Overall, 13 FGs were conducted with a total of 94 HPs enrolled (40 GPs, 20 CPs, and 34 nurses). The sociodemographic characteristics of the participants are summarized in Table 1.
Table 1
Participants characteristics
General Practitioners |
Female (n = 16) | Male (n = 24) | Total (n = 40) |
Age |
46.6 (27–65) | 53.0 (28–66) | 50.5 (27–66) |
Nurse |
Female (n = 32) | Male (n = 2) | Total (n = 34) |
Age | | |
45.1 (32–63) | 42 (38–46) | 44.9 (32–63) |
Community Pharmacist | | |
Female (n = 17) | Male (n = 3) | Total (n = 20) |
Age | | |
40.8 (23–58) | 30.7 (24–36) | 39.11 (23–58) |
“Please insert Table 1”
Qualitative analysis resulted in four major themes: poor compliance and polypharmacy - a vicious cycle perpetuated by the behaviour of older adults, organization of the healthcare system, communication among healthcare professionals and strategies to prevent inappropriate polypharmacy (Table 2).
Table 2
Major themes from focus groups
Theme | Subthemes | Coding concepts |
Poor compliance and polypharmacy - a vicious cycle perpetuated by the behaviour of older adults | 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-HP communication | Lack of communication |
Influencers | TV supplements |
Neighbours medication |
Herbal products | Interactions |
Medicines managing | Handling |
Generic medicines |
Organization of healthcare system | Healthcare directrices | Prescribing guidelines |
Patients empowerment |
Clinical appointments | Lack of time |
Communication among health professional | General practitioner’s -Community pharmacists | Trust/mistrust |
General practitioner’s -Specialist physicians | Lack of communication |
Multiple prescribers |
Strategies to prevent inappropriate polypharmacy | Prescribing | managing |
Generic medicines |
Promotion of compliance | Empowerment of patients |
Support teams |
“Please insert Table 2”
Poor compliance and polypharmacy – a vicious cycle perpetuated by the behaviour of older adults
According to HPs, aged-related comorbidities prone older adults to multiple prescriptions, and, for this reason, polypharmacy is an unavoidable consequence of aging.
“The presence of multiple comorbidities is a normal consequence of ageing and for this reason polypharmacy in older patients is common practice”, FG5GP1.
HPs also perceive that polypharmacy and poor compliance are two faces of the same coin, because polymedicated older adults have difficulties to comply with the therapeutic regime, hampering the achievement of clinical outcomes and leading GPs to prescribe one more medicine.
“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 other problem”, FG13GP1.
Because older adults value medicines and admit that they are essential to promote wellbeing, HPs believe that, in most of the time, medication errors are unwitting and committed due to the lack of knowledge of older adults.
“polypharmacy is closely related with literacy”, FG11GP1.
From this point of view, lack of literacy, sociocultural factors, such as the absence of family and/or relatives to take care and help with the management of medicines are the main contributors to medication errors.
“The problem of polypharmacy is the loneliness of the older adults that do not have any young familiar near to help” FG2CP2.
During their daily routine, HPs perceived that because older patients recognize medicines by the colour and/or shape of the pill, duplication mistakes, mainly due to generic medicines confusion, or taking medicines which belong to others, can easily happen.
“One older woman takes 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 colour of the tablet…/if a doctor prescribes to him another medicine or deprescribed that medicine if they have the pill at home, they will continue to take it”, FG1CP1.
During FG sessions, it was also perceived that older adults have some difficulties to understand the duration of treatments, and for this reason, they tend to prolong the treatments for more time than it is recommended by the GP. These mistakes are frequently detected in medicines prescribed for an acute episode that requires an emergency room visit.
“After an emergence visit, we frequently observed that older patients, come to the pharmacy with a specific medication, and a certain point they do not know if they should stop or not with that medicine, and for this reason, they continue taking it” FG1CP1.
According to HPs, difficulties related to the use of some medicines, such as inhalators, can influence on the efficacy of treatments.
“there is a lot of confusion, for example, inhalators, they had difficulties, the device has a counter but they don’t know, and sometimes they arrive at the pharmacy and told us that the inhalator is empty but is new, they do not use it”, FG2CP1.
According to HPs, the desire of older adults to achieve better wellbeing makes them easily influenced by the neighbours or even by television commercials that potentiate the consumption of over-the-counter (OTC) drugs, supplements, or even herbal products, that besides interfering with chronic medication, might be contraindicated for their health problems.
They are easily influenced by their neighbours, that say to their: 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 neighbours” FG1CP1.
“There are several patients that by on TV calcium pills” FG1FGP1.
HPs believed that polypharmacy per se is a contributor to poor compliance, because older adults take so many medicines that they easily withdraw some that they believe to be less important.
“Sometimes some patient complain that they take more medication than food”, FG1CP1.
According to HPs perception, the huge number of pills throughout the day prompts older adults to skip a dose, to give up some medicines that they undervalue, or that they believe might cause adverse effects.
“Polymedicated patients always try to remove one or another pill that they believe does not affect”, FG3GP1.
“If someone referred to the side effects of statin, patients automatically stop taking”, FG8GP1.
During their practice GPs perceived that fake beliefs of older adults makes the deprescription of medicines difficult.
“Deprescribing some medicines it was almost impossible, for example, trimetazidine was 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 causing more harm than well… it is very difficult”, FG5GP2.
