Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom

Consumer Involvement in the Design and Development of Medication Safety Interventions or Services in Primary Care: A Scoping Review

INTRODUCTION

Medication-related problems remain a significant burden despite the availability of various interventions and services in primary care. Involving health care consumers to design interventions or services across health disciplines is becoming more widely used as this type of engagement reportedly leads to more accessible, acceptable and sustainable health services and quality of life. We conducted a scoping review to examine when and how consumers have been involved in the design and development of medication safety interventions or services within the primary care.

METHODS

We searched five key databases (MEDLINE (EBSCOhost), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), Embase (Elsevier) and Cochrane Library (Wiley)) for relevant articles published up to February 2024. Studies were included if they involved adult consumers (≥ 18 years), their families, carers or the wider community as stakeholders. This review only included studies where the aim was to improve safe and effective medication use, delivered exclusively in primary care. To examine consumer involvement approaches and methods we adapted a framework describing the stages of consumer involvement for the data extraction tool.

RESULTS

Overall, 15 studies were included (comprising 24 articles). Codesign, experience-based codesign, coproduction and participatory action research were commonly used approaches. Meetings, interviews, surveys/questionnaires were commonly used methods. Two studies reported consumer involvement across all stages of the research study, and only one study described the consumer experience of being involved in the research process. The impact of consumer involvement on the effectiveness of these services or interventions was mixed.

CONCLUSION

The potential benefits of consumer involvement in the design and development of medication safety interventions or services may not have been fully maximised, given that genuine consumer involvement across all stages of the research study appears uncommon. More transparent and consistent reporting around the description of consumers involved, their experience of being involved and overall impact and quality of consumer participation is needed.

PATIENT OR PUBLIC CONTRIBUTION

This scoping review was undertaken without consumers, patients, service users, caregivers or people with lived experience or members of the public due to resource limitations. This scoping review was undertaken and written by academics, who have undertaken codesign with consumers and stakeholders and also have personal lived experience of medication-related problems.

A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study

INTRODUCTION

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them.

METHODS

Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis.

RESULTS

Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication.

CONCLUSION

SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Enhancing care in the initiation and management of insulin in older people with diabetes: A collaborative journey with older individuals and their caregivers using Experience-Based Co-Design

INTRODUCTION

Initiating insulin therapy in older individuals with type 2 diabetes (T2DM) poses unique challenges and requires a nuanced understanding of the age-related factors that impact safety and efficacy. This study employed Experience-Based Co-Design (EBCD) to enhance the insulin initiation and management experience for this population, emphasising a collaborative approach involving patients, caregivers, and healthcare professionals.

AIM

The primary aim of the research was to develop a tailored care pathway, utilising co-design and the Behaviour Change Wheel (BCW), which addressed issues specific to older adults on insulin therapy. The study sought to identify key challenges, propose practical interventions, and construct a logic model illustrating a pathway for enhanced insulin treatment experiences.

METHODS

An adapted EBCD process was used which integrated the Medical Research Council (MRC) Framework and BCW. The study involved thematic synthesis, video interviews, and feedback focus groups with patients, caregivers, and healthcare professionals. The 'Crazy Eights' brainstorming method, as part of the co-design workshop, generated practical solutions which informed subsequent logic model development.

RESULTS

Focus group findings revealed distressing insulin initiation experiences, inconsistent dietary advice, and perceived disparities in care between type 1 and type 2 diabetes. The co-design workshop identified eight key challenges, leading to proposed interventions aligned with the BCW. The logic model illustrates a pathway for older individuals undergoing insulin treatment, emphasising behaviour change among patients, caregivers, and healthcare professionals.

CONCLUSION

The collaborative efforts of participants contributed valuable insights in terms of the unique educational and emotional needs of patients, the importance of care continuity and of improving access to specialist services. Findings from this study can be used to inform and enhance tailored support strategies for older adults with T2DM during their insulin transition and ongoing management.

Barriers to person-centered service design in pharmacy practice: examples, lessons, and potential solutions

Despite increased attention to, and frameworks conceptualizing person-centered care, systematic, organizational, and provider-level barriers continue to discourage the development and delivery of person-centered care (PCC) in pharmacy practice and beyond. This commentary describes existing pharmacy-specific literature related to PCC, barriers to PCC within the context of pharmacy practice, and potential solutions to increase person-centeredness in pharmacy services. Literature to substantiate and describe barriers and potential solutions was identified from 2008 to 2023, a period where the emphasis on PCC in pharmacy practice dramatically increased. Overall, pharmacy-specific literature was identified describing four key barriers to PCC. Several potential solutions were identified, including: using innovative and theory-informed approaches to collecting individual need and preference information, employing processes and equipping providers to facilitate trust, changing organizational culture, and aligning quality metrics and financial incentives with PCC. Identified solutions may be used to address individual, organizational, and systematic barriers to promote PCC.

A Qualitative Meta-Synthesis of the Challenges Perceived by Nurses in Home Health Nursing

PURPOSE

To aggregate and synthesize the findings of qualitative studies exploring the challenges perceived by nurses in home health nursing.

DESIGN

A qualitative meta-synthesis.

METHOD

A comprehensive search of multiple databases was conducted in December 2020 and updated in October 2022. Data were analyzed using the meta-aggregation method, and the analytical process used to derive themes was inductive.

FINDINGS

Eleven qualitative studies were included, and four major challenges perceived by nurses were identified: (1) challenges in the performance of duties, (2) struggles with specific and restricted factors related to practice, (3) underestimation of the value of emotion, and (4) a difficult-to-surmount relationship gap.

CONCLUSIONS AND CLINICAL EVIDENCE

Home health nursing is associated with numerous challenges due to its complexity and high demand. The findings of this study are beneficial with respect to obtaining a deeper understanding of the challenges associated with home nursing. After considering the existing problems, it is necessary to take measures to overcome these challenges, and individuals, families and society should make efforts to develop this profession further.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.