Management Of Polypharmacy Research Articles

Excessive Hypocoagulation in Therapy with Warfarin within Polypharmacy: Using online database Multi-Drug Interaction Checker and Graphic “Time-Effect-Drug Administration” to Eliminate Adverse Drug Event (Case Report)

The purpose of this article is to demonstrate a new approach to polypharmacy management in ambulatory practice using as example a case report of adverse drug event (ADE) in patient with atrial fibrillation and comorbidity. The patient had excessive polypharmacy level (11 drugs). Minor bleeding developed when using these drugs (INR – 6.70). The analysis of drug interactions was performed at patient’s home by online database Multi-Drug Interaction Checker and Time-effect-drug graphic. As a result of analysis, it was described two drug interactions led to minor bleeding: warfarin+rosuvastatin, warfarin+amiodarone. It was found that the patient had not taken rosuvastatin before and it was first-time administration of rosuvastatin. Therapy was corrected, the causes and effects of ADE are eliminated. The drugs without proven benefit and known drug interactions were cancelled. There were no clinical signs of bleeding after correction and the last INR was 2.54. Combined using of Multi-Drug Interaction Checker and Time-effect-drug graphic allowed to detect causal relationship between ADE and drugs initiating it and then to make a rational decision right at the patient’s home in a short time.

Health care providers' roles and responsibilities in management of polypharmacy: Results of a modified Delphi.

Little is known about the roles that allow interprofessional teams to effectively manage older patients experiencing polypharmacy. To identify and examine the consensus on salient interprofessional roles, responsibilities and competencies required in managing polypharmacy. Four focus groups with 35 team members practising in geriatrics were generated to inform survey development. The sessions generated 63 competencies, roles or responsibilities, which were categorized into 4 domains defined by the Canadian Interprofessional Health Collaborative. The resulting survey was administered nationally to geriatric health care professionals who were asked to rate the importance of each item in managing polypharmacy; we sought agreement within and across professions using a confirmatory 2-round Delphi method. Round 1 was completed by 98 survey respondents and round 2 by 72. There was high intra-professional and interprofessional consensus regarding the importance of competencies among physicians, nurses and pharmacists; though pharmacists rated fewer competencies as important. Less consensus was observed among other health care professionals or they indicated the nonimportance of competencies despite focus group discussion to the contrary. Although there is a strong consensus of polypharmacy management competencies across team members who have been more traditionally involved in medication management, there continue to be health care providers with differing understandings of competencies that may contribute to reduced reliance on medication. Lower importance ratings suggest pharmacists may not acknowledge or recognize their own potential roles in interprofessional polypharmacy management. Further exploration to understand the underutilization of professional expertise in managing polypharmacy will contribute to refining role clarity and translating competencies in practical settings, as well as guiding educators regarding curricular content.

The Association between Polypharmacy and Hip Fracture in Osteoporotic Women: A Nested Case-Control Study in South Korea.

Polypharmacy, regarded as an indicator of potentially inappropriate medications (PIMs), may lead to a higher risk of serious health consequences in elderly patients with osteoporosis. Thus, this study aimed to analyze the association between polypharmacy and hip fracture in patients with osteoporosis because only a limited number of studies have reported on this association, with inconsistent results to date. In this nested case-control study using a population-based sample cohort, the target cases were female patients with hip fracture diagnosed with osteoporosis and aged ≥ 50years. Polypharmacy (prescription of an average of five or more daily drugs), PIMs for hip fracture (such as benzodiazepines and glucocorticoids), Charlson Comorbidity Index (CCI) score, and other comorbidities were analyzed during the year preceding the diagnosis of hip fracture. Adjusted odds ratios (ORs) for hip fracture for the variables were also analyzed. The cases (n = 1003) showed higher exposure rates to polypharmacy, glucocorticoids, and benzodiazepines, and had more severe comorbidity statuses compared with the controls. The ORs for hip fracture adjusted for confounders increased with polypharmacy level, with persistent statistical significance in most analyses. The ORs (95% confidence intervals), with reference to the 0 to < 1 drug group, were 1.65 (1.31-2.08) and 2.11 (1.12-3.96) for the 5 to < 10 and 10 + drug groups, respectively, with adjustment for PIMs, and 1.34 (1.04-1.72) and 1.45 (0.76-2.80) for the 5 to < 10 and 10 + drug groups, respectively, with adjustment for PIMs and CCI score. The results suggest that polypharmacy is associated with an increased risk of hip fracture after adjustment for confounders in patients with osteoporosis. These results highlight the importance of polypharmacy management in preventing hip fractures in patients with osteoporosis.

Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity

BackgroundIn primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care.MethodsData were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs.ResultsTwenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. “Under” and “over” consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment.DiscussionPatient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with ‘under’ or ‘over’ consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.

Pharmacological treatment of chronic non-malignant pain among elderly persons: an integrative review

Abstract Objective: The objective of the present study was to perform an integrative review of proposed pharmacological treatments for chronic non-malignant pain in elderly patients. Method: An integrative review was carried out. The search of literature included papers about the treatment of chronic pain among the elderly, published from 2007 to 2017 and available in Portuguese or English. Searches were conducted on the LILACS and MEDLINE electronic databases using the key words “chronic pain”, “treatment” and “elderly” combined with the Boolean operator “AND”. To analyse methodological quality, the adapted Critical Appraisal Skill Program (CASP) was used. Results: Of a total of 303 studies found, 32 were included. The articles selected included 20 reviews, five observational studies, five clinical trials, one case series and one retrospective study. A total of 75% of the articles were published in the last five years, of which one was in Portuguese and 31 in English. Conclusion :The results demonstrate a variety of treatments for chronic pain among the elderly population, highlighting the role of opioids which, according to more recent evidence, can be carefully used in treatment. Several drugs, however, have not been specifically tested for the elderly population. A number of factors are relevant in pain management of elderly patients, including comorbidities, polypharmacy and patient functionality. An individualized approach should be applied to elderly patients to improve outcomes and reduce side effects.

A cornerstone of healthy aging: do we need to rethink the concept of adherence in the elderly?

Worldwide, the population is aging and this trend will increase in the future due to medical, technological and scientific advancements. To take care of the elderly is highly demanding and challenging for the health care system due to their frequent condition of chronicity, multimorbidity and the consequent complex management of polypharmacy. Nonadherence to medications and to medical plans is a well-recognized public health problem and a very urgent issue in this population. For this reason, some considerations to identify a new shared approach to integrated care of older people are described. The concept of adherence should be considered as a complex and continuous process where family, caregivers and patients’ beliefs come into play. Moreover, a new culture of adherence should contemplate the complexity of multimorbidity, as well as the necessity to renegotiate the medication regimen on the basis of each patient’s needs.

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

BackgroundMultimorbidity 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.MethodsChange 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.ResultsPolypharmacy 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.ConclusionWithin 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.

Reviews on the Current Status and Appropriate Management of Polypharmacy in South Korea

Reviews on the Current Status and Appropriate Management of Polypharmacy in South Korea

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.

BackgroundInappropriate 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.MethodsForty-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.ResultsNinety 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.ConclusionConsensus 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.

Medication review and polypharmacy management in the hospital setting. The cases of Greece and Catalonia

Introduction: Medication review and polypharmacy management, especially in the elderly, are key components of integrated care. Although polypharmacy management is often associated with the primary care setting, hospital clinicians, who are often members of multidisciplinary therapeutic teams, have an opportunity to improve the management of polypharmacy, which has the potential to improve health outcomes in both hospital and primary care. Methods: Mixed-methods (desk reviews, key informant interviews and focus groups) case studies were carried out in Greece and Catalonia, in the framework of the SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) project, in order to describe policies and procedures on the management of polypharmacy and adherence in the elderly and describe implementation strategies. Kotter’s Eight Step Process for transforming change and normalization process theory (NPT) were applied both in data collection tools and in the analysis. Progress report: At both sites there was awareness regarding the need for management of polypharmacy in the elderly, although in Greece awareness had not translated to a sense of urgency, a critical early step in Kotter’s process. Barriers to implementation in Greece included extreme financial pressure, lack or organizational culture supporting multidisciplinary teams and shared decision making, and lack of guidance from central health authorities. However, despite the lack of national guidelines, hospital pharmacists in state (public) hospitals currently review medication for inpatients and out-patients, and interventions regarding inappropriate polypharmacy and reconciliation of care have been piloted. In Catalonia, implementation of an Institutional network sponsored model has been implemented and it is being evaluated. Polypharmacy was integrated as a specific component of a broader patient-centered service model, driven by a small multidisciplinary team, with a focus on global health outcomes. Facilitators, to implementation included an organizational culture of innovation and shared decision making, advanced training requirements of all hospital pharmacists, and regional health policies focusing on improved care for patients with complex chronic disease. Conclusion and future work: Although Greece is a country with no programme of polypharmacy management identified, there are some policies and clinical activities in place that could support future programmes. National guidance will ultimately be needed to mobilize health professionals and ensure consistency of care. The Catalan experience demonstrates that polypharmacy management can occur in the hospital setting. Future challenges include scaling the current model into other units within the hospital and into primary care. Given the pharmacist training and current medicines management activities in Greece, the hospital may be an appropriate entry point for polypharmacy management activities in that country, later scaling up to the community. As other health systems look to address polypharmacy, hospital should be considered a potential starting point for initiating a programme. Funding: This poster is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020).

