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

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          Abstract

          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); w hy 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.

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          Most cited references27

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          Potential pitfalls of disease-specific guidelines for patients with multiple conditions.

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            Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity.

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              Understanding patients' experiences of treatment burden in chronic heart failure using normalization process theory.

              Our goal was to assess the burden associated with treatment among patients living with chronic heart failure and to determine whether Normalization Process Theory (NPT) is a useful framework to help describe the components of treatment burden in these patients. We performed a secondary analysis of qualitative interview data, using framework analysis, informed by NPT, to determine the components of patient "work." Participants were 47 patients with chronic heart failure managed in primary care in the United Kingdom who had participated in an earlier qualitative study about living with this condition. We identified and examined data that fell outside of the coding frame to determine if important concepts or ideas were being missed by using the chosen theoretical framework. We were able to identify and describe components of treatment burden as distinct from illness burden using the framework. Treatment burden in chronic heart failure includes the work of developing an understanding of treatments, interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments. Factors that patients reported as increasing treatment burden included too many medications and appointments, barriers to accessing services, fragmented and poorly organized care, lack of continuity, and inadequate communication between health professionals. Patient "work" that fell outside of the coding frame was exclusively emotional or spiritual in nature. We identified core components of treatment burden as reported by patients with chronic heart failure. The findings suggest that NPT is a theoretical framework that facilitates understanding of experiences of health care work at the individual, as well as the organizational, level. Although further exploration and patient endorsement are necessary, our findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.
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                Author and article information

                Contributors
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                18 April 2018
                2018
                : 13
                : 4
                : e0195232
                Affiliations
                [1 ] Departament de Recerca i Innovació, Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain
                [2 ] School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland
                [3 ] Pharmacy Department, Uppsala University Hospital, Uppsala, Sweden
                [4 ] Effective prescribing and therapeutics, Health and social care directorate, Scottish Government, Edinburgh, Scotland
                [5 ] Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
                [6 ] Servei de Farmàcia, Hospital Clínic de Barcelona, Barcelona, Spain
                [7 ] Institute for Medicines Research, Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Lisboa, Portugal
                [8 ] Pharmacy Department and Regional Medicines Optimisation Innovation Centre(MOIC) Northern Health and Social Care Trust, Antrim, Northern Ireland
                [9 ] Department of Social and Education Policy, University of Peloponnese, Korinthos, Greece
                [10 ] eHealth Innovation Unit, 1 st Regional Health Authority of Attica, Athens, Greece
                [11 ] Department of Health, Belfast, Northern Ireland
                [12 ] Federico II University Hospital, Naples, Italy
                [13 ] Institute of General Practice, Hannover Medical School, Hannover, Germany
                [14 ] Department of Family Medicine, Medical University of Lodz, Lodz, Poland
                [15 ] Institute of Biomedical Imaging and Life Sciences (IBILI) and Institute of Pharmacology and Experimental Therapeutics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
                [16 ] CIRFF, Center of Pharmacoeconomics, University of Naples Federico II, Naples, Italy
                [17 ] Clinical & Practice Research Group, School of Pharmacy, Queen’s University, Belfast, Northern Ireland
                University of Basel, SWAZILAND
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ‡ Authors listed alphabetically.

                ¶ Membership of the SIMPATHY Consortium is provided in the Acknowledgments.

                Author information
                http://orcid.org/0000-0002-8140-9304
                Article
                PONE-D-17-27920
                10.1371/journal.pone.0195232
                5905890
                29668763
                9e27ecaf-0139-46a9-bb7d-374c584cfd5f
                © 2018 McIntosh et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 26 July 2017
                : 8 March 2018
                Page count
                Figures: 3, Tables: 3, Pages: 20
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100007565, Consumers, Health, Agriculture and Food Executive Agency;
                Award ID: 663082
                Award Recipient :
                This work has been supported by the SIMPATHY project, grant agreement number 663082 to AM, co-funded by the European Commission CHAFEA Health Program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Pharmacists
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Medicine and Health Sciences
                Geriatrics
                Medicine and Health Sciences
                Health Care
                Health Services Administration and Management
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Allied Health Care Professionals
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Medicine and Health Sciences
                Health Care
                Primary Care
                Custom metadata
                Data from this study are qualitative in nature and cannot be made publicly available due to ethical restrictions, as they contain potentially identifying participant information. Researchers who meet the criteria for access to confidential data may contact the SIMPATHY consortium to request data from this study using the following form: http://www.simpathy.eu/contact-us. This request form will be monitored by someone within the Scottish government; all of the internal documents that were part of project SIMPATHY that are not currently published on our website will be backed up and accessible to the person monitoring the email address. The authors confirm that co-authorship is not required by the SIMPATHY consortium to gain access to the data.

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