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Appropriate Polypharmacy and Adherence in Integrated care

Aim: to facilitate collaboration across disciplines and across countries to enhance our understanding, adoption and evaluation of addressing appropriate polypharmacy as a key component of pathway for people centred integrated care.

Objectives: Due to advances in pharmacotherapy, those with multiple morbidities are increasingly likely to be prescribed multiple medications. Prescribing is largely based on single disease evidence-based guidance which does not generally take account of multi-morbidity, now the norm in those over 65 years2. Consequently patients are prescribed several medicines recommended by a disease specific guideline which is potentially harmful and challenging for them to manage. Inappropriate polypharmacy and medication non-adherence are two key, inter-related problems in elderly multi-morbid patients, with negative effects on health outcomes. It is recognised that lifestyle can not only contribute to multimorbidities that require management with medication, but that addressing this might be appropriate when considering alternatives to medication.
Medication is the single most common intervention for those with multiple morbidities and is known to contribute to between 7-14% of all hospital admissions with these patients twice as likely to be admitted again due to their medication. Despite this evidence, there is not usually a focus on medication appropriateness as part of the patient pathway.
The group would facilitate work across disciplines about developing guidelines, tools for accelerating implementations of programmes as part of the patient pathway so that outcomes from medications are optimised whilst reducing harm, including economic modelling tools that can demonstrating that models can be designed to demonstrate sustainability in different healthcare systems.
Collaboration will allow the group to build a repository of these relevant tools, best practice and outcomes from members, undertake twining activities and carry out joint evaluation of implementation so that scale up of programmes can be accelerated.

Activities: The SIG will provide a platform for members to share implementation experience, highlight examples of good practice, signpost practical resources, and agree and collaborate on research, education and evaluation priorities for polypharmacy as a key component of people centred integrated care. Members will shape the scope of SIG activities and outputs. These may include:
• Webinars and online peer support
• Good practice case studies
• Practical resources – guidance and tools
• Study / Twining visits
• Blogs
• Evidence reviews
• Consensus documents
• Collaborative action research
• Benchmarking
• Presence in the ICIC conferences and involvement in the development of workshops.

Get involved: The group composition will incorporate a diversity of profiles that will bring in the different perspectives of polypharmacy in the context of people centred integrated care, to enable sharing of best practice and wider engagement. The area leads below are anticipated:
• Geriatrician
• Primary care Physician
• Pharmacist
• Health Economist
• Nurse practioner
• Group administrator
• Adherence expert

The SIG is for practitioners, pharmacists, managers, researchers, students, and policy makers including health economists engaged in planning, designing and delivering appropriate polypharmacy reviews as part of integrated Care pathway for people in different health and care systems.
If you have an interest in Appropriate Polypharmacy and Adherence in Integrated care, can share your practical experience or resources, or have a question, challenge or suggestions for future SIG
activities please contact Marie Curran, SIG facilitator at IFICScotland@integratedcarefoundation.org

Additional information

What is Polypharmacy?
The term polypharmacy itself just means “many medications” and has often been defined to be present when a patient takes five or more medications. However, it is important to note that polypharmacy is not necessarily a bad thing. For example, secondary prevention of myocardial infarction often already requires the use of four different classes of drugs (antiplatelets, statins, ACE inhibitor, beta blocker). Polypharmacy can be both rational and required. It is therefore crucial to distinguish appropriate from inappropriate polypharmacy1.
Inappropriate polypharmacy is present, when one or more drugs are prescribed that are not or no longer needed, either because: (a) there is no evidence based indication, the indication has expired or the dose is unnecessarily high; (b) one or more medicines fail to achieve the therapeutic objectives they are intended to achieve; (c) one, or the combination of several drugs cause inacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs, or because (d) the patient is not willing or able to take one or more medicines as intended.
Appropriate polypharmacy is present, when: (a) all drugs are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient; (b) therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future; (c) drug therapy has been optimised to minimise the risk of ADRs and (d) the patient is motivated and able to take all medicines as intended

Facilitated by:

Dr. Albert Alonso

Dr. Albert Alonso is Chair of the International Foundation for Integrated Care (IFIC) and Special Interest lead for Appropriate Polypharmacy and Adherence in Integrated care
Email: AALONSO@clinic.ub.es

Alpana Mair

Alpana Mair is Head of Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government and Special Interest lead for Appropriate Polypharmacy and Adherence in Integrated care
Email: alpana.mair@gov.scot