Background
Methods
Setting
Holding of focus group sessions
Analysis
Results
General Practitioners | ||
---|---|---|
Female (n = 16) | Male (n = 24) | Total (n = 40) |
Mean age (min; max) | ||
46.6 (27–65) | 53.0 (28–66) | 50.5 (27–66) |
Mean years of experience (min; max) | ||
22.2 (1–31) | 25.3 (2–40) | 23.7 (1–40) |
Nurse | ||
Female (n = 32) | Male (n = 2) | Total (n = 34) |
Mean age (min; max) | ||
45.1 (32–63) | 42.0 (38–46) | 44.9 (32–63) |
Mean years of experience (min; max) | ||
25.7 (3–41) | 11.5 (4–19) | 18.6 (3–41) |
Community Pharmacist | ||
Female (n = 17) | Male (n = 3) | Total (n = 20) |
Mean age (min; max) | ||
40.8a (23–58) | 30.7 (24–36) | 39.11 (23–58) |
Mean years of experience (min; max) | ||
15.4 (1–34) | 7.0 (1–12) | 11.21 (1–34) |
Theme | Subthemes | Coding concepts | |
---|---|---|---|
“Poor compliance and polypharmacy- A perpetuated vicious cycle”. | Polypharmacy | Perception | |
Socioeconomic factors | Familial context | ||
Economic factors | |||
Knowledge | Literacy | ||
Identification of medicines | |||
Duration of treatment | |||
Compliance | Adverse effects | ||
Priority | |||
Patients beliefs | |||
Deprescribing | Difficulties | ||
Patients-HPs communication | Lack of communication | ||
Influencers | TV supplements | ||
Neighbours medication | |||
Herbal products | Interactions | ||
Medicines managing | Handling | ||
Generic medicines | |||
Organization of healthcare system | Medication management directives | Healthcare directives | Prescribing guidelines |
Patients empowerment | |||
Clinical appointments | Clinical appointments | Lack of time | |
Interaction and communication between Health professionals | External responsibility | General practitioner’s -Community pharmacists | Trust/mistrust |
General practitioner’s -Specialist physicians | |||
lack of time to communicate | General practitioner’s -Specialist physicians | Lack of communication | |
General practitioner’s -Community pharmacists | |||
General practitioner’s -Specialist physicians | Multiple prescribers | ||
Strategies to prevent inappropriate polypharmacy | Prescribing | managing | |
Generic medicines | |||
Promotion of compliance | Empowerment of patients | ||
Support teams |
Poor compliance and polypharmacy- a perpetuated vicious cycle
“The presence of multiple comorbidities is a normal consequence of ageing and for this reason polypharmacy in older patients is common practice”, FG5GP1.
“Polypharmacy leads to poor compliance and the poor compliance conduce to polypharmacy …. Because if they do not adhere to a therapeutic regime … we prescribe for one situation, after that for another problem”, FG13GP1.
“Polypharmacy is closely related to literacy”, FG11GP1.
“The problem of polypharmacy is the loneliness of the older adults that do not have any young familiar near to help” FG2CP2.
“One older woman brought to the healthcare center, both their medicines and the medicines of their husbands because they do not recognize their pills”, FG6N3.
“There are several generic medicines for the same active substance (from different holders) and older patients identify the medicines by the color of the tablet … /if a doctor prescribes to him another medicine or deprescribes a medicine if they have the pill at home, they will continue to take it”, FG1CP1.
“After an emergence visit, we frequently observed that older patients, come to the pharmacy with a specific medicine, and at a certain point they do not know if they should stop or not take that medicine, and for this reason, they continue taking it” FG1CP1.
“There is a lot of confusion, for example, inhalators, they have difficulties, the device has a counter but they don’t know, and sometimes they arrive at the pharmacy and told us that the inhaler is empty but is new, they do not use it”, FG2CP1.
They are easily influenced by their neighbors, which say: I took this pill and I am feeling very well” FG3GP1.
“Hide a lot of information, sometimes there is no medical prescription, it was a recommendation of the neighbors” FG1CP1.
“Several patients buy on TV calcium pills” FG1FGP1.
“Sometimes some patients complain that they take more medication than food”, FG1CP1.
“Polymedicated patients always try to remove one or another pill that they believe does not affect”, FG3GP1.
“If someone refers to the side effects of statin, patients automatically stop taking”, FG8GP1.
“Deprescribing some medicines it was almost impossible, for example, trimetazidine is very, very hard”, FG3GP1.