Polypharmacy and Integrated Care: Identifying synergies in implementation

Introduction : Integrated care has the potential to assist health systems in achieving the triple aims of improving the experiences of individual patients, the health of the population, whilst at the same time increasing efficiencies. Integrated care can impact significantly those with complex needs such as older, multimorbid patients, in whom inappropriate polypharmacy has emerged as a key issue. Unfortunately, the pharmacists’ role within integrated care medicines optimisation is often not explicitly addressed; meaning potential opportunities to achieve the triple aims are being missed. As part of project SIMPATHY (Stimulating Innovative Management of Polypharmacy and Adherence in the Elderly), case studies were conducted in a sample of European Union countries with the aim of identifying components of, and implementation strategies, adopted in polypharmacy management targeting integrated care for the elderly. Objectives : To identify commonalities between integrated care frameworks and polypharmacy case studies to facilitate implementation of polypharmacy management and medicines optimisation into integrated care networks. Methods : Case studies in nine sites in eight countries (Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), United Kingdom (Northern Ireland and Scotland), and Sweden) have been completed. A narrative literature review identifying commonly used frameworks and taxonomies in integrated care implementation is ongoing. Common elements will be identified within these frameworks and mapped to findings from the case studies. Preliminary results : Core components of polypharmacy initiatives identified in the case studies included: the need to implement multidisciplinary teams; to establish responsibilities of team members; to target specific groups of complex patients; and move beyond the focus on single disease state guidelines. Other key themes related to: change management and implementation strategies, including the importance of developing local solutions; the need to align polypharmacy management with other healthcare priorities and initiatives; the important role of healthcare provider education; the need to align personnel and remuneration with polypharmacy management goals; the need for strategic planning from policy makers and managers together with clinical leadership; and the important role of both information technology and communication systems initiatives within a supportive culture. The role of legislation and high level policies supporting polypharmacy management were also noted. Comparing these results to the initial findings of the literature reviews reveals that there is strong concordance between the case study findings and elements of conceptual frameworks for integrated care. Many elements of systems, organisational, professional, and clinical integration were aligned as well as normative and functional integration. There was also significant agreement with proposed taxonomies of integrated care, although discrepancies, most notably in the areas of professional and functional integration, were identified. Discussion and Future Research : Based on the initial level of concordance, we anticipate the results of this work will inform the development of common approaches to implementing medicines management into integrated care initiatives for multimorbid, older people. Beyond polypharmacy, we also see that the approach developed here will be applicable to the introduction of other specific health services targeting particular populations. Acknowledgements : We would like to acknowledge the significant contributions of the SIMPATHY consortium on the case studies.

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.

