Polypharmacy is defined as the systematic use of five or more medications regularly. Polypharmacy is common among older adults and younger at-risk populations (Halli-Tierney et al., 2019). Medication use may be associated with significant risks that can outweigh the benefits, especially in the cases when medications are no longer useful or when several drugs are involved in the treatment process (Mackey & Bornstein, 2020). Older adults are especially vulnerable to polypharmacy due to the increased possibility of falls, adverse drug events (ADEs), and increased length of stay (Mackey & Bornstein, 2020). Polypharmacy is a complicated issue that requires an understanding of the responsibilities of different actors. A concept map can help to visualize such a complex issue as polypharmacy to acquire a clear understanding of the current state of knowledge concerning the matter. The present paper focuses on developing a concept map that describes the roles and responsibilities of the relevant actors in addressing polypharmacy.
Concept Definitions and Interconnections
Polypharmacy is the use of multiple medications during prolonged periods for treating multiple morbidities. According to Wastesson et al. (2018), more than 50% of all older adults experience polypharmacy. Even though it is commonly known that polypharmacy is associated with increased morbidity, the methods for assessing the issues are to be refined. A recent systematic literature review conducted by Davies et al. (2020) revealed that the evidence concerning the association between polypharmacy and adverse outcomes, such as ADEs and disability, was uncertain. At the same time, no studies assessed the effect of polypharmacy on social outcomes, such as loneliness and isolation (Davies et al., 2020). Since the problem of polypharmacy is growing worldwide, it has become crucial to develop effective interventions that address its negative effects.
There are several approaches to reducing the effects of polypharmacy. All the approaches are associated with effective medication management through optimization of prescribing, reviewing the current medication regimen, deprescribing, and reducing inappropriate prescribing (Anderson et al., 2019). The role of interdisciplinary teams appeared crucial for the reduction of inappropriate prescribing, as it can help to reduce therapeutic duplications and “medications prescribed without an indication of benefit” (Baruth et al., 2020). Another approach to the reduction of polypharmacy is deprescribing after a pharmacist-led or a therapist-led review of the medication regimen (Anderson et al., 2019). The aim of all the interventions is to minimize risks and maximize the benefits of medication use.
Medication management is a practice that describes the safe and effective use of drugs by patients and care providers. Medication management touches upon three central topics, including prescribing, dispensing, and administration of medications (Davies et al., 2020). Medication management touches upon the common issues of medication use associated with prescribers, caregivers, and patients. These issues include drug-drug interactions, inappropriate prescribing, medication discrepancies, non-adherence, medication errors, mismanagement, and underprescribing.
Inappropriate prescribing is one of the issues discussed by medication management. Inappropriate may be associated with overprescribing, underprescribing, and mistakes in prescribing (Davies et al., 2020; Liew et al., 2019). Underprescribing may be associated with failure to prescribe medications that would be beneficial for a patient as well as prescription of insufficient doses. Overprescribing is prescribing higher-than-needed doses of medications, prescribing drugs that are not required to treat the patients’ conditions, and duplicates in prescription due to lack of review of the current medication regimen or lack of multidisciplinary collaboration.
Deprescribing is one of the instruments used by medication management to address polypharmacy and inappropriate prescribing. Deprescribing is defined as “a solution proposed to address the use of unnecessary or inappropriate medications through the process of safely stopping or reducing harmful or unnecessary medication” (Mackey & Bornstein, 2020, p. 4). Deprescribing is usually initiated after a review of a patient’s current medication regimen initiated by the pharmacists or a therapist.
Actors and Their Responsibilities
There are three levels of actors associated with addressing the problem of polypharmacy. These actors include system-level actors, prescribers, care providers, patients, and caregivers. The present section reviews the responsibilities of these actors.
