studies in the education of adults

Studies in the Education of Adults

Subject Area and Category

• Sociology and Political Science

Taylor and Francis Ltd.

Publication type

02660830, 14789833

Information

How to publish in this journal

[email protected]

The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

The SJR is a size-independent prestige indicator that ranks journals by their 'average prestige per article'. It is based on the idea that 'all citations are not created equal'. SJR is a measure of scientific influence of journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from It measures the scientific influence of the average article in a journal, it expresses how central to the global scientific discussion an average article of the journal is.

Evolution of the number of published documents. All types of documents are considered, including citable and non citable documents.

This indicator counts the number of citations received by documents from a journal and divides them by the total number of documents published in that journal. The chart shows the evolution of the average number of times documents published in a journal in the past two, three and four years have been cited in the current year. The two years line is equivalent to journal impact factor ™ (Thomson Reuters) metric.

Evolution of the total number of citations and journal's self-citations received by a journal's published documents during the three previous years. Journal Self-citation is defined as the number of citation from a journal citing article to articles published by the same journal.

Evolution of the number of total citation per document and external citation per document (i.e. journal self-citations removed) received by a journal's published documents during the three previous years. External citations are calculated by subtracting the number of self-citations from the total number of citations received by the journal’s documents.

International Collaboration accounts for the articles that have been produced by researchers from several countries. The chart shows the ratio of a journal's documents signed by researchers from more than one country; that is including more than one country address.

Not every article in a journal is considered primary research and therefore "citable", this chart shows the ratio of a journal's articles including substantial research (research articles, conference papers and reviews) in three year windows vs. those documents other than research articles, reviews and conference papers.

Ratio of a journal's items, grouped in three years windows, that have been cited at least once vs. those not cited during the following year.

Evolution of the percentage of female authors.

Evolution of the number of documents cited by public policy documents according to Overton database.

Evoution of the number of documents related to Sustainable Development Goals defined by United Nations. Available from 2018 onwards.

Leave a comment

Name * Required

Email (will not be published) * Required

* Required Cancel

The users of Scimago Journal & Country Rank have the possibility to dialogue through comments linked to a specific journal. The purpose is to have a forum in which general doubts about the processes of publication in the journal, experiences and other issues derived from the publication of papers are resolved. For topics on particular articles, maintain the dialogue through the usual channels with your editor.

Follow us on @ScimagoJR Scimago Lab , Copyright 2007-2024. Data Source: Scopus®

Cookie settings

Cookie Policy

Legal Notice

Privacy Policy

• Study With Us
• Visiting Us
• Centre for English Language Education
• Schools Partnership Gateway
• China School Website
• Malaysia School Website
• Email this Page

Studies in the Education of Adults

During 2022, Dr Sharon Clancy has taken on the role of Journal Editor for Studies in the Education of Adults.

Dr Clancy is an Assistant Professor in Educational Leadership and Management and a member of the Centre for International Education Research .

Studies in the Education of Adults is a scholarly refereed journal that theorises and critically examines the education of adults as well as engages with international debates and national issues. It is also equally focused on lifelong-learning, adult learning, the nature of adult curriculum and on the role of the educator. 

For more information about the journal and to access articles, please visit the publisher's website .

School of Education

University of Nottingham Jubilee Campus Wollaton Road Nottingham, NG8 1BB

Legal information

• Terms and conditions
• Posting rules
• Accessibility
• Freedom of information
• Charity gateway
• Cookie policy

Connect with the University of Nottingham through social media and our blogs .

The right to lifelong learning: Why adult education matters

There are 771 million illiterate adults globally today, according to UNESCO’s Institute of Statistics . And many more do not have the adequate skills and knowledge needed to navigate through our increasingly digital 21 st century demands. How is this still possible in this day and age?

While participation in adult education is improving in some places, access to learning opportunities remains profoundly unequal, and millions continue to be left out.  

From the pandemic to the climate crisis, to the digital revolution and mass movements of populations around the world, we know that today, more than ever, it is critical to ensure access to quality education and learning opportunities throughout life for everyone, everywhere.

Here’s what you need to know about adult education and learning.

Why is adult education crucial?

The speed of today’s changes calls for opportunities to learn throughout life, for individual fulfilment, social cohesion, and economic prosperity. Education can no longer be limited to a single period of one’s lifetime. Everyone, starting with the most marginalized and disadvantaged in our societies, must be entitled to learning opportunities throughout life both for employment and personal agency. 

In order to face our interconnected global challenges, we must ensure the right to lifelong learning by providing all learners - of all ages in all contexts - the knowledge and skills they need to realize their full potential and live with dignity.

This call was highlighted in UNESCO’s flagship Futures of Education report ‘ Reimagining our futures together: A new social contract for education ’ published in November 2021. The right to lifelong learning will also be echoed at the Transforming Education Summit in September 2022, building upon the UN Secretary-General’s call for formal recognition of a universal entitlement to lifelong learning and reskilling in his report “Our Common Agenda”.

What is the situation of adult learning and education today?

The main challenge for adult learning and education across the globe is to reach those who need it most. That is the core message of UNESCO’s latest Fifth Global Report on Adult Learning and Education (GRALE).

The report shows that while there is progress, notably in the participation of women, those who need adult education the most – disadvantaged and vulnerable groups such as Indigenous learners, rural populations, migrants, older citizens, people with disabilities or prisoners – are deprived of access to learning opportunities.

About 60% of countries reported no improvement in participation by people with disabilities, migrants or prisoners. 24% of countries reported that the participation of rural populations declined. And participation of older adults also decreased in 24% of the 159 surveyed countries.

How can we guarantee the right to lifelong learning?

The GRALE report details the crucial steps needed to guarantee the right to lifelong learning.

Greater participation and inclusion are key : Vulnerable groups, such as migrants, indigenous learners, older citizens and people with disabilities, are too often excluded from adult education and learning.

More financing is needed : Investment in adult learning and education is currently insufficient. Countries must live up to their commitment to seek investment of at least 6% of GNP in education, increasing the allocation to adult learning and education. There is wide diversity in terms of public funding devoted to adult learning and education, with only 22 out of 146 countries spending 4% or more of their public expenditure for education on adult learning and education, and 28 spending less than 0.4%.

Stronger policies are essential : Effective policies are key for adult learning and education across the globe. 60% of countries have improved policies since 2018. But we need further efforts to transition education systems to lifelong learning systems.

Progress in governance : Partnerships and cooperation between ministries, the private sector and civil society are essential for adult learning and education to thrive. Almost three-quarters of countries reported progress in governance, particularly in low-income and upper middle-income countries, and in both sub-Saharan Africa and Asia and the Pacific.

Improved quality : Effective teacher training and the professional standards for adult educators are essential to the quality of earning. Most countries reported progress in relation to quality of curricula, assessment and the professionalization of adult educators. Over two-thirds reported progress in pre-service and in-service training for educators, as well as in employment conditions, though this progress varies considerably by region and income group.

The importance of citizenship education : Responding to contemporary challenges, such as climate change and digitalization, demands citizens who are informed, trained and engaged, active, who recognize both their shared humanity and their obligations to other species and to the planet. Citizenship education is a key tool in this endeavour to empower learners to take action and help transform our collective future.

What has been the impact of COVID-19 on adult learning?       

During the COVID-19 pandemic, most countries reported rapid transitions to online, digital and distance learning or modifications of in-person learning arrangements. The widespread adoption of digital technology, including televisions, radios and telephones, has supported educational continuity for millions during lockdowns.

There are many examples of countries responding innovatively to the crisis to ensure the continuation of adult learning by adopting new policies and regulations to support this process, or by adjusting existing quality standards and curricula.

However, the COVID-19 pandemic has also caused some regions and population groups, particularly in parts of the world where resources and infrastructure are scarce, to lag even further behind.

How does UNESCO support adult education and learning?

The UNESCO Institute for Lifelong Learning strengthens the capacities of Member States to build effective and inclusive lifelong learning policies and systems, in line with Sustainable Development Goal 4. It aims to develop learning ecosystems that work across life, in every setting and benefit everyone through building capacity at local and national levels, strengthening partnerships, and offering data and knowledge.

To advance the world’s commitment to the right to lifelong learning, UNESCO is convening the Seventh International Conference on Adult Education (CONFINTEA VII) in Marrakech, Morocco from 15 to 17 June 2022. Participants from across the globe will come together to take stock of achievements in adult learning and education, discuss challenges, and develop a new framework for action to make adult learning and education a reality around the world. CONFINTEA VII is hosted by and co-organized with the Kingdom of Morocco.

• More about CONFINTEA VII
• Access the GRALE Report
• More about the UNESCO Institute for Lifelong Learning

Related items

• Lifelong education
• Right to education

More on this subject

Other recent news

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Studies in the education of adults

Studies in the Education of Adults

Related Papers

International Journal of Lifelong Education

Marcella Milana

Erika Behrisch Elce

Ricarda Motschilnig

European Journal for Research on the Education and Learning of Adults, Vol.3, No.2, 2012, pp. 103-117

This article reflects on the shift in vocabulary from (adult and continuing) education to (lifelong) learning and the ideological and purposive orientations it carries. It does so by critically addressing the changes occurred in policy discourses concerned with the education of adults after WWII at transnational level. The main argument is that the shift in vocabulary has been favoured by an increased voice acquired by transnational and inter-states entities (i.e. OECD, UNESCO, EU) in educational matters, however in combination with a change in political emphasis, at least within the European Union, from creating jobs opportunities towards securing that citizens acquire marketable skills. While both trends seems to point at the demise of the nation state as a guarantor for social justice, more research is needed to deepen our understandings of the interplay between transnational and nation-state levels; thus the article concludes by suggesting a research agenda to move in this direction.