A federated collaborative care cure cloud architecture for addressing the needs of multi-morbidity and managing poly-pharmacy (c3-cloud project)

A federated collaborative care cure cloud architecture for addressing the needs of multi-morbidity and managing poly-pharmacy (c3-cloud project)

Baseline characteristics and clinical outcomes of older patients admitted as an emergency to general surgical wards. Salford-POPS – GS

BackgroundIncreasing numbers of older people undergo emergency hospitalisation and surgery. The benefits of a comprehensive multidisciplinary service for older adults have not been evaluated. This prospective, single centre study describes patient characteristics and clinical outcomes of older people admitted under general surgery as an emergency. Material and methodsBetween 9th September 2014 and 30th November 2015, 300 consecutively admitted patients received input from the liaison service. ResultsSeventy patients (23.3%) underwent surgery, 82 (27.3%) a non-surgical procedure, and 148 (49.3%) were managed non-invasively. Mean age was 82.5years (70–98), 55.7% were female, most lived in their own home (90.7%), and were independent in basic (77.5%) and instrumental (52.5%) activities of daily living. A total of 46.3% mobilised with no walking aids or using a stick. Patients had 5.2 chronic conditions and took 8.6 medications on average. Thirteen point seven percent had a diagnosis of dementia. Liver and biliary conditions (23%) and cancer (19.3%) were the most common diagnoses. Mean LOS fell from 14.6 to 12.5 days, and median LOS from 11 to 7 days after the service became fully established (February 1st 2015). Thirty-day readmission rate was 14.3% (40/279). Mortality rates in hospital, 30-days after hospital admission, 30-days after surgery and 30-days postdischarge were 7%, 8.7%, 8.6% and 5.4%. ConclusionsOlder individuals admitted non-electively under general surgery often have cognitive or functional impairment and complex social issues. A geriatrician-led liaison service benefits length of stay, facilitates recognition of complications, enhances management of multimorbidity and polypharmacy and drives discharge planning.

The Quality of Polypharmacy Management

Polypharmacy is commonly seen among the elderly and its management is difficult. The adverse effects of medications can contribute to conditions such as delirium, falls, sedative and/or anticholinergic properties, and are common causes of morbidity and hospitalisation. Little is known about the relation between the quality of prescriptions and the patient-indices: Drug Burden Index (DBI), Delier, Fall, Sedative and Anticholinergic burden (ACB). We hypothesise that the quality of polypharmacy management – operationalised through the alerts of a Clinical Decision Support System (CDSS) – is correlated to patient-indices. In a primary care setting, patients aged >60 taking five or more drugs were selected. Their medications were analysed by a CDSS, consisting of 469 drug safety rules. Developed to support medication reviews. CDSS gives a red-alert in case medication was wrong and a green-alert when no problem was encountered. We looked for a correlation between the patient-indices and the CDSS-alerts, eg number of red-alerts per patient (R), number of green-alerts per patient (G), R/R+G. We analyzed 751 patients from 24 general practices. The CDSS generated 11,559 alerts; 1489 red alerts and 10,070 green-alerts. Table. Correlation between number of alerts and patient-indices.Tabled 1DBIACBdelierFallSedR/R+G–0,40473–0,3530,232574–0,15581–0,27803R–0,12207–0,121970,3469740,064280,012146G0,5907480,510860,1727360,3484160,547824 Open table in a new tab In the present study several indices were associated with a negative correlation, where we expected a positive correlation (eg more red-alerts, an higher DBI). Delirium had a positive correlation with R, but this was too low. We expected a negative correlation between G and the indices, but this appeared to be positively correlated. We concluded that we did not find the expected correlation between the CDSS-alerts and the patient indices.

Current and future perspectives on the management of polypharmacy

BackgroundBecause of ageing populations, the growth in the number of people with multi-morbidity and greater compliance with disease-specific guidelines, polypharmacy is becoming increasingly common. Although the correct drug treatment in patients with complex medical problems can improve clinical outcomes, quality of life and life expectancy, polypharmacy is also associated with an increased risk of adverse drug events, some severe enough to result in hospital admission and even death. Hence, having systems in place to ensure that medications are started only when there is a suitable indication, ensuring patients are fully aware of the benefits and complications that may arise from their treatment, and reviewing patients regularly to ensure their medication regime remains appropriate, are essential.DiscussionThe development and rapid uptake of electronic patient records – particularly in primary care settings where the majority of prescribing takes place – makes monitoring of patients more straightforward than in the past; and allows identification of sub-groups of patients at particularly high risk of adverse drug events and complications. It also facilitates ‘deprescribing’ the process by which medications are reviewed and stopped if not clinically beneficial. In recent years, we have also seen the development of smartphone ‘apps’ to improve communication between patients and healthcare professionals, improve people’s understanding of their conditions and their treatment, and maintain a record of changes made to patient’s medication. In the longer term, developments such as the introduction of artificial intelligence and clinical decision support systems also have the potential to improve prescribing and minimise the risks from polypharmacy. Finally, there is considerable scope to improve the quality of prescribing and reduce risks from poly-pharmacy using non-medical groups such as pharmacists, specialist nurses and physician assistants.SummaryPolypharmacy has increased in recent decades and will continue to increase as populations age and the number of people with multiple long-term conditions increases. As with all areas of medicine, the evidence-base in this area continues to evolve. Further trials on the impact on patients with polypharmacy of new interventions such as technology-based solutions and the use of different professional groups are needed to improve the evidence-base in this area.