System-level actors include hospital managers, government authorities, insurance companies and pharmaceutical firms. At this level, actors have varying responsibilities depending on addressing polypharmacy. On the highest level, the government sets rules and regulations for addressing all the problems associated with healthcare (Kaur & Victoria, 2017). In other words, the responsibility of the government is to create a regulatory base that can help to address the problem of polypharmacy. The government needs to support pro-activity in addressing all the health problems, which implies that the government needs to encourage the prevention of such conditions (Kaur & Victoria, 2017). This may be achieved by creating incentives for research in the sphere or by creating evidence-based recommendations concerning polypharmacy.
The primary responsibility of the insurance companies is to ensure that all healthcare organizations are not reimbursed from preventable problems. Insurance companies need to create incentives for improving patient safety, which may mean establishing no-pay policies for conditions associated with errors in prescription, overprescribing, underprescribing, and errors in administration (Nash et al., 2019).
The role of pharmaceutical companies is also central to medication management. Two central responsibilities of these companies can be outlined, including appropriate advertising and reporting any known adverse events associated with the use of medication (Sperling & Fairbanks, 2021). Today, patients seek higher control over their treatment, which may often mean inquiry about different medications based on direct-to-consumer advertising (Sperling & Fairbanks, 2021). Without a careful outline of the probable ADEs, drug-to-drug interactions, and indications for use, caregivers, patients, and prescribers will not be able to make informed decisions about using the drug. Moreover, adequate and responsible advertising is crucial for the same reason.
Hospital managers have numerous responsibilities concerning the improvement of medication management. The managers can affect the problems associated with inadequate medication management on the organization’s level. The common barriers to adequate medication management on the systems level include inadequate policies concerning time for consultations, insufficient compensation, and lack of multidisciplinary communication and coordination (Mackey & Bornstein, 2020). Thus, it is managers’ responsibility to address these barriers by setting adequate policies for consultation time and compensation. Additionally, hospital managers need to create and coordinate multidisciplinary teams to reduce inappropriate prescribing (Liew et al., 2019).
There are several enablers of efficient medication management at the hospital level. They include access to professional and technical support, knowledge and skill improvement, and support of cultural and behavioral changes (Mackey & Bornstein, 2020). These changes can be facilitated by applying organizational change theories and the latest empirical evidence. In other words, the responsibility of managers is to provide prescribers and care providers with access to the professional support of the IT specialists, pharmacists, and clinical record system. Managers also need to ensure that there is enough time during the consultation to use this access. Additionally, managers need to provide interdisciplinary education to ensure patient-centered care, create evidence-based guidelines to minimize medication-associated mistakes, and ensure that patients are adequately informed and trained in terms of medication use, prescribing, and deprescribing (Mackey & Bornstein, 2020). Thus, it may be concluded that the managers’ role is most noticeable among the system-level actors.
Prescribers and Care Providers
There are several barriers to effective medication management on the provider level. These barriers include providers’ perceptions and concerns, concerns about inter-professional relationships, and limitations of knowledge (Mackey & Bornstein, 2020). The concerns include fear of the negative effects of prescribing and deprescribing, fear of poor patient outcomes and losing patient trust (Mackey & Bornstein, 2020). Additionally, care providers may be uncertain about their responsibilities concerning prescribing and deprescribing, which may affect the decision-making process about medication management. Finally, prescribers and care providers may have insufficient knowledge and skills of prescribing and administrations. Thus, the providers’ and prescribers’ responsibilities include learning about the biases that may affect the decision-making concerning medication management, collaborating with other care providers to realize their roles and responsibilities and participating in training to constantly improve their level of knowledge and skills concerning prescribing, deprescribing, and administration of medications.
There are several enablers that may improve medication management. They include adequate providers’ perspectives and concerns concerning their role, practical knowledge about adverse drug reactions, and positive provider-patient relationships (Mackey & Bornstein, 2020). Thus, apart from all the responsibilities mentioned above, care providers are to build trustful relationships with patients. Such relationships can improve adherence to medication regimens, which is crucial for decreasing ADEs.