Another important compliance-influence factor that emerged during the FG discussions was the price of medicines.
“Price of the medicines also contributes too poor adherence” FG1GP1.
According to HP, patients with economic problems try to adjust the therapeutic regimen to spend less money.
“…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.
During FG sessions, it was perceived that the lack of communication between patients and physicians is not only an important polypharmacy-related factor but also an influencer of compliance. Because patients do not report to their GP neither the specialist appointments that they had nor the new prescriptions or other products that they take, inappropriate polypharmacy is harder to detect.
“…older adults do not report their specialist/ emergency room visits to the GP, for these reasons’ patients’ GP have difficulties in detecting this inappropriate polypharmacy” FG1GP5.
“Teas and other bled beverages that patients buy here or there because of their health problems... One for gallbladder, other to the head, other to the kidney, and all of these substances have an active substance. All of them can cause interactions…. That we cannot control” FG5GP1.
Organization of the healthcare system
HPs perceived that the organization of the health care centers doesn´t simplify the identification of DRPs. According to them, the lack of centralization of chronic medication management compromises clinical outcomes and promotes duplication mistakes.
“The lack of centralization of chronic management medication 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.
According to HPs, the short time of the clinical appointments’ hampers not only the therapeutic review process but also the review of the handling of medicines by older adults.
“The 15 minutes of clinical appointment turns out to be little to explore these issues”, FG13GP2.
HP also refer that the lack of time during clinician appointments is an important polypharmacy-related factor that sometimes is undervalued.
“It takes time to see all… and we do not have time” FG2GP5.
The Portuguese National Health system (NHS) guidelines recommend that HPs “must privilege the use of electronic means to support the processes of prescribing, dispensing and billing of all types of medicines, as well as health products”(14). According to HPs, these directrices make the empowerment of patients on medication management difficult.
“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 they want to see the treatment guide but press the wrong button and once upon a time a treatment guide, they delete all”, FG5N2.
Communication among health professionals
HPs believed that in some health care centers the interaction among HPs promotes the detection of Drug-Related Problems (DRPs).
“…yesterday, a pharmacist calls to tell me that a patient bought a statin different that I had prescribed, I appreciate that”, FG4GP3.
However, when managing patients’ therapeutics, this is not always a reality.
“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 due therapeutic revision and presently GP, perhaps because they lack time, they are not due it”, FG2CP3.
According to GPs, CPs are not doing their job because before selling a medicine they should ensure that patients know how to use the medicines.
If patients had doubts is pharmacist faults…. They must explain well because they sell the medicines, they have all the material”, FG10GP3.
GPs also affirm that some duplication mistakes occur, because CPs replace the original medicines, that they prescribed, by generic medicines. On the other hand, CPs feel undervalued by physicians who tend to forget their role and the fact that their proximity with older patients makes them know patients’ needs better. Moreover, CPs affirm that when selling a generic medicine, they do it responsibly and because they know the economic context of the patient.
“ 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 for by this…”/ we are not changing the therapeutic, we are first helping the patients” FG10CP2.
In Portugal, primary health care centers are the gatekeeper of the NHS, so, whenever a patient needs a specialist appointment, the GP requests the appointment and sends all the clinical process of the patients to the specialist. During FG sessions, it was perceived that it is hard to obtain the return information, suggesting that there is a lack of communication between GPs and the other physicians.
“…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 principle 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 group, that sometimes, must not be taken with the hypertensive medicine prescribed by me. But the physician, that works at the emergency room, did not take the trouble to see the chronic medication of the patients, and the patients take the pills”, FG10GP1.
This lack of communication becomes more demanding in circumstances such as the deprescribing process.
“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.
Strategies to prevent inappropriate polypharmacy
According to HPs, polypharmacy could be reduced if GPs were able to act as the manager of all prescriptions, i.e. GP should have the opportunity to validate/ or not a prescription, prescribed by other physicians, before the dispensing.
“All the prescription must have to be authorized and validated by the GP, that managing and planning the health of the patient”, FG1GP1.
During FG sessions it was perceived that HPs admitted that the introduction of the platform of electronic prescription (PEM) promotes the managing of medicines, however, this platform had some gaps that make the detection of DRPs a hard task. GPs affirmed that when using PEM, they find difficulties updating chronic medication. They also believed that all HPs should have access to this platform. HPs believed that the limited access of PEM to the nurses hampers their role in DRPs detection. Moreover, CPs could also have a more active role in DRPs detection, if they could access to PEM. CPs could relieve the burden of primary healthcare centers in terms of time and duration of clinical appointments, through the opportunity to renew the chronic medication.
“If the PEM allows the update of chronic medication and if pharmacist could access to the PEM, the pharmacist can make the renewal of the chronic medication and this in turns relieve the burden that physicians have in terms of patients appointment” FG1GP1.
To avoid DRPs related to duplication of medicines, HPs suggested that the pharmaceutical industry should agree to standardize the boxes of medicines and even, if possible, the colour and form of pills by active substance.
“The boxes of the same active principle should have the same colour…” FG1GP2.
“the pills should also be standardized in terms of shape and colour, FG1N1.
Lastly, health professionals believed that to decrease DRPs it is essential to support, empower the patients and promote health literacy.
“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, because they 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 manage”, 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 the health literacy”, FG3GP2.
“The awareness campaigns could be a good help to patients and healthcare professional”, FG5N1.