Development and implementation of strategic frameworks for polypharmacy management in healthcare organisations: a scoping review

Abstract

Introduction: 'Polypharmacy management' (PM) guidelines exist (1) but there are challenges to implementation and WHO recommends theory-based organisational change strategies to address this (2). Aim: To identify current evidence base around the development and implementation of strategic frameworks for polypharmacy management in healthcare organisations. Methods: The Arksey and O'Malley framework and the PRISMA Scoping Reviews extension were used. Databases (Medline, IPA, CINAHL and Business Source Complete) were searched to December 2020. After title and abstract screening full text articles were reviewed. Search, data extraction and eligibility criteria were defined (table). Included studies were charted to collate extracted information and a descriptive narrative approach to data synthesis was taken. All steps involved independent checks by two team members with disagreement mediation by a third. Table: Search terms, data extracted & eligibility criteria for study selection. Search terms Polypharmacy AND Prescribing: Polypharmacy management OR Polypharmacy (MH) OR Inappropriate polypharmacy OR Multiple medication* OR Comorbidity (MH) OR Deprescriptions (MH) AND Rational prescribing OR Prescribe* OR Prescribing error OR Inappropriate prescribing (MH) OR Therapeutics (MH) OR Drug prescriptions (MH) OR Drug Overdose (MH) OR Prescription drug; overuse (MH) OR drug misuse (MH) OR diversion (MH) Framework OR Organisational change: Framework OR Strategic planning (MH) OR Strategic framework OR Organisational change OR Organizational change OR Organizational innovation (MH) OR Change management (MH) OR Organizational objectives (MH) OR policy (MH) OR culture (MH) OR affiliation (MH) OR Models (MH) Data extracted Authors & year of publication, title, aim/objectives, methods, characteristics of implementation strategies and frameworks, setting, country, sector, specialty, professions, participants, intervention, findings, barriers and facilitators to implementation. Eligibility criteria for study selection Inclusion criteria Rationale for inclusion and exclusion Concept: Implementation of organisational change strategies regarding polypharmacy management. Frameworks unrelated to polypharmacy management were excluded as future research aims to utilise one of the existing polypharmacy guidelines. Context: Country: Global (all countries) Sector: All sectors of practice and specialties, all levels of care: primary/secondary/tertiary. All relevant areas and settings were included to ensure inclusion of a broad base of global evidence. Language: English. Articles not in English were excluded because of lack of resource for translation. Data range: No restriction on research dates. To broaden the search and retrieve all relevant papers. Types of evidence: Full text peer reviewed papers reporting empirical data from primary research, review articles including systematic reviews / scoping reviews / narrative reviews. To maintain quality of evidence, grey literature, conference abstracts, protocols, book reviews, opinion articles and editorial reviews were excluded. MH = MeSH Heading. Results: Initially 702 records were identified after removal of duplicates, 632 of these were excluded after screening leaving 70 papers. A further 63 of these 70 papers were excluded after full text review. The seven papers remaining met the eligibility criteria fully and showed: despite wide availability of polypharmacy guidelines in the West, particularly the UK and European Union, there is limited evidence on the strategic development and implementation of PM frameworks. The main characteristics of strategic approaches used included: Kotter's eight step process for organisational change, theoretical domains framework to identify individual behavioural determinants, and a community-based medication management intervention. Reported barriers were: lack of data to create a sense of urgency, lack of a national plan for implementation, monitoring and evaluation, poor coordination of care, lack of time for staff, unclear allocation of tasks and responsibilities and lack of training. Organisational level facilitators included: government funding streams and strict regulatory environment, national emphasis on quality and presence of contextual evidence. Conclusion: Despite PM guidance this review shows limited evidence on development of theory based strategic frameworks for organisational change. Evidence was from Western contexts only. A strength of this work is that it searched internationally but was limited by exclusion of grey literature. Further work is required on theory based strategic organisational change in PM particularly in contexts out with the Western world. References: (1) Mair A, Fernandez-Llimos F, Alonso A, Harrison C, Hurding S, Kempen T, Kinnear M, Michael N, McIntosh J, Wilson M, the SIMPATHY Consortium. Polypharmacy Management by 2030: a patient safety challenge. 2nd edition. Coimbra: SIMPATHY Consortium; 2017. (2) World Health Organization. Medication safety in polypharmacy: technical report. Geneva: World Health Organization; 2019.