Patients are crucial actors of medication management, as they are the center of care. There are several barriers to medication management associated with patients that include their personal perspectives and attitudes and inadequate knowledge (Mackey & Bornstein, 2020). For instance, patients may lack trust in the care provider, prescriber, or the producer of a medication, which may lead to low adherence to the medication regimen (Davies et al., 2020). Moreover, low adherence may be caused by insufficient knowledge about the possible risks and drug-to-drug interactions (Mackey & Bornstein, 2020). Thus, it may be concluded that the central responsibilities of patients include adherence to medication regimen, asking questions about changing the regimen to address uncertainty, taking necessary training about medication use, and learning about possible biases (such as fear of side effects) that may lead to unfavorable patient outcomes.
Concept maps are powerful tools for visualizing complex problems or concepts. Such maps are crucial for summarizing all the knowledge about a complicated subject. A good concept map includes all the concepts and phenomena in one place and describes intricate relationships between them (Mind Mapping, 2018). Concept maps are very close to mind maps; however, unlike mind maps, concept maps depict cross-connections between concepts.
A concept map is usually organized around one central idea or problem. The central concept of the present paper is medication management. Even though the purpose of the present paper was to create a mind map that describes the responsibilities and roles of different actors to address polypharmacy, the latter was found to be one of the problems that medication management strives to resolve. Thus, it was decided to create a concept map around medication management along with its problems, tools, and actors. The final concept map for addressing polypharmacy is provided in Appendix A.
The present paper described inter-relations between the concepts of polypharmacy, medication management, inappropriate prescribing, and deprescribing. It was revealed that polypharmacy is one of the problems addressed by medication management. The actors that address the problem can be divided into three levels, including the patient level, provider level, and systems level. A concept map was created to summarize and visualize the responsibilities and roles that different actors have in addressing the problem of polypharmacy.
Anderson, L. J., Schnipper, J. L., Nuckols, T. K., Shane, R., Sarkisian, C., Le, M. M., & Pevnick, J.M. (2019). A systematic overview of systematic reviews evaluating interventions addressing polypharmacy. American Journal of Health-System Pharmacy, 76(21), 1777-1787.
Baruth, J. M., Gentry, M. T., Rummans, T. A., Miller, D. M., & Burton, M. C. (2020). Polypharmacy in older adults: The role of the multidisciplinary team. Hospital Practice, 48(sup1), 56-62.
Davies, L. E., Spiers, G., Kingston, A., Todd, A., Adamson, J., & Hanratty, B. (2020). Adverse outcomes of polypharmacy in older people: systematic review of reviews. Journal of the American Medical Directors Association, 21(2), 181-187.
Halli-Tierney, A. D., Scarbrough, C., & Carroll, D. (2019). Polypharmacy: evaluating risks and deprescribing. American family physician, 100(1), 32-38.
Kaur, A., & Victoria, E. L. (2017). Major Stakeholders in Health Care System: Government, Non-government & Other Professionals. Global Journal of Business & Management, 2(1), 1-5.
Liew, T. M., Lee, C. S., Shawn, K. L. G., & Chang, Z. Y. (2019). Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies. The Annals of Family Medicine, 17(3), 257-266.
Mackey, S., & Bornstein, S. (2020). Deprescribing Medications: Barriers and Enablers. Newfoundland Center of Applied Health Research. Web.
Mind Mapping. (2018). The Differences Between Mind Maps and Concept Maps. iMind.
Nash, D. B., Joshi, M. S., & Ransom, E. R., & Ransom, S. B., (Eds.). (2019). The healthcare quality book: Vision, strategy, and tools (4 ed.). Health Administration Press.
Sperling, L., & Fairbanks, M. B. (2021). Polypharmacy and the senior citizen: The influence of direct-to-consumer advertising. Journal of Gerontology and Geriatrics, 69, 19-25.
Wastesson, J. W., Morin, L., Tan, E. C., & Johnell, K. (2018). An update on the clinical consequences of polypharmacy in older adults: A narrative review. Expert Opinion on Drug Safety, 17(12), 1185-1196.