“If I want to deprescribe pills that the patient is taking to 30 or 25 years, with which they felt good … we understand that it’s causing more harm than good … it is very difficult”, FG5GP2.
“The price of the medicines also contributes to poor adherence” FG1GP1.
“… a large number of older adults that take oral anticoagulants, the new ones that are more expensive, sometimes instead of taking two pills only take one” FG4GP3.
“Low price of some medicines, namely insulin promotes the wastage of health resources because patients tend to open new insulin before the first finished, and put the older on the garbage” FG2CP1.
“… older adults do not report their specialist/ emergency room visits to the GP, for these reasons’ GP has difficulties in detecting this inappropriate polypharmacy” FG1GP5.
“Teas herbal products and other blend beverages that patients buy here or there because of their health problems... One for the gallbladder, one another to the head, other to the kidney, and all of these substances have an active substance. All of them can cause drug interactions …. That we cannot control” FG5GP1.
Organization of the healthcare system
Medication management directives
“The lack of centralization of chronic medication management is a problem, because we have many vulnerable older patients … , who have several physicians’ appointments, consequently to many prescribers, both in the public and private sector. These physicians have very great freedom to prescribe, which makes that the physician where all the information should converge, theoretical the GP, have difficulties in handling and evaluate all the prescribed medication …. And this then generates situations such as polypharmacy, adverse reaction, drug interaction”, FG1GP1.
“I think, there is some pressure for physicians to stop printing the treatment guide …. The older population needs the guide treatment written in a paper”, FG5N1.
“Into the older population that has a cell phone, some do not know how to use it, and when they want to see the treatment guide sometimes, they press the wrong button and once upon a time a treatment guide, they delete all”, FG5N2.
Clinical appointments
“The 15 minutes of clinic appointment turns out to be little to explore these issues”, FG13GP2.
“It takes time to see all … and we do not have time” FG2GP5.
Interaction and communication between health professionals
Lack of time to communicate
“… yesterday, a pharmacist called to tell me that a patient bought a statin different from what I had prescribed, I appreciate that”, FG4GP3.
“There are units that make protocols with local pharmacies … the problem is the lack of time” FG1GP1.
“… must-have big management of medicines, and for this is necessary do therapeutic revisions and presently GP, perhaps because they lack time, they are not doing it”, FG2CP3.
“… we are obliged, and even if we were not, we always send complete information with the medication with everything, and then we never get the return”, FG4GP1.
“Sometimes happens patients are taking an active substance for hypertension prescribed by the GP, therefore prescribed by myself, in the meanwhile, for any reason they go to the emergency service and comes to the home with other hypertensive medicines from another chemical group, which must not be taken with the previously prescribed hypertensive. Because physician, that works at the emergency service, did not take the trouble to see the chronic medication of the patients, the patients take the pills”, FG10GP1.
“I do not feel comfortable to remove some medicines, a cardiologist appointment, patients expect eternity, so they go to a private clinic and, if I call the cardiologist, he will say if you want to remove the medicine do it, but is your responsibility”, FG10GP5.
External responsibilities
If patients have, doubts are pharmacist faults …. They must explain well because they sell the medicines, they have all the material”, FG10GP3.
“What happens is that GP does not have the perspective of the price of medicines, and they prescribe medicine and, when the patient came to the pharmacy they ask us if we do not have a cheaper medicine, “I do not have money to buy this …” / we are not changing the therapeutic, we are first helping the patients” FG10CP2.
Strategies to prevent inappropriate polypharmacy
“All the prescription must have to be authorized and validated by the GP, that managing and planning the health of the patient”, FG1GP1.
“If the PEM allows the update of chronic medication and if pharmacists could access the PEM, the pharmacist can make the renewal of the chronic medication and, this in turn, relieve the burden that physicians have in terms of patient appointment” FG1GP1.
“the pills should also be standardized in terms of shape and color, FG1N1.
“The ideal would be to have a support team not only to make the dressings and emergencies but also to visit the needy patients that live alone. Older adults often do things on their way because they don’t want to ask for help and they don’t have support either... The support would be to try to understand if the medication is being well managed”, FG5N1.
“The user comes to the health center, takes the prescription I can even know if he raised the boxes in the pharmacy, but on the home visit, I can find a warehouse of boxes of medicines”, FG5GP1.
“Promote health literacy”, FG3GP2.
“The awareness campaigns could be a good help to patients and healthcare professionals”, FG5N1.