International Review of Education

European Journal for Research on the …

Andreas Fejes

George K. # Zarifis

Slowey Maria Swimming With the Stream the Relationship of Adult Education and the Lifelong Learning Agenda in Post Devolution Uk the Adult Learner 2004 2004 Pp 27 41 Issn 0790 8040

Maria Slowey

Studies in Continuing Education

Christine Jarvis

RELATED PAPERS

Invenio Revista De Investigacion Academica

Hygino Belli

Journal of clinical chemistry and clinical biochemistry. Zeitschrift für klinische Chemie und klinische Biochemie

Erwin Schleicher

Claudio de Farias

Engineering & Technology

Bryan Betts

Journal of Mathematics and the Arts

Anne Spalter

Revista Brasileira de Geociências

sergio huhn

Giuseppe Previtali

Tierra Infinita

IEEE Transactions on Biomedical Engineering

Kazunari Owada

Atmospheric Chemistry and Physics Discussions

Paulo Artaxo

Bulletin of Electrical Engineering and Informatics

riandini riandini

Chemical Research in Toxicology

Oksana Lockridge

International Journal of Paediatric Dentistry

Roberta lione

Revista Brasileira de Ginecologia e Obstetrícia

Erica Marcos de sousa

EPJ Web of Conferences

Jurnal Psikologi

Aliva Kemala

La nueva vida de Carlos Massad

Jaime Troncoso Rojas

Vigilância Sanitária em Debate

Alexandre Soares Leal

Adrian Kliks

jean-marie lagache

Emre Demiralp

Paul Caceres

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

Where are we from?

Active members come from most parts of Europe.

The Secretariat of ESREA e.V. is located at the German Institute for Adult Education (DIE) in Bonn, Germany.

ESREA e.V. is in legal terms a non-profit organization governed under german law.

Learning is not a

Product of schooling, but the, lifelong attempt to acquire it., albert einstein.

Along with Stanford news and stories, show me:

• Student information
• Faculty/Staff information

We want to provide announcements, events, leadership messages and resources that are relevant to you. Your selection is stored in a browser cookie which you can remove at any time using “Clear all personalization” below.

Flora, a 32-year-old single mother, faces a dilemma shared by many of the millions of American adults without a college degree.

A new report, co-authored by Stanford scholars, advises National Science Foundation on building an applied science to support “working learners.” (Image credit: Getty Images)

She’s an excellent, highly motivated Tier 1 patient care representative at a health insurance firm. Now, her company is automating the work she does, and all of the Tier 1 positions will be eliminated. Her company will be promoting workers to Tier 2 patient care representative positions, something Flora has long desired. Unfortunately, she doesn’t have the degree the job requires. Flora earned a certificate in customer service at work and has six credits at a community college, but she can’t afford to go back to school.

The case study of Flora, who is a composite of research interviews and analyses of demographic data, helped guide a year-long effort by leading educators, convened by the Graduate School of Education and Stanford’s Transforming Learning Accelerator, to build an applied science to study the needs of “working learners,” a term that refers to adults pursuing paid employment and learning opportunities at the same time. The project culminated in nine recommendations, released Jan. 19, as part of a concise  report  to the National Science Foundation, which funded the endeavor.

“In a nutshell, we’re calling on government to play a leadership role in investing in an applied science of adult and lifelong learning, with a particular emphasis on understanding the educational needs of working adults who do not have four-year college degrees,” said Mitchell Stevens, a sociologist and professor at Stanford Graduate School of Education (GSE) who is a leader of the project. “Most education research looks solely at the first quarter of life. The relationships between school, work and biography across the lifespan are a black box.”

In recent years, growing numbers of government agencies, nonprofits, for-profit companies, philanthropies and education institutions have developed programs to support working learners, spurred by the recognition that many adults without college degrees struggle with the impact of new technologies on work and the accompanying shifts in employment qualifications. But there is not yet a reliable way to evaluate the effectiveness of such programs, or even of determining whether they address the most critical challenges working learners face. The new report suggests that a major research initiative can determine how best to build an education system for working learners and how to invest public and private resources most effectively.

The recommendations include identifying new educational opportunities that may benefit workers throughout their working lives, promoting collaboration between researchers and businesses to better understand how new credentials are affecting hiring decisions; and developing data collection systems that will enable researchers to track transitions between learning and employment experiences as people progress from young adulthood to retirement. The report also recommends that such research be conducted by bringing together different stakeholders regionally.

Universities have a particular role to play as conveners, as employers and as educators and researchers, said Stanford University President Marc Tessier Lavigne when he spoke at the last of four discussion sessions in July that laid the basis for the new report. More than 180 education leaders from different sectors – government, private and nonprofit organizations, philanthropies and higher education – joined the online gatherings, which were convened with NSF funding by Stevens and the  Transforming Learning Accelerator  (TLA), a university-wide initiative to develop more equitable and scalable learning solutions. More than 35 Stanford faculty, staff members and students contributed to the project.

“To be effective, this must be a true cross-sector discussion because any science we develop requires the contributions of all of these stakeholders,” Tessier-Lavigne said at the July 28 meeting. “This is the beginning of a conversation that has the potential to make a difference for working learners for the long term.”

Daniel Schwartz, the I. James Quillen Dean of the Graduate School of Education who leads TLA, added in a recent interview that the report underscores the importance of work underway at Stanford. “We are creating new scholarship and learning solutions that bridge discoveries in education, neuroscience, humanities, data science, psychology, law and other fields to serve the needs of working learners,” he said. “We need to foster a future where all learners thrive – no matter their cultural backgrounds, zip code or age.”

The summer meetings led Stanford’s Office of Community Engagement to convene a campus conversation to explore how the university could deepen collaboration to support working learners. Megan Swezey Fogarty, Stanford’s associate vice president of community engagement and a participant in the July gatherings, explained, “We need to learn from leaders across campus, local community colleges, workforce development agencies and others how we can contribute to improve knowledge and skills not only for our own employees but for others in our region as well.”

Stanford Digital Education, a unit in the provost’s office, plans to help implement the recommendations of the report by piloting new programs, jointly developed with partners, for working adults. These programs could, in turn, yield new research opportunities in the emerging science of lifelong learning. Stanford Digital Education was launched last year to advance educational innovations for social impact and strengthen Stanford’s digital learning infrastructure.

Attention to working learners has grown in recent years as part of a sea change in thinking about national education policy. Since the Higher Education Act of 1965 expanded the GI Bill’s subsidy of college access for WWII veterans to include all citizens, the nation has sought to provide economic mobility by promoting college for all. However well-intended, that policy prescription has come to create its own problems. Key among them is that possession of a college credential has become a fateful divide in American life .

“On one side lie reasonably well-compensated jobs, better health, more stable families and more informed civic participation,” Stevens said. “On the other lie precarious, marginal employment, dangerous debt levels, strained relationships, depression and anger.”

In the hypothetical case study, Flora, the insurance employee whose job is being eliminated, finds herself stuck on the wrong side of that divide. To move ahead, she must consider a dizzying plethora of new educational services from big tech companies and smaller recently established edtech ventures, without data to help her choose a path that would improve her prospects.

“That’s a new frontier for the science of working learners,” said Stevens, noting that researchers will need data if they are to find answers. More and more of that data are proprietary and in the hands of private parties. The new report calls for researchers, government and other stakeholders to create new data infrastructures that can match the systems in place to evaluate K12 and higher education programs.

Like many working learners, Flora may decide to take advantage of online courses. Such offerings are convenient but may not necessarily be suited for the learning needs of older people. The use of digital education to serve working learners is still in relative infancy, and the report calls for identifying which approaches work best for which groups.

“To serve working learners effectively we have to marry their educational needs with our technological and human capacities,” said Matthew Rascoff, Stanford’s vice provost for digital education, who participated in the NSF-funded project and is one of the leaders in the Stanford Community of Practice on Working Learners. “Working learners need the scheduling flexibility of asynchronous online learning – but also need to connect with a supportive learning community that encourages growth. Our design challenge is to balance those needs in models that scale.”

“We’re still very much in the discovery phase,” Rascoff said.

At 9 a.m., Pacific time, Jan. 19, Stevens and a colleague will host a virtual forum on the report, featuring Luther Jackson, program manager of Silicon Valley  NOVAworks job center; Katherine Newman , system chancellor for academic programs at the University of Massachusetts; and Sarah Turner , university professor of economics and education at the University of Virginia. Journalist Paul Fain of The Job will moderate. To attend, please register here .

Jonathan Rabinovitz is Stanford Digital Education’s communications director .

• Bachelor of Professional Studies
• Professional Studies and Continuing Education
• Finish Your Degree 100% Online

Learning That Fits Your Life

We know that many adult students are juggling work and family commitments. The Bachelor of Professional Studies (B.P.S.) program was designed with this in mind. Choose the B.P.S. program to achieve something you've always wanted, in a way that works for you.

Apply for 2024

Important Dates

Fall 2024 program start.

• apply by June 14, 2024
• get notified of acceptance by June 28, 2024

Spring 2025 Program Start

• apply by November 1, 2024
• get notified of acceptance by November 15, 2024

Two Concentration Options

The B.P.S. bachelor's degree program allows you to choose from one of two concentrations, each including the added value of a Certificate of Undergraduate Studies (C.U.S.):

• Organizational Leadership (C.U.S. in Workplace Diversity)
• Social Services (C.U.S. in Nonprofit Studies)

Each concentration emphasizes diversity and ethics, while teaching concepts and skills delivered efficiently and accessibly that are required for career advancement. There is also a foundation in the arts and sciences through the B.P.S. general education requirements. 

Learn Alongside Your Peers

The program is structured as a cohort model, so you will be part of a group of adults who have work experience, along with college credit. In your first class, you will learn how to create a B.P.S. prior learning portfolio of your work/life experience for a potential credit award of up to 32 credits.

2 Courses at a Time

The B.P.S is designed to fit within a busy working adult’s schedule. Here’s how it works: 

• program runs during the Fall and Spring semesters 
• each semester is split into two 7-week sessions 
• 2 courses are taught in each session  
• courses are delivered in a blended online format
• synchronous courses in each semester are taught back-to-back on the same day of the week

Fully Online Courses, Synchronous and Asynchronous

Courses are delivered in a blended online format:

• asynchronous = students view course materials and complete assignments without specified class meetings
• synchronous = students and instructors are talking, teaching, and learning via Zoom in real time

Please Note: No more than half of the classes meet synchronously.

Admission Requirements

• 24 years or older at time of application
• 5 years of documented comprehensive work experience and/or military training
• a minimum of 24 earned college credits from a regionally accredited college or university 
• a cumulative college GPA of 2.0 or higher
• no prior bachelor’s degree earned

Please Note: Current RIC students (still active as degree students) who wish to change their major to the B.P.S. need to submit a Change of Major Request to B.P.S. Form .

Tuition + Fees Per Semester (2024-2025)  

• $358/credit
• $105 technology fee
• $52 library fee
• $275 B.P.S. program fee

Financial Aid

Our Office of Financial Aid is ready to answer any questions about financial assistance.

Contact Financial Aid

Academic Components

• minimum of 120 earned college credits (including up to 75 transfer credits)
• concentration: 36–39 credits
• general education requirements: 40 credits (some of which may be from prior earned credit)
• prior learning portfolio and/or elective credits: if needed to reach the 120 credits for graduation

B.P.S. Course Details

Required courses.

Please Note: Organizational Leadership students may count ECON 200 and Social Services students may count SWRK 325 towards four of the remaining general education credits. Prior earned college credit will be evaluated to see which may be used to fulfill remaining credits to reach the minimum of 40 required General Education credits. 

Total Credits: 35

Total Credits: 36

Move Forward Today and Apply to the B.P.S. Program

We're currently accepting applications for 2024 and hope that you're willing to take the next step to advance your career in a program that understands the needs of adult learners.

Meet Our B.P.S. Students through Stories and Video

First cohort from b.p.s. program reaches the finish line.

Bachelor of Professional Studies Program lauds its inaugural class at pinning ceremony.

Meet Our B.P.S. Students: Jason Melise Aims for a Top Spot in Banking

Melise is thankful to be a member of the second cohort in RIC's new Bachelor of Professional Studies Program.

Office of Professional Studies and Continuing Education

Professional Studies and Continuing Education (PSCE) extends the educational offerings and resources of Rhode Island College (RIC) and provides administrative programming support and assistance to affiliated agencies and organizations on and off campus.

• email [email protected]
• phone 401-456-8909
• place Roberts Hall
• Request Information

In some Chicago neighborhoods, almost half of all teens and young adults are not going to school or working

Sign up for Chalkbeat Chicago’s free daily newsletter to keep up with the latest education news.

The portion of young Chicagoans neither going to school nor working is returning to pre-COVID levels — but it’s an uneven recovery that has left behind Black teens as well as adolescents in the city’s most disadvantaged neighborhoods.

Overall, about 45,000 16- to 24-year-olds in the city are disconnected from both school and work, accounting for roughly 12% of the city’s residents in that age group — a rate just slightly higher than pre-COVID.

“In the aftermath of the pandemic when things looked really shaky, these overall numbers are very encouraging,” said Matthew Wilson, associate director at the University of Illinois Chicago’s Great Cities Institute and one of the authors of a new study on youth disconnection.

That was until researchers zeroed in on Black teens, he added: “When I saw these numbers, I thought, ‘Wait a minute.’”

The new report found the number of Black 16- to 19-year-olds who are not in school, college, or the workforce more than doubled from 2021 to 2022, the most recent year for which U.S. Census data is available.

Statewide, roughly 136,000 teens and young adults are not in school or working — a number that would make it Illinois’ third-largest city, the report’s authors note.

Chicago continues to lag behind the state and the country in getting young people reconnected to school and work since the height of the pandemic.

The Chicago-based nonprofit Alternative Schools Network commissioned the report for the second year as part of a push to ask Illinois lawmakers to allocate $300 million to a new youth employment program statewide. In Chicago, Mayor Brandon Johnson has also championed youth jobs, vowing to double the number of opportunities open to teens and young adults, though his administration made more limited headway in boosting that number by 20% last summer, his first in office.

Experts believe that re-engaging young people who are neither working nor going to school is key to addressing poverty, racial disparities, and gun violence. Even short stints of disconnection can have a lasting effect on a person’s earning potential, health, relationships, and odds of becoming incarcerated, research has shown.

The disconnection rate dipped for Black and Latino 16- to 24-year-olds overall in 2022 while continuing to rise for their white counterparts. Nevertheless, that rate still remains much higher for young people of color. Almost a quarter of Black youth that age were out of school and out of work compared with 11% for Latinos and about 7% for whites.

The disconnection rate for Black 20- to 24-year-olds declined markedly. But the rate for 16- to 19-year-olds shot up from about 9% to more than 17%.

Wilson believes Black teens might still grapple with disconnection at a higher rate because that age group bore the brunt of the pandemic’s learning disruption and social-emotional toll during their all-important high school years.

“Being a high school student during COVID times was just a really bad place to be,” he said. “Your chance of having a meaningful attachment to school and being on a good trajectory after high school was diminished.”

The report also highlights dramatic differences in the rate of youth disconnection among Chicago neighborhoods and between the city and its north suburbs. That rate is less than 2% in some Cook County communities — and more than 48% in the West Side neighborhoods of Austin, North Lawndale, and Garfield Park.

“If every other young person is not working and not in school, that’s a crisis,” Wilson said.

The Alternative Schools Network helped craft legislation to launch a $300 million program to hire some 80,000 young people statewide and enlist the network and other nonprofits to prepare them and support them in those jobs.

“Lower-income kids just don’t have the connections to the labor market and to jobs that middle-income and upper-class kids have,” said Jack Wuest, the network’s executive director.

“It’s a terrible loss of potential.”

Becky Vevea contributed reporting.

Mila Koumpilova is Chalkbeat Chicago’s senior reporter covering Chicago Public Schools. Contact Mila at [email protected] .

Representing families challenging school segregation, here’s what the NAACP’s chief legal counsel told the high court.

Daniel Kiel, whose documentary chronicled the ‘Memphis 13,’ sees vouchers and ‘colorblind’ policies eroding progress on desegregation.

The changes tweak previous language on homework assignments, dress code, and how to approach discipline.

lllinois lawmakers overhauled K-12 funding seven years ago and promised to 'adequately fund' every district by 2027. A new report finds that won’t happen until 2034, unless more education money is budgeted every year.

Nearly half attend schools with high concentrations of poverty, while funding disparities undermine recovery from learning loss.

A survey of Michigan residents found wide support for higher salaries for beginning teachers.

• - Google Chrome

Intended for healthcare professionals

• Access provided by Google Indexer
• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• Deprescribing in older...

Deprescribing in older adults with polypharmacy

• Related content
• Peer review
• Anna Hung , assistant professor 1 2 3 * ,
• Yoon Hie Kim , assistant professor 4 * ,
• Juliessa M Pavon , associate professor 4 5
• 1 Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
• 2 Duke-Margolis Center for Health Policy, Durham, NC, USA
• 3 Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
• 4 Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
• 5 Geriatrics Research, Education, and Clinical Center (GRECC) Durham VA Health Care System, Durham, NC, USA
• * Co-first authors
• Correspondence: A Hung, anna.hung{at}duke.edu

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Introduction

Polypharmacy, commonly defined as taking at least five drug treatments, is common in older populations. 1 2 The prevalence of this condition, when combined across multiple countries, is about 45% in older populations (those aged 65 years or older) compared with 27% in younger populations (those aged under 65 years). 1 Although older adults are more likely to have multiple chronic conditions, and guidelines often recommend multiple drug treatments, studies have found that polypharmacy can lead to problems such as adverse drug events, drug–drug interactions, drug treatment non-adherence, 3 4 cognitive and functional impairment, 5 and increased risk of frailty, disability, falls, hospitalizations, and mortality. 6 7 8

Polypharmacy is also associated with the use of potentially inappropriate medications, 9 10 which is linked to increased risk of hospitalization and visits to the emergency room. 11 Furthermore, polypharmacy can result in higher healthcare costs; the total healthcare costs of patients with polypharmacy are twice as high as those of patients without polypharmacy. 12 Affordability of drug treatments is already problematic, given that, for example, nearly one third of older adults in the United States with multiple chronic conditions spend more than 20% of their income on medical care. 13

One way to tackle polypharmacy is via deprescribing, which can be defined as the “systematic process of identifying and discontinuing drugs when existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, functional status, life expectancy, values, and preferences.” 14 This process is often supervised by a healthcare professional, but shared decision making is critical, because deprescribing decisions need to consider patient and care partner values and preferences. 15 16 Contrary to a simplistic goal of reducing the number of drug treatments, the essence of deprescribing lies in achieving a nuanced balance: acknowledging the concept of “appropriate polypharmacy.” 17 18 This approach recognizes that certain medical conditions can warrant the use of multiple drug treatments to effectively manage symptoms, prevent complications, and improve overall patient wellbeing. Deprescribing, in this context, seeks not to diminish the drug treatment count arbitrarily, but rather to ensure judicious and contextually appropriate drug treatment use.

Coined in 2003, the term “deprescribing” has witnessed significant growth in usage, research, and the development of supporting networks, and has gained particular momentum since 2016. 19 This evolution highlights the growing acknowledgment of deprescribing as a crucial strategy in optimizing drug treatment regimens to meet the specific needs and goals of individual patients. Concurrently, the substantial growth in randomized controlled trials evaluating deprescribing interventions attests to the increasing emphasis on evidence based approaches. Several excellent reviews of deprescribing interventions in older adults exist, but they differ slightly in focus; for example, some are limited to comprehensive medication review interventions, or target a specific population such as community dwelling, frail, or multimorbid. 20 21 22 23 This narrative review summarizes randomized controlled trials that assess deprescribing interventions addressing polypharmacy in older adults.

Prevalence of polypharmacy

Over the past few decades, polypharmacy has become a common and widespread problem among older adults. In the US, for example, the prevalence of polypharmacy among adults aged 65 and older increased from 13% in 1998 to 43% in 2014, 24 25 with the most recent estimates from 2017-2018 at 45%. 26 This increase was driven in particular by the growing use of cardioprotective and antidepressant drug treatments, 24 and the highest prevalence of polypharmacy is seen among populations with heart disease. 26 Additional reasons for increases in the use of drug treatments include the start of Medicare Part D (ie, prescription drug coverage for older adults) in 2006, as well as quadrupled spending on direct-to-consumer pharmaceutical advertising (from $985 million in 1996 to $4.24 billion in 2005). 27

Similarly, a survey conducted across 17 European countries and Israel also revealed a high prevalence of polypharmacy in adults aged 65 and older, varying from 26% to 40%, with the lowest estimates in Switzerland, Croatia, and Slovenia and the highest estimates in Portugal, Israel, and the Czech Republic. 28 In other regions of the world, the prevalence of polypharmacy was 46% in Hong Kong, 39% in Taiwan, 32% in South Korea, and 20% in Australia. 29

Whereas polypharmacy is a pervasive phenomenon in contemporary healthcare, particularly as individuals contend with complex and coexisting health conditions, a distinction must be made between inappropriate polypharmacy and appropriate polypharmacy, which ensures optimal patient care. Inappropriate polypharmacy refers to the excessive, unnecessary, or unmonitored use of drug treatments, potentially leading to adverse effects, drug–drug interactions, and diminished overall wellbeing. On the contrary, appropriate polypharmacy entails the deliberate and evidence based use of multiple drug treatments to serve the specific needs of a patient, often stemming from the complexity of their medical conditions. In the context of deprescribing, the focus shifts to identifying instances of inappropriate polypharmacy and streamlining drug treatment regimens, to align with the principles of appropriate polypharmacy. Thus, the objective of deprescribing is to tailor treatment regimens to individual patient needs, minimize potential adverse effects, and ensure that the remaining prescribed drug treatments contribute meaningfully to a patient’s overall health and quality of life, while accounting for the principles of evidence based practice.

Barriers to deprescribing

Patient barriers.

Despite the need to tackle inappropriate polypharmacy, deprescribing is not commonplace. Published literature has identified a myriad of barriers at the patient, provider, and system levels. One example of a patient barrier is uncertainty of outcomes from deprescribing (and a fear of negative consequences). Other patient barriers could be poor access to deprescribing education, or difficulty in understanding medical jargon. 30 31 Deprescribing of a drug treatment can also represent a radical change for patients with a chronic condition, who might have been told for a long time to focus on achieving adequate disease control (eg, low A1c in the case of diabetes). 32

Provider barriers

Meanwhile, providers can also lack training and evidence on how to deprescribe (eg, how to taper and monitor), and can also lack knowledge and experience in engaging in complex conversations about deprescribing. 31 33 34 35 Providers themselves might fear the potential consequences of discontinuing drug treatments (eg, potential adverse drug withdrawal events, inadequate disease control) especially if they do not have guaranteed follow-up with the patient. Another provider barrier is inertia around making changes to drug treatments when patients are not experiencing any drug treatment related problems. Additional provider barriers include consultation constraints (eg, insufficient time or resources to support deprescribing), uncertainty around discontinuing a drug treatment that, for example, was initiated by another provider, uncertainty around roles and responsibilities among providers, and poor communication and collaboration among providers. 31 33 34 35 Many of these barriers are due to the healthcare environment in which providers work.

System barriers

Many system barriers exist. One example is a culture of diagnosing and prescribing in medicine. 31 33 34 Evidence based guidelines often recommend prescribing medicine but do not make recommendations on when to later stop the medicine. Evidence based guidelines also focus on a single disease, and evidence based guidelines for older adults with multimorbidity are lacking. Care itself for these older adults is fragmented, with multiple specialists and potential delays and/or mishaps in communication, which can further contribute to inappropriate polypharmacy. Additionally, the payment incentive structure in healthcare does not encourage complicated conversations around deprescribing, in-depth consideration of patient care goals, and often there is a lack of shared decision making tools and resources. 31 33 34 Also, performance metrics for providers and insurance plans can inadvertently encourage inappropriate overuse of drug treatments (to ensure adequate disease control) and make it difficult for deprescribing to attain individual patient goals. 36

Barriers across settings

These barriers are not uniform across healthcare settings; primary care, hospitals, long term care, and private settings face unique challenges. 30 35 37 For instance, primary care confronts challenges using a diagnostic and prescribing culture, while hospitals contend with competing inpatient tasks, patient resistance during hospitalization, and post-discharge follow-up concerns. Long term care settings grapple with resource shortages and coordination gaps, and private settings face obstacles related to awareness, commitment, and incentives for deprescribing. Healthcare providers, including physicians, pharmacists, and nurses, exhibit varied attitudes and knowledge gaps, influencing deprescribing implementation. Specific drug treatment classes, such as benzodiazepines, introduce unique challenges, including patient beliefs, lack of knowledge, and emotional attachments to the drug treatment. 38 39

Implementation strategies

Overcoming these barriers is paramount for successful deprescribing, and implementation science can offer valuable tools and strategies. Key implementation strategies for successful deprescribing include structured education and training for providers and patients to enhance knowledge and confidence, patient centered approaches like shared decision making and motivational interviewing, offering non-pharmacological alternatives to reduce drug treatment reliance, and providing resources such as clinical decision support tools and deprescribing algorithms. 40 Additionally, fostering improved communication and collaboration among healthcare settings and providers is crucial for maintaining continuity and consistency of care. Integrating implementation science principles requires understanding healthcare system complexities, securing provider buy-in, and tailoring interventions to specific contexts, as recent research underscores the value of this approach in overcoming barriers and optimizing facilitators in diverse healthcare landscapes.

Facilitators to deprescribing

Studies have identified patient, provider, and system facilitators that cover a wide spectrum. 30 31 33 35 Most older adults (84-88%) are willing to deprescribe their drug treatment, based on provider recommendations. 41 42 In fact, 67% of older adults report wanting to reduce the number of drug treatments they are taking, and this desire increases when they are taking more drug treatments. 43 Patient willingness and attitudes toward deprescribing vary, but it should be noted that this desire on average does exist.

Shared decision making processes with clear communication and a gradual introduction of the topic, as well as active patient and caregiver involvement, can enable deprescribing. Examples of provider facilitators include training to achieve in-depth drug treatment knowledge related to deprescribing outcomes (eg, potential adverse drug withdrawal events) along with multidisciplinary provider teams that have clear roles and responsibilities related to deprescribing decisions.

Examples of system facilitators include resources and tailored support tools to enable deprescribing conversations, deprescribing guidelines, and evidence on optimal deprescribing practices. 30 31 33 35 The greater availability and acceptability of non-pharmacological alternatives, which allows for substitution of the deprescribed drug treatment, can also allow for patients and providers to feel more comfortable with deprescribing. At the broader system level, insurance plans have medication therapy management programs and have been incentivized through quality measures to monitor and encourage discontinuation of potentially inappropriate medications. 44

Finally, increasing awareness of drug treatment overload; for example, media campaigns and reducing industry influence can also help facilitate a culture that normalizes deprescribing. 45 Facilitators and barriers to deprescribing are important to consider in deprescribing interventions, and in our review of studies, we extracted various intervention components that would deal with some of these facilitators and barriers.

Source and selection criteria

A literature review was conducted to identify published randomized controlled trials of deprescribing interventions in older adults with polypharmacy. Searches were conducted in PubMed and Embase on 2 April 2023 using the free text search terms, “deprescribing” and “polypharmacy”, and filtering on randomized controlled trials, controlled studies, systematic reviews, and meta-analyses. We included studies that were published from 1 January 2012 to the day of the search and were in English. We limited our search to randomized controlled trials that enrolled those at least 65 years of age and with polypharmacy (defined as taking at least five drug treatments). We excluded pilot/exploratory randomized controlled trials and ancillary publications of the randomized controlled trial (eg, trial protocol only, process evaluation). We also manually searched through references of identified studies and systematic reviews of broader scope interventions for older adults with polypharmacy, and included studies if deprescribing was a part of the intervention (either explicitly by the term “deprescribing” or implicitly by reporting reduction in drug treatments as a trial outcome). Two reviewers reviewed each article and any discrepancies were resolved through discussion. We described intervention components and summarized key findings based on primary outcomes and any key secondary outcomes that were reported in the publication abstract. This distinction was made because many of the trials included a very long list of secondary outcomes. We then categorized whether the study intervention was found to have a statistically significant effect (p<0.05) on: (a) at least one primary outcome; (b) if not, at least one of the key secondary outcomes; or (c) neither primary nor key secondary outcomes. We acknowledge that if a randomized controlled trial tested many outcomes, then there could be multiplicity concerns. For this narrative review, we report on these outcomes without adjustment and are limited by what was reported on in the randomized controlled trial.

Secondarily, we searched for ongoing randomized controlled trials of deprescribing interventions in older adults with polypharmacy and applied the same inclusion/exclusion criteria as aforementioned. We defined the randomized controlled trial as “ongoing” if the primary outcome results had not yet been published as a manuscript. To identify these ongoing studies, we documented any trials that had published protocols from the aforementioned PubMed and Embase searches that did not yet have primary outcomes results reported in a manuscript, and also searched through the ClinicalTrials.gov and the International Standard Randomised Controlled Trial Number Registry databases.

When conducting this narrative review, we identified several completed studies 46 47 48 49 50 and ongoing studies 51 52 that were excluded because they included slightly younger populations (minimum of 50, 55, or 60 years of age). Similar to prior reviews, we chose an age cutoff of ≥65 because interventions and outcomes can vary for different ages. 20 21 22 For example, the Beers criteria that are intended for use in older adults aged ≥65 define a commonly used list of potentially inappropriate medications that might be used if interventions are targeting older adults. 53 Similarly, additional studies were excluded if they did not specify that the recruited patients had to be using a minimum of five drug treatments (ie, the most common definition of polypharmacy), because the scope of this narrative review was older adults with polypharmacy.

Out of 433 articles identified, 21 articles met all eligibility criteria ( fig 1 ). Of these articles, 15 took place in primary care (11 in primary care practices and four in community pharmacies), four focused on hospital transitions, and two on nursing home settings ( fig 2 ). Most studies took place in Europe or North America, and over half (12 of 21) were cluster randomized controlled trials (see supplementary table 1). While the majority (12 of 21) targeted patients aged ≥65, four studies targeted patients aged ≥70, and five studies targeted patients aged ≥75 ( figs 3-7 ). The majority (12 of 21) examined populations with at least five drug treatments, while eight studies used higher thresholds (eg, at least 7, 8, 10, or 15 drug treatments). Three studies additionally targeted deprescribing of specific drug classes (eg, benzodiazepines, psychotropics, anticholinergics). In addition to targeting older populations with polypharmacy, five studies further focused on frail populations or those with multiple chronic conditions, alongside specific disease states such as dementia or cardiovascular disease.

Flow diagram of included studies.

• Download figure
• Open in new tab
• Download powerpoint

Number of studies by targeted setting.

Summary of findings from published deprescribing randomized controlled trials in older adults with polypharmacy (part 1). *Unless noted, the control arm was usual care. †Results on secondary outcomes were included if they were notable enough to be included in the abstract. Focus on adjusted results and intention-to-treat analyses when available. DRP=drug related problem; EQ=EuroQol; HRQoL=health related quality of life; MAI=Medication Appropriateness Index; PCP=primary care physician; PIM=potentially inappropriate medication; SD=standard deviation; SPPiRE=Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care.

Summary of findings from published deprescribing randomized controlled trials in older adults with polypharmacy (part 2). *Unless noted, the control arm was usual care. †Results on secondary outcomes were included if they were notable enough to be included in the abstract. Focus on adjusted results and intention-to-treat analyses when available. CI=confidence interval; DBI=drug burden index; DRP=drug related problem; GP=general practitioner; GPGP= Good Palliative-Geriatric Practice; HRQoL=health related quality of life; OR=odds ratio; PIM=potentially inappropriate medication; STOPP/START=Screening Tool of Older Person's Prescriptions/Screening Tools to Alert Doctors to Right Treatment.

Summary of findings from published deprescribing randomized controlled trials in older adults with polypharmacy (part 3). *Unless noted, the control arm was usual care. †Results on secondary outcomes were included if they were notable enough to be included in the abstract. Focus on adjusted results and intention-to-treat analyses when available. ADE=adverse drug event; ADWE=adverse drug withdrawal event; CI=confidence interval; DRP=drug related problem; GP=general practitioner; HRQoL=health related quality of life; MAI=Medication Appropriateness Index; PACIC=Patient Assessment of Care for Chronic Conditions; SD=standard deviation; STOPPFrail=Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy; STRIPA=Systematic Tool to Reduce Inappropriate Prescribing Assistant; TRIM=Tool to Reduce Inappropriate Medications.

Summary of findings from published deprescribing randomized controlled trials in older adults with polypharmacy (part 4). HR=hazard ratio; PIM=potentially inappropriate medication; S$=Singapore dollar; VAS=Visual Analogue Scale.

Frequency of intervention components.

All studies compared the intervention with usual care. We found a wide variety of interventions, with most including more than one component to overcome different barriers to deprescribing. Common intervention components explicitly described in studies included medication reviews, shared decision making processes and/or a focus on patient care priorities, active involvement of a multidisciplinary team, training for healthcare professionals, electronic clinical decision support tools or websites, patient facing deprescribing educational materials, and involvement of family ( fig 7 ). Below, we summarize the intervention and key findings from each randomized controlled trial according to setting. We highlight whether study interventions were found to have a significant impact on at least one primary outcome assessed; or if not, at least one key secondary outcome; or none, and report on that impacted outcome ( figs 3-7 ). Within setting, we also organize the studies based on the components included in the intervention. This categorization is helpful in framing our findings, but not absolute, as there could be overlap and variation in how much focus was given to each of the components.

Primary care

Historically, medication reviews with the patient have been a common approach to optimizing drug treatment management among older adults with polypharmacy in the primary care setting. These medication reviews typically consist of a healthcare professional, such as a pharmacist, reviewing a patient’s list of drug treatments, identifying potential drug related problems, meeting with the patient, and providing recommendations to the patient, physician, or both. Medication reviews can be broad in nature and include patient education and/or drug treatment changes such as reductions in dose, discontinuing a drug treatment, or adding drug treatments when appropriate. In our review, two thirds (10 of 15) of primary care interventions centered around medication reviews, and all affected at least one primary or secondary outcome (with a majority (7 of 10) affecting the primary outcome; figs 3-7 ).

Medication reviews can vary depending on how the drug treatment data are collected, who is performing the review, and the extent to which follow-up is performed, along with whether additional components (such as training for the healthcare professional) are provided. In one study, a medication review conducted by a pharmacist based on a questionnaire completed by patients led to a larger reduction in the number of drug treatments in the intervention group versus the control group at 12 months (p<0.046; primary outcome). 60 In another study, pharmacist conducted medication reviews were preceded by a three day training course for pharmacists and succeeded by six month follow-up with the patient. 61 Recommendations were made to patients, their physicians, or both, and this intervention led to a greater reduction (0.21 ± 0.06 drugs, 95% confidence interval 0.092 to 0.335) in the number of drug treatments in the intervention group compared with the control group, improved quality of life in the intervention group (p<0.001), and a dominant strategy in a cost–utility analysis (all primary outcomes).

In addition to healthcare professional training, another component commonly added to medication review interventions was the active involvement of a multidisciplinary team, which can improve communication and minimize provider barriers around uncertainty in role regarding changes to the patient’s drug treatment regimen. In one such medication review intervention, a primary care provider would send records to a homecare specialist, who would collect information to help inform a pharmacist’s medication review. This medication review was then followed up with recommendations that were sent back to the homecare specialist and primary care provider. 62 This intervention was found to decrease the mean drug treatment appropriateness index score (indicating improvement in appropriateness) from the control phase to the intervention phase at 15 months (p≤0.001; primary outcome). In another medication review intervention, the multidisciplinary team included a geriatrician and a family practitioner who met after a medication review and clinical geriatric assessment. This intervention led to a higher mean health related quality of life (HRQoL) score in the intervention group versus the control group (p=0.03; primary outcome). 63

Yet another component added to medication reviews was an electronic decision support website and a focus on patient care priorities or shared decision making, which can align deprescribing decisions with patient goals, facilitate communication between patients and providers, and reduce uncertainty in the deprescribing process. In one study, general practices were given access to a website that provided an educational module and template for general practitioners to conduct medication reviews that identified potentially inappropriate medications, opportunities for deprescribing, and patient priorities for care. 64 This study found a larger reduction in the number of drug treatments in the intervention group versus control group at six months (p=0.045; primary outcome). In a second study, general practices were given a deprescribing guideline and training sessions on family conferences, during which a medication review took place with a frail patient and their family caregivers. 65 While no effect was found on the primary outcome (number of hospitalizations in 12 months), the number of drug treatments (p=0.001) and number of potentially inappropriate medications (p=0.04; secondary outcomes) were lower in the intervention group than in the control group at six months.

Four more medication review interventions involved both multidisciplinary teams and focused on patient goals or shared decision making. In one of these studies, community pharmacists conducted medication reviews with patients with a drug burden index of ≥1 and subsequently met to discuss with the patient’s general practitioner, with patient expectations and desires as key elements in final decisions. 66 This study did not find an impact in the proportion of patients who reduced their drug burden index by ≥0.5 at three months (primary outcome), but did find an impact on cognitive function (p=0.021) and fewer sedative side effects (p=0.024; secondary outcomes). Another study included a medication review by three experts (internal medicine specialist, clinical pharmacologist, and evidence based medicine expert) who provided specific recommendations for drug discontinuation to a general practitioner, who was invited to act on the recommendations based on a shared decision making process with the patient. 67 This intervention was not found to affect hospital admissions or death (primary outcome) but did lead to fewer falls (p=0.04; secondary outcome). In a third study, a pharmacist performed a medication review with the final decisions agreed upon by both the physician and the patient in a face-to-face visit. This intervention led to fewer drug treatments (p=0.001) immediately after the review, and a greater likelihood of drug treatment discontinuation, dose adjustment, and substitution at three, six, and 12 months (primary outcomes). In a fourth study, the medication review conducted by the pharmacist incorporated goal setting by the patient and was followed up with face-to-face meetings with the patient’s general practitioner and discussion and follow-up with the patient. Compared with the control group, this intervention led to an improvement in HRQoL (3.4 points, 95% confidence interval 0.94 to 5.8, p=0.006) and a reduction in the number of health problems with moderate to severe impact on daily life in the intervention group (−0.34 problems, 95% confidence interval −0.62 to −0.044, p=0.024) at six months (primary outcomes).

Beyond medication reviews with patients, other interventions focused on patient facing deprescribing educational materials, 2 deprescribing clinical decision support tools, 3 or both. 1 Patient facing deprescribing educational materials can empower patients to take a more active role in deprescribing decisions, thereby serving as facilitators to deprescribing. Of the two interventions focused on patient facing deprescribing educational materials, one was focused on benzodiazepines and provided specific information around the risks of benzodiazepine use and a stepwise tapering protocol. 68 This study was conducted by community pharmacies and reduced benzodiazepine use (27% of the intervention group discontinued benzodiazepine use v 5% of the control group, risk difference 23%, 95% confidence interval 14% to 32%) at six months (primary outcome). The other study mailed a general deprescribing educational brochure and questionnaire to patients with dementia or mild cognitive impairment and their family members prior to a primary care visit. 69 This was coupled with clinician notification and deprescribing tip sheets, but the intervention was not found to impact the primary outcomes (ie, number of long term drug treatments or proportion of individuals prescribed ≥1 potentially inappropriate medication) at six months.

Deprescribing clinical decision support tools coupled with shared decision making processes can help overcome patient, provider, and system barriers to deprescribing. Two such studies applied clinical decision support tools that reviewed drug treatments, and identified potential problems for providers to then make subsequent treatment changes based on shared decision making with the patient. 70 71 Neither study was found to impact their primary outcome (ie, hospital admission or death within 24 months, drug treatment appropriateness at 12 months); however, one study did find a greater reduction in number of drug treatments (p<0.001), which was a secondary outcome. 70 A fifth study combined use of a clinical decision support tool in primary care clinics with individualized patient facing materials that included brief coaching on how to discuss concerns with the provider. 72 The intervention was found to be associated with significantly more active patient communication, facilitative clinician communication, and drug treatment related communication among patients and clinicians (primary outcomes).

At hospital discharge, four study interventions focused on sending deprescribing reports to clinicians 2 and medication reviews. 2 Interventions generating individualized deprescribing reports can help providers with specific, actionable steps in deprescribing, such as which drug treatment to deprescribe, level of priority (among multiple drug treatments that should be deprescribed), and how to taper and monitor. In one study, a deprescribing plan was generated by a study physician, 73 and in the second study, a report providing deprescribing opportunities was generated by clinical decision support software. 74 In the first study, the report was sent to the patient’s physician, and in the second study, the report was sent to physicians, pharmacists, patients, and family members. Although the second study was not shown to reduce adverse drug events (primary outcome), both interventions led to deprescribing, as evidenced by a greater reduction in the mean number of drug treatments after three months (−2.6 intervention group v −0.36 control group, mean difference 2.25, 95% confidence interval 1.18 to 3.32; primary outcome for the first study) or increased deprescribing within 30 days (29.8% control group v 55.4% intervention group, adjusted risk difference 22.2%, 95% confidence interval 16.9% to 27.4%; secondary outcome for the second study).

Two additional studies involved either a pharmacist 75 or a physician 76 conducting a medication review, and then sending recommendations to the patient’s general practitioner. In the second study, two intervention arms were tested to allow for further patient engagement in one of those arms (eg, a drug treatment record sent to the patient). 76 Across both studies, the interventions were not found to affect prescribing appropriateness, prescribing quality (eg, number of drug treatments, number of potentially inappropriate medications), or HRQoL (all primary outcomes). One study did report on implementation outcomes; for example, that 750 causes of drug related problems were identified, and that general practitioners implemented 42.4% of recommendations. 75

Nursing homes

The two interventions targeting nursing home populations were both medication reviews involving multidisciplinary teams including pharmacists, physicians, and nurses. The first intervention also optionally involved family members for patients with cognitive impairment, and was not found to reduce falls at six months (primary outcome), but was found to reduce mortality (p<0.001) and hospitalization (p<0.001; secondary outcomes). 77 The second study focused on older populations (aged ≥75 years) taking ≥10 drug treatments (specifically, ≥3 psychotropics), and was found to reduce the number of patients with ≥1 potentially inappropriate medication and the number of patients using ≥10 drugs at two months (p=0.007 and p=0.001, respectively; primary outcomes). 78

In summary, various deprescribing interventions in older adults with polypharmacy have been tested in randomized controlled trials across different settings, with most (15 of 21 studies) conducted in primary care settings. The majority of interventions centered around medication reviews, with a mix of including additional components, such as a focus on shared decision making and/or patient care priorities, multidisciplinary teams, training for healthcare professionals, electronic clinical decision support tools or websites, patient facing deprescribing educational materials, and involvement of family. Such diverse intervention components represent how complicated deprescribing is and what is needed to overcome the myriad of existing patient, provider, and system barriers to deprescribing. Medication reviews with patients were generally successful in primary care settings (7 of 10 studies showing an impact on at least one primary outcome, and all showing an effect on at least one primary or key secondary outcome), but not always successful in other settings such as the hospital (two of two studies not showing an effect on primary or key secondary outcomes), although the number of studies was very small. Great variation in the mix of intervention components, as well as diversity in study population, led to small sample sizes within each stratum, making it difficult to determine if one particular component was considered to be more or less successful. Ongoing randomized controlled trials of deprescribing interventions in older adults with polypharmacy will provide more evidence, and further patterns should emerge as the number of studies grows.

Primary outcomes assessed across studies included drug treatment related outcomes (13 studies), HRQoL or health problems with impact on daily life, clinical outcomes such as falls, emergency room visits, hospitalizations, and deaths, cost, and outcomes related to shared decision making or patient/clinician communication ( fig 8 ), and even greater diversity was observed in the secondary outcomes collected (see supplementary table 1). Of the 21 studies, just over half 11 reported a significant effect on at least one primary outcome. Another six showed an effect on at least one of the key secondary outcomes, and four did not show an effect on primary or key secondary outcomes. The variability in results can be attributed to not only heterogeneity in intervention, but also the choice of primary outcomes. Notably, several studies emphasized the inadequacy of using clinical outcomes like hospitalization and death as a sole measure for deprescribing success, owing to challenges in translating the impact of discontinuing drugs into such downstream outcomes. Several studies using HRQoL as their primary outcome, and one study focusing on shared decision making and patient-provider communication as its primary outcomes, further underscored the need for a more comprehensive understanding of appropriate key clinical endpoints in deprescribing interventions.

Frequency of primary outcome assessed and if an effect was shown.

Furthermore, variability in drug treatment related outcomes across deprescribing studies adds to the complexity. Among primary outcomes, drug treatment related outcomes included number of drug treatments; number or proportion of potentially inappropriate medications; medication appropriateness index, drug burden index or other prescribing appropriateness criteria; drug related problems or adverse drug events; drug treatment changes (such as discontinuation, dose adjustment, or substitution; and proportion with ≥10 drug treatments ( fig 9 ). This diversity hinders the comparison and generalization of findings, emphasizing the need for standardized measures. To tackle these problems, the use of core outcome sets can provide a standardized approach to outcome measurement and enhance comparability across diverse populations and settings in deprescribing research. 79 80 81 Commonly recommended outcomes within core outcome sets include drug treatment appropriateness, drug related problems, and hospitalizations associated with drug treatments, ensuring a more consistent and comprehensive evaluation of deprescribing interventions.

Frequency of specific drug treatment related primary outcomes.

In addition to outcome variability, difficulties such as overestimating intervention effects, limited provider acceptance, intervention spillover effects, and challenges in tracking pharmacy adherence in real world settings contribute to study variability. Recognizing the necessity of longer observation periods aligns with the complex nature of deprescribing interventions over time. Best practices for successful deprescribing interventions require targeting provider behavior change, employing methods to limit contamination effects in trials (eg, cluster randomized trials), powering studies for clinically meaningful effect sizes, and emphasizing longer follow-up periods. These practices contribute to a more robust understanding of deprescribing interventions and guide the development of effective strategies. While study follow-up periods varied ( fig 10 ), with six months being the most commonly used timeframe, and 22 of 25 primary outcome measures within 12 months, the question of whether deprescribing interventions have long term effects remains unanswered. Two studies with 24 months of follow-up conducted in general practices indicated effectiveness in reducing falls and the number of drug treatments taken, suggesting potential long term benefits. However, further evidence is needed to establish the sustained efficacy of deprescribing interventions over extended periods.

Frequency of follow-up period for primary outcome.

Emerging interventions

Four ongoing randomized controlled trials are testing deprescribing interventions in older adults with polypharmacy in Canada, Germany, and Ireland, and are all focused on older adults who are being seen in primary care practices ( table 1 ). The first two randomized controlled trials are investigating training for healthcare professionals. In the SPIDER cluster randomized controlled trial, targeting those taking ≥10 drug treatments in Canada, primary care practices will develop interprofessional learning collaboratives and work with quality improvement coaches. 54 55 The intervention will be compared with usual care, and the primary outcome will be reduction of potentially inappropriate medications at 12 months. Secondary outcomes include cost effectiveness, as well as patient and care provider perceptions of the intervention.

Characteristics of ongoing deprescribing randomized controlled trials in older adults with polypharmacy

• View inline

Next, the PARTNER cluster randomized controlled trial in Germany targeting patients using ≥1 psycholeptic, sedative, or anticholinergic drug treatments comprises a multilevel, multicomponent intervention. 56 Firstly, educational material will be provided for general practitioners and pharmacists on deprescribing psycholeptics, sedatives, and anticholinergics, and a moderated interprofessional workshop will take place. Secondly, leaflets will be used to encourage patient empowerment during a patient-pharmacist consultation. Thirdly, a patient-general practitioner consultation involving shared decision making will take place. This intervention will be compared with usual care, plus a patient-pharmacist consultation updating plans for drug treatment (but without a focus on psycholeptics, sedatives, or anticholinergics). The primary trial outcome will be reduction in exposure to psycholeptics, sedatives, or anticholinergics as measured by a point reduction of ≥0.15 in drug burden index at six months. Secondary outcomes include drug treatment related outcomes, such as frequency of deprescribing and frequency of other potentially inappropriate medications as well as quality of life and clinical outcomes such as falls, fall related hospitalizations, cognition, and insomnia.

Two additional trials are testing interventions focused on medication reviews. In the TAPER randomized controlled trial targeting those ≥70 years in Canada, a multidisciplinary comprehensive medication review focused on reducing drug treatment burden and conducted by pharmacists and physicians with patients will be compared with usual care. 57 The primary outcome will be the number of drug treatments at six months and there are numerous secondary outcomes related to drug treatment use (eg, successful discontinuation or dose reduction, changes in drug treatment side effects and symptoms), quality of life, clinical outcomes like cognition, physical functional ability, and falls, healthcare resource use and cost effectiveness, and patient-reported deprescribing measures, such as confidence in drug treatment discontinuation and experience with the deprescribing process.

Lastly, a cluster randomized controlled trial in Ireland will use targeted medication reviews, in which pharmacists will meet with both patients and prescribers. 58 59 The intervention will be compared with usual care, and the primary outcome will be the number of potentially inappropriate medications at four months. Secondary outcomes include drug treatment related outcomes (eg, polypharmacy, drug treatment changes, adverse drug reactions, adverse drug withdrawal events), quality of life, and patient reported deprescribing measures (eg, patient attitudes toward deprescribing and the necessity of drug treatments).

In summary, four ongoing randomized controlled trials are being conducted in primary care practices, with a mix of intervention components such as medication reviews, patient empowerment leaflets, and training for healthcare professionals. The primary outcomes are all drug treatment related, such as reduction in potentially inappropriate medication or based on a score measuring drug treatment appropriateness (eg, medication appropriateness index or drug burden index), and are measured over 4-12 months of follow-up. Secondary outcomes are numerous, and include newer patient reported deprescribing measures (eg, attitude toward deprescribing and confidence in drug treatment discontinuation), as well as implementation outcomes (eg, costs, and patient/provider perception of, experience with, and satisfaction with the deprescribing intervention).

Deprescribing guidelines, algorithms, and additional resources have been developed in recent years for specific drug classes such as proton pump inhibitors, 82 diabetes drug treatments, 83 antipsychotics, 84 benzodiazepines and Z drugs, 85 and dementia drug treatments 86 by the deprescribing.org research team. 87 Another research team has also developed deprescribing guides for antidepressants, anticholinergics for Parkinsonism, antimuscarinics, sedating antihistamines, and opioids. 88 Medstopper is a freely available web based tool that provides recommendations related to tapering and more. 89 Additionally, countries such as Wales have produced guidance documents around management of polypharmacy in older adults, including recommendations on how to deprescribe specific drug classes. 90 Not all drug classes have deprescribing guidelines, and evidence is still needed to support recommendations around optimal tapering and monitoring strategies. While a previous review identified several drug classes at increased risk of adverse drug withdrawal events, 91 further evidence (such as through deprescribing trials) is needed to better understand the risk and severity of adverse drug withdrawal events after deprescribing, how this varies, and how to minimize these potential risks. 92 To help fill these evidence gaps, multiple deprescribing networks are growing in Canada, 93 Australia, 94 the US, 95 and Europe. 96

Additionally, disease specific guidelines are also beginning to include consideration of discontinuation or de-intensification of treatment, especially among older adults with multiple comorbidities and polypharmacy. For example, the American Diabetes Association guidelines and the American Geriatrics Society guidelines both recommend de-intensification of diabetes drug treatments and individualized glycemic targets among older adults with multiple comorbidities. 97 98

Polypharmacy in older adults is associated with an increased risk of using potentially inappropriate medications, 9 10 and several guidelines relate to potentially inappropriate medications. These guidelines include the Beers criteria in the US, 99 the STOPP/START (screening tool of older persons’ prescriptions/screening tools to alert doctors to right treatment) criteria in Europe 100 and Japan, 101 the PRISCUS list in Germany, 102 the European Union (7) potentially inappropriate medications (EU(7)-PIM) list which was developed by experts from seven European countries, 103 STOPPFrail (screening tool of older persons’ prescriptions in frail adults with limited life expectancy) criteria in frail populations with limited life expectancy, 104 RASP, 105 and NORGEP. 106 Other approaches and tools developed to help clinicians determine drug treatment appropriateness include the drug burden index, 107 the anticholinergic risk scale, 108 the medication appropriateness index, 109 and the medication regimen complexity index. 110 Across study interventions identified in this review, the most commonly used guidelines to identify potentially inappropriate medications were the STOPP, STOPP/START or STOPPFrail criteria (7 of 21) and Beers criteria (6 of 21; fig 11 ). Other ways to identify potentially inappropriate medications were based on country specific guidance, drug interaction databases (eg, LexiComp, UpToDate), EU(7)-PIM, NORGEP, or targeting specific drug classes such as benzodiazepines or opioids.

Frequency of guideline used to identify potentially inappropriate medications. STOPP=screening tool of older persons’ prescriptions; START=screening tool to alert doctors to right treatment study. *Included country specific guidelines, the EU(7)-PIM list, NORGEP, drug-drug interaction databases (eg, LexiComp, UpToDate), and targeting specific drug classes like benzodiazepines and opioids. †Study interventions could apply more than one guideline.

Furthermore, quality measures have also been used over the years to discourage potentially inappropriate medication use. For example, in the US, the Centers for Medicare and Medicaid Services has evaluated potentially inappropriate medication use in older populations through various quality measures for Part D prescription drug insurance plans, either generally (eg, high risk drug treatments in older people largely based on Beers criteria), or focused on specific drug classes and disease states (eg, antipsychotic use among older adults with dementia, multiple anticholinergic drug treatments, or multiple central nervous system active drug treatments in older adults with polypharmacy). 44 Prescription drug plans are incentivized to reach out to beneficiaries and reduce potentially inappropriate medication use to perform well on these measures, because these measures can potentially influence beneficiary enrollment and bonus payments. In 2022, a new quality measure focused on deprescribing benzodiazepines in older adults was developed, 111 indicating that future deprescribing quality measures could be used alongside guidelines to incentivize deprescribing at a large scale. Similarly, the Centers for Medicare and Medicaid Services also applies quality measures for nursing homes to monitor antipsychotic and sedative use. 112

In summary, recently developed deprescribing guidelines and algorithms have focused on collating evidence and providing recommendations (eg, whether and how to taper) for specific drug classes. A variety of potentially inappropriate medication guidelines to help identify inappropriate drug treatment use exists, and quality measures can be used to incentivize reduction of inappropriate drug treatment use. As disease specific guidelines begin to include deintensification of treatment and the number of studies testing various deprescribing interventions grows, future guidelines should report on the intervention components and implementation strategies that have led to successful deprescribing interventions, and how these vary across setting.

Conclusions

This review summarizes published and ongoing deprescribing randomized controlled trials in older adults with polypharmacy, and describes important barriers and facilitators to deprescribing, as well as guidelines and resources that can support deprescribing. Medication reviews in primary care settings continue to represent a majority of deprescribing interventions, with many interventions incorporating a mix of components. Other intervention components included a focus on shared decision making and/or patient care priorities, active involvement of multidisciplinary teams, training for healthcare professionals, patient facing educational materials, and involvement of family members, which shows how complicated deprescribing can be. Just over half of interventions were found to be efficacious based on assessment of primary outcome alone, suggesting that applying such intervention components can help to overcome barriers in deprescribing. Most outcomes were assessed within 12 months of follow-up, and varied widely: drug treatment related (eg, number of drug treatments or number of potentially inappropriate medications), clinical outcomes (eg, hospital, death), HRQoL, and more. Ongoing trials are focused on primary care settings and are adding newer patient reported deprescribing outcome measures (eg, attitude toward deprescribing and confidence in drug treatment discontinuation), as well as implementation outcomes (eg, costs, and patient/provider perception of, experience with, and satisfaction with the deprescribing intervention).

Questions for future research

How effective are deprescribing interventions in the long term (>2 years)? What patient, provider, and system factors are associated with reinitiating treatments following deprescribing, and how should these be dealt with? How sustainable are deprescribing interventions in real world clinical settings, and what are the associated costs (eg, to support staff)?

What is the ideal primary outcome and core outcome set? How might these outcomes be based on setting, deprescribing intervention component, and study population?

To what degree have patients been involved as stakeholders in the design of deprescribing interventions, and to what extent do they affect effectiveness and implementation? How might patient input affect measures around adverse drug events?

How does deprescribing differ across populations; for example, in under-resourced populations? How do social determinants of health and the influence of cultural traditions and provider bias limit the effectiveness and implementation of current deprescribing interventions?

How do system level barriers like uncoordinated health services delivery affect deprescribing? How do disparate healthcare access, mistrust in health systems, poor communication, and provider negligence in considering patients’/caregivers’ values, healthcare beliefs, and literacy levels affect patients’/caregivers’ deprescribing decisions?

What types of culturally tailored interventions, shared decision making, and educational tools specific to deprescribing are most effective?

How patients were involved in the creation of this article

We thank the US Deprescribing Research Network Stakeholder Engagement Core and the two patient stakeholders who provided valuable feedback, including specific future directions for the ‘‘Questions for future research’’ section.

Acknowledgments

AH acknowledges the US Deprescribing Research Network Junior Investigator Intensive Program and the AGING Initiative Multiple Chronic Conditions Scholars Program.

State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors.

Funding: AH is supported by VA HSR&D (Career Development Award IK2 HX003359) and by the US Deprescribing Research Network (R24AG064025). JMP is supported by a Career Development Award K23AG058788 from the National Institute on Aging.

Sponsor’s role: The funders had no role in the design, analysis, or preparation of the paper. The contents do not represent the views of the US Department of Veterans Affairs or the US Government.

Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: AH reports funding from the US Deprescribing Research Network (R24AG064025), honorariums and conference support from Academy of Managed Care Pharmacy, and honorariums from the Journal of Managed Care and Specialty Pharmacy. No other authors declare interests.

Contributing author statement: All authors made substantial contributions to the conception of the work, drafting/reviewing for important intellectual content, final approval of the version to be published, and agree to be accountable for all aspects of the work. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Provenance and peer review: commissioned; externally peer reviewed.

• Masnoon N ,
• Kalisch-Ellett L ,
• Gurwitz JH ,
• Harrold LR ,
• Gnjidic D ,
• Hilmer SN ,
• Roitto HM ,
• Akazawa M ,
• Igarashi A ,
• Oliveira MVP ,
• Shaver AL ,
• Aurelio LA ,
• Chiadika S ,
• Ter Meulen R
• Cadogan CA ,
• O’Donnell LK ,
• Thompson W ,
• Steinman MA
• Bloomfield HE ,
• Linsky AM ,
• Ibrahim K ,
• Stevenson JM ,
• Fraser SDS ,
• Charlesworth CJ ,
• Alramadhan F ,
• ↵ National Center for Health Statistics. Health, United States, 2016: with chartbook on long-term trends in health. Hyattsville, MD. 2017.
• Donohue JM ,
• Cevasco M ,
• Rosenthal MB
• Giardini A ,
• Menditto E ,
• Marques I ,
• ↵ Doherty AJ, Boland P, Reed J, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open 2020;4:bjgpopen20X101096.
• Schoenborn NL ,
• Maruthur NM ,
• Crutzen S ,
• Zechmann S ,
• Neuner-Jehle S
• Keller MS ,
• Carrascoza-Bolanos J ,
• Zimmerman KM
• Heinrich CH ,
• McCarthy S ,
• Le Couteur DG ,
• Beuscart JB ,
• Spinewine A
• Okeowo DA ,
• Zaidi STR ,
• Ailabouni NJ ,
• Schneider CR ,
• Bayliss EA ,
• ↵ Pharmacy Quality Alliance. PQA Measure Use in CMS’ Part D Quality Programs . 2011. https://www.pqaalliance.org/medicare-part-d
• ↵ Lown Institute. Eliminating Medication Overload: A National Action Plan . 2020. https://lowninstitute.org/wp-content/uploads/2020/01/lown-eliminating-medication-overload-web.pdf
• Vasilevskis EE ,
• Hollingsworth EK ,
• Uhlmann L ,
• Haefeli WE ,
• Grischott T ,
• Rachamin Y ,
• Rosemann T ,
• ↵ ClinicalTrials.gov. Pharmacist intervention to reduce post-hospitalization utilization . 2023. https://clinicaltrials.gov/ct2/show/NCT04071951
• ↵ ISRCTN registry. The general practice-based pharmacist: supporting medicines management in older adults . 2023. https://www.isrctn.com/ISRCTN18752158
• ↵ 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults . J Am Geriatr Soc 2023 ; 71 : 2052 - 81 . OpenUrl CrossRef
• ↵ ClinicalTrials.gov. SPIDER: A research & QI collaboration supporting practices in improving care for complex elderly patients (SPIDER) . 2022. https://classic.clinicaltrials.gov/ct2/show/NCT03689049
• Greiver M ,
• Dahrouge S ,
• O’Brien P ,
• ↵ ClinicalTrials.gov. Patient-centred deprescribing of psychotropic, sedative and anticholinergic medication in elderly patients with polypharmacy (PARTNER) . 2023. https://classic.clinicaltrials.gov/ct2/show/NCT05842928
• ↵ ClinicalTrials.gov. Team approach to polypharmacy evaluation and reduction (TAPER-RCT) . 2022. https://classic.clinicaltrials.gov/ct2/show/NCT02942927
• Moriarty F ,
• ↵ ISRCTNregistry. The general practice-based pharmacist: supporting medicines management in older adults . 2020. https://www.isrctn.com/ISRCTN18752158
• Lenander C ,
• Elfsson B ,
• Danielsson B ,
• Hasselström J
• Jódar-Sánchez F ,
• Malet-Larrea A ,
• Martín JJ ,
• Köberlein-Neu J ,
• Mennemann H ,
• Hamacher S ,
• Romskaug R ,
• Skovlund E ,
• Straand J ,
• McCarthy C ,
• SPPiRE Study team
• Mortsiefer A ,
• Löscher S ,
• Pashutina Y ,
• van der Meer HG ,
• Wouters H ,
• Mahlknecht A ,
• Wiedermann CJ ,
• Tannenbaum C ,
• Tamblyn R ,
• Benedetti A ,
• Shetterly SM ,
• Rieckert A ,
• Altiner A ,
• Ansorg AK ,
• Floriani C ,
• Niehoff KM ,
• Street RL ,
• Jennings E ,
• McDonald EG ,
• Rashidi B ,
• Basger BJ ,
• Olsson IN ,
• Runnamo R ,
• Bondesson Å ,
• Dalleur O ,
• Martin-Kerry J ,
• Millar AN ,
• Daffu-O’Reilly A ,
• Hughes CM ,
• CHIPPS Team, University of East Anglia
• Farrell B ,
• Bjerre LM ,
• ↵ deprescribing.org. Deprescribing guidelines and algorithms . 2023. https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
• ↵ NSW Therapeutic Advisory Group Inc. Deprescribing tools . 2021. https://www.nswtag.org.au/deprescribing-tools/
• ↵ Medstopper. Homepage . 2023 . https://medstopper.com/
• ↵ All Wales Medicines Strategy Group. Polypharmacy in older people: a guide for healthcare professionals . 2023. https://awttc.nhs.wales/medicines-optimisation-and-safety/medicines-optimisation-guidance-resources-and-data/prescribing-guidance/polypharmacy-in-older-people-a-guide-for-healthcare-professionals/
• Hanlon JT ,
• Canadian Medication Appropriateness and Deprescribing Network
• Australian Deprescribing Network
• US Deprescribing Research Network
• Network of European Researchers in Deprescribing
• American Diabetes Association Professional Practice Committee
• Mangione CM ,
• Vaisberg E ,
• American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus
• By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel
• O’Mahony D ,
• Cherubini A ,
• Guiteras AR ,
• Mizukami K ,
• Working Group on Guidelines for Medical Treatment and its Safety in the Elderly
• Schmiedl S ,
• Thürmann PA
• Renom-Guiteras A ,
• Gallagher P ,
• Parsons C ,
• Van der Linden L ,
• Decoutere L ,
• Flamaing J ,
• Rognstad S ,
• Fetveit A ,
• Spigset O ,
• Wyller TB ,
• Simonsick EM ,
• Rudolph JL ,
• Angelini MC ,
• McGlinchey RE
• Schmader KE
• Bailey MJ ,
• ↵ National Committee for Quality Assurance. HEDIS MY 2023: See what’s new, what’s changed and what’s retired. national committee for quality assurance . 2022. https://www.ncqa.org/blog/hedis-my-2023-see-whats-new-whats-changed-and-whats-retired/
• ↵ Centers for Medicare and Medicaid Services. MDS 3.0 quality measures user’s manual (v16.0) . 2023. https://www.cms.gov/files/document/mds-30-qm-users-manual-v160pdf.pdf

• Open access
• Published: 10 May 2024

An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland

• Magdalena Jasińska-Stroschein 1 ,
• Justyna Dymek 2 ,
• Mariola Drozd 3 ,
• Olga Sierpniowska 4 ,
• Artur Jędra 5 ,
• Agnieszka Stankiewicz 6 ,
• Paulina Stasiak 1 ,
• Sylwia Cholewa 1 ,
• Magdalena Nowakowska 7 &
• Magdalena Waszyk-Nowaczyk 7  

BMC Medical Education volume  24 , Article number:  521 ( 2024 ) Cite this article

174 Accesses

19 Altmetric

Metrics details

Background. The New Medicine Service (NMS) was developed in England more than ten years ago, as a three-stage consultation led by community pharmacists to support patients taking new medication for a chronic disease. In Poland, the scheme was officially introduced in January 2023. However, its implementation into common practice has been presented with various obstacles, including the need to develop relationships with general practitioners, resolve the payment structure, and provide training with adequate supporting materials. Hence, written materials have been designed for use as an optional tool for counselling patients receiving an NMS in community pharmacies. Methods. The present study evaluates the ability of these materials to inform patients about the need to adhere to anti-hypertensive medication. A group of 401 randomly-selected adult visitors to pharmacies and/or healthcare centres were surveyed; one third had hypertension in their history. Results. The structure, grammar and readability of the text achieved the required threshold of 40% according to the Plain Language Index. The designed materials effectively informed the patients about anti-hypertensive medication, reflected in an increased score in a knowledge test, and were rated positively regarding information level, comprehensibility and presentation. Conclusion. The proposed material may serve as an additional, “patient-friendly” educational tool for use as part of an NMS.

Peer Review reports

The New Medicine Service (NMS) was introduced in England in 2011 by community pharmacists to support patients taking new medication for a chronic disease. Briefly, the NMS consists of a structured and documented one-to-one intervention comprising a set of three consultations, to be completed within the first four weeks of starting a new medication; its aim is to resolve individual patient specific drug problems by providing information, education and advice [ 1 ]. Recent findings indicate that the NMS offers various potential benefits, including supporting better medication adherence for chronically-ill patients, including these starting on cardiovascular medication [ 2 , 3 ]. Its educational function covers the supplementation and reinforcement of information provided by the prescriber, to help patients make informed choices about their care. An NMS was officially introduced in Poland in January 2023 by the present authors, as a three-stage, structured consultation supported by a set of proposed documents (Fig.  1 ) [ 4 , 5 ]. The introduction was made possible by legislation in 2020 obliging pharmacists to provide pharmaceutical care. Pharmacists recently were presented with the opportunity to take a more patient-centred role beyond simply dispensing medicines by performing standardized pharmaceutical consultations (e.g., NMS), medication reviews, prescribing the fully-reimbursed drugs pro auctore and pro familiae , and administering COVID-19 vaccinations; however, the service faces many problems, particularly lack of financing. Nevertheless, cardiovascular disease (CVD) with arterial hypertension (HTN) is currently eligible for pharmaceutical consultation, including NMS.

New medicine service flow chart – Polish adaptation

CVD remains a predominant cause of illness and death globally [ 6 ]. Poor control of HTN has been correlated with a higher risk of cardiac abnormalities including myocardial infarction, stroke, ischemic and brain haemorrhage and peripheral arterial disease [ 7 ]. The prevalence of HTN is believed to be 32.5% among Polish residents between 18 and 80 years of age, and that among 10.8 million Polish patients suffering from HTN, only 2.6 million are receiving successful treatment. Current guidelines indicate one major cause of poor control of BP is non-adherence to treatment [ 8 , 9 ].

A variety of interventions aimed at improving medication adherence in HTN have been assessed to date. These approaches include patient education about medication therapies (e.g., their rationale, proven benefits, indications, contraindications, adverse reactions, dosage regimens), counselling about secondary lifestyle modifications (e.g., blood pressure control, alcohol and smoking cessation, exercise, healthy diet, etc.), as well as monitoring and risk screening [ 10 ]. Other tools could include adherence aids (pillbox which the patient practices filling, personalized illustrated medication schedule), event diaries (e.g., symptom monitoring diary cards) as well as educational booklets and leaflets (written, audiovisual or downloadable formats) [