Polypharmacy, medication adherence and medication management at home in elderly patients with multiple non-communicable diseases in Thai primary care

Polypharmacy, medication adherence and medication management at home in elderly patients with multiple non-communicable diseases in Thai primary care

Is Polypharmacy Associated with Frailty in Older People? Results From the ESTHER Cohort Study.

To investigate the relationship between polypharmacy and frailty. Longitudinal, observational cohort study. Saarland, Germany. 3,058 community-dwelling adults aged between 57 and 84years. Frailty was assessed according to the frailty phenotype, described by Fried etal. Polypharmacy and hyperpolypharmacy were defined as the concomitant use of five or more and 10 or more drugs, respectively. We assessed associations between polypharmacy and prevalent and incident frailty within 3years of follow-up by logistic regression models controlled for multiple potential confounders including comorbidity. Additionally, cubic splines were used to assess dose-response associations. Polypharmacy was reported in 39.1% (n=1,194), and hyperpolypharmacy in 8.9% (n=273) of participants. Prevalent frailty was present in 271 (8.9%) participants; 186 (9.3%) of 1,998 non-frail participants with follow-up data became frail within 3years. After adjustment, polypharmacy and hyperpolypharmacy were associated with prevalent frailty with adjusted odds ratios (95% confidence interval) of 2.30 (1.60-3.31) and 4.97 (2.97-8.32), respectively. Polypharmacy (odds ratio (OR) 1.51 (1.05-2.16)) and hyperpolypharmacy (OR 1.90 (1.10-3.28)) were also independent predictors of incident frailty. Furthermore, there was a moderate exposure-response relationship between the number of medicines and prevalent as well as incident frailty. Our study showed that polypharmacy is associated with frailty. Further research should address the potential benefit of reducing of inappropriate polypharmacy and better pharmacotherapeutic management for preventing medication-associated frailty.

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. Target participants : Policymakers, health system administrators, managers, clinicians Proposed structure and timing : What do we mean when we say polypharmacy? How does it apply to me? Alpana Mair; Deputy Chief Pharmaceutical Officer for Scotland, Healthcare Quality and Strategy Directorate, Scottish Government Health Department Medicines management should be a key component of integrated care, affecting nearly all providers in all settings, and is paramount in the older population. However, health care providers are often faced with problems related to inappropriate management of polypharmacy and poor adherence by patients. This presentation will introduce the audience to the concept of polypharmacy and adherence, its importance, and what tools and evidence already exist to create solutions. Looking at Europe: A diverse and emerging picture of polypharmacy Jennifer McIntosh; Research Scientist at Hospital Clinic Barcelona / FCRB Building on original research undertaken by the SIMPATHY Consortium, a picture of current policies around polypharmacy in Europe has emerged. The picture is complex, with multiple economic, social, and cultural factors explaining the development of these programmes. The details of this picture provide a strong foundation for the development of future policies for appropriate management of polypharmacy. This presentation will detail the findings of 8 European case studies, showcasing current approaches polypharmacy management. _(Important: The details of each case study will be presented in a set of 8 posters that will be submitted to the conference by each institution carying out the work)_ Scaling up polypharmacy management: The Scottish success story Alpana Mair; Deputy Chief Pharmaceutical Officer for Scotland, Healthcare Quality and Strategy Directorate, Scottish Government Health Department Implementing a new programme into existing practice is one of the most challenging aspects of creating integrated health care systems. The Scottish National Health Service has achieved this by successfully developing and implementing a comprehensive polypharmacy management policy throughout their healthcare system. This programme has become a model on an international level, and is currently a reference point for the development of European wide policies to address polypharmacy in the elderly. This presentation will describe the rationale that prompted the development of the Scottish programme, unique features of the programme including leveraging national level patient data to identify patients at risk for inappropriate polypharmacy, and management strategies that facilitated the integration of the programme into daily practice on a wide scale. Polypharmacy and teamwork: The Catalan multidisciplinary experience Carles Codina; Head of Pharmacy Department at Hospital Clinic Barcelona - Consorci Hospitalari de Vic Nuria Molist; physician at the Acute Geriatrician Unit Consorci Hospitalari de Vic - Hospital Santa Creu de Vic Introducing new practices requires champions, especially in complex institutions. Although multidisciplinary teams are becoming the functional decision making unit, their implementation requires support from multiple stakeholders. Pharmacists in particular have a central role to play on these teams in developing a new understanding about the importance of appropriate polypharmacy management. This presentation will describe the development and implementation of a patient centred multidisciplinary care team, highlighting the role both the pharmacy and geriatric medicine departments played in creating a successful and sustainable programme. Facilitated discussion Albert Alonso (moderator); Innovation Directorate at Hospital Clinic Barcelona This work has been supported by the SIMPATHY project, grant agreement number 663082, co-funded by the European Commission CHAFEA Health Program

Polypharmacy and Adherence: Key Components of Integrated Care, The case of Catalonia

Introduction: Polypharmacy and medication adherence in the older population are significant public health issues throughout the European Union (EU), and are an important component of integrated care. SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) is a consortium of 10 organizations representing 8 EU countries and is working to address these issues by developing change management tools to facilitate EU policy makers in integrating polypharmacy and adherence into existing health care systems.Objectives: 1) Map existing components of polypharmacy and adherence programme in Catalonia and; 2) describe change management and implementation strategies used in the development, implementation, and scale up of the programme.Methods: We conducted a mixed-methods case study in Catalonia, Spain. Policies and practices of the Catalan Health Department and two clusters of healthcare institutions (one urban, one rural) including a teaching hospital, primary care centre, and long-term care facility were included for analysis. The study consisted of three phases: I) desk review of the polypharmacy and adherence policies at the government, regional and institutional level; II) key informant interviews with policymakers, managers, and clinicians responsible for developing and implementing the programme and; III) focus group of clinicians and managers familiar with the programme to validate preliminary results. Polypharmacy management involves multiple care providers and practice settings, so can be categorized as a complex intervention. Therefore, multiple theories and frameworks were used in the study design and analysis. Change management was assessed using Kotter’s 8 principles of leading change while the four main constructs of normalization process theory (NPT) were used to evaluate integration of the programme into daily practice (coherence, cognitive participation, collective action, and reflexive monitoring).Preliminary results: Two distinct programme types emerged in the analysis: a government sponsored programme lead by the Department of Health and targeted at primary care physicians, and an institutional sponsored programme lead by geriatrician clinicians and supported by department heads and hospital administrators. Participants in both programme types recognized the importance of polypharmacy in the older population and the need to take action on the issue, and both were guided by the regional health plan. The government programme utilized a top down or vertical approach to implementation with the primary focus on patient safety (preventing drug interactions, therapeutic duplications, or avoiding contraindicated drugs), individual physician prescribing, and had a goal of implementation throughout the entire healthcare system. The programme was supported by an extensive information technology system of electronic medical records and a pay for performance contract. A limited number of change management principles were identified, and implementation was limited by restricted personnel resources and lack of attention to integrating the new practice into daily work flow, as exemplified by the NPT analysis. The institutional programme employed a middle out, or horizontal implementation strategy with a global patient-centred focus, of which polypharmacy management was one component. It was driven by a small multidisciplinary team of physicians and pharmacists with the initial goal of creating a well-developed pilot that would be scaled up at a later point. Many change management principles and NPT constructs were identified. Key facilitators included a “culture of geriatrics” that supported the use of multidisciplinary teams and a culture of innovation within the hospital.Conclusion and future work: Catalonia has two examples of well-developed polypharmacy management programmes. The government sponsored approach had a narrower focus on patient safety and less use of multidisciplinary teams, but was able to be implemented throughout the healthcare system. Use of a more robust change management approach in the institutional setting facilitated the implementation, including the use of multidisciplinary teams. Both provide lessons for other health systems wanting to integrate management of polypharmacy into existing care models.