

Sustainable Implementation of Polypharmacy reviews as part of integrated care at Scale

Medication is the most common form of intervention to prevent disease or slow disease progression, with guidelines for single diseases recommending evidence based drug treatments. There remains the mismatch between prescribing guidelines for specific medical conditions and the range of clinical complexity found in individual adults with multiple morbidities. The resulting polypharmacy (use of multiple medicines) can be both appropriate and inappropriate and the key healthcare aim for individual patients is to ensure the on-going safe and effective use of their multiple medicines.NHS Scotland developed, designed and implemented national policy to consider the patient pathway and the flow of work needed to be undertaken in clinical practice to address appropriate management of Polypharmacy. Implementation across all 14 health boards serving a population of 5.5 million people in Scotland utilised Kotter’s 8 steps[1] for implementation of change supported by clinical and policy leadership, economic data and clinical outcome data. NHS Scotland have provided leadership for a European work plan. SIMPATHY , Stimulating Innovation in Managment of Polypharmacy and Adherence in the Elderly, (www.simpathy.eu) has benchmarked European strategies to address polypharmacy and through in-depth case studies in 10 EU countries, is developing strategies and tools to support innovation in polypharmacy and adherence management across Europe.Synthesis of the findings from application of change management tools such as Kotter, PESTEL (Political, Economic, Social,Technological, Environmental and Legal) and SWOT ( Strenghts Weaknesses, Opportunities and Threats), together with the case studies serve to inform further innovation. Comparison was made to other EU countries, that had started to implement a programme..Work undertaken in the Scottish programme has been used to develop an economic tool that may be used by other countries to explore the economic benefits of a national polypharmacy management programme. Transferability of innovation will be supported through publication of a reference book based on the findings of SIMPATHY.Synthesis of findings confirmed that key principles of Kotter influenced the successful implementation of national policy for management of polypharmacy in Scotland. It was identified that policy and clinical leadership were essential drivers along with a policy change that supported implementation in the service together with contractual arrangements . Lessons learned from national policy implementation in Scotland and from local programmes in other EU countries, including facilitators and barriers, together with key features of an economic tool will inform innovation of integrated care at a policy level

Age-Related Medicine

A meeting organised by the Academy of Pharmaceutical Sciences focussed on the challenges of developing medicines for older adults. International experts discussed the complexity introduced by polypharmacy and multiple morbidities and how the risk–benefit ratio of a medicine changes as an individual ages. The way in which regulatory authorities are encouraging the development of age-appropriate medicines was highlighted. Examples were provided of the difficulties faced by the older population with some medicinal products and suggestions given as to how the pharmaceutical scientist can build the requirements of the older population into their development of new medicines, as well as improvements to existing ones

A case study of the implementation and sustainability of medication reviews in older patients by clinical pharmacists.

Background : Medication reviews have been introduced as healthcare interventions to decrease inappropriate polypharmacy in older patients, but implementation in practice is challenging. Objective: This case study aimed to explore the events, actions and other factors that were involved in the implementation and sustainability of medication reviews in older patients by clinical pharmacists in Region Uppsala, Sweden. Methods: A case study design informed by change management principles (Kotter) and normalization process theory, consisting of a review of published and grey literature, key informant interviews and focus group triangulation. Findings from additional literature review and interviews were integrated into a final thematic analysis. Ten healthcare professionals, managers and policy makers participated as key informants. The study included data up to 2015. Results : Factors were identified across all Kotter's principles and normalization process theory domains, ranging from the first evidence on inappropriate polypharmacy in the 1980s until the creation of permanent clinical pharmacist positions in recent years. Examples of facilitating factors were a national focus on quality of care for the elderly, multiprofessional teamwork, key individuals of different professions, education, financial support and local evidence. Barriers included an unclear allocation of tasks and responsibilities, a lack of time and continuity, and a lack of a national plan for implementation, monitoring and evaluation. Conclusions : Multiple factors across the full range of change management and implementation principles were involved in the implementation and sustainability. A systems approach, including these factors, should be considered in similar future initiatives, both in Sweden and settings in other countries