Alpana Mair

Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments.

ABSTRACT Introduction: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, ‘Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY’, which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter’s eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people

Background Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. Methods Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. Results Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. Conclusion Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

A case study of polypharmacy management in nine European countries: implications for change management and implementation.

Background Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. Methods Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases. Results Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. Conclusion Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives.

The use of PESTEL as a change management tool to inform change management of polypharmacy and adherence within SIMPATHY program

Introduction : Polypharmacy and medication adherence in the older populationwith multiple chronic conditionsare significant public health issues across all the European Union (EU) countries. SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) is a consortium of 10 organizations representing 8 EU countriesaiming to provide to EU policy makers the evidence and tools, including Change Management methodologies, to support to formulate and introduce new policies. Methods : The selection the Change management approach, in SIMPATHY, aimed to provide the analytical tool to identify the impact of various factors affecting polypharmacy, not only currently but also in the short and long run. The approach selected is the PESTEL analysis, it has been deployed in three steps andis expected to provide projection of the estimated impact of the factors up to 10 years. First step aimed to create a PESTEL analysis framework and to prepare guide to help the partners to conduct the analysis; a pilot testing performed in three of the partner countries for assessing the specificity, objectivity and robustness of the multidimensional content, before the finalization of the relevant Handbook. The second step focused to conduct the analysis -through interviews and workshopsamong the stakeholders, decision makers and focus groups across all eight countries.The third step refers to the interpretation of the results in order the evident drivers and barriers to change polypharmacy landscape to be identified and to be taken into consideration for future strategy development. Process and preliminary results: The change management approach stimulated a dynamic process within SIMPATHY. The first and second step of the entire PESTEL process is about to be completed. The PESTEL frameworkhasbeen formulated incorporating economic, political, legaland cultural contextas well as alternative interventionsrelated to the health system structure and attributes in health and social care delivery process among EU countries.Pilot analyses results mainly focused on the comprehensiveness and objectivity of the factors included in the PESTEL framework and contributed to the Handbook’s improvement and finalization. Finally, the analysis conducted by each country is expected to provide interesting results about the differences, particularities and similarities among the countries, especially regarding the attributes of health care delivery, medication prescribing and dispensing, controlling mechanisms, the role of payers as well as doctors’, pharmacists’ and patients’ behaviour. These will create a rich picture of the drivers and barriers for change in each country but also in all countries and potentially provide a clear understanding of the measures necessary to be taken and the policies to be implemented in the future. Conclusion : SIMPATHY preliminary Change Management results support the formulation of a strategy of introducing changes over a 10 years’ time horizon and give evidence to EU to develop a policy framework to address inappropriate polypharmacy and improve adherence, by involving decision makers, health professionals, stakeholders and by supporting the enhancement of the integration in all levels of health and social care. Funding : This poster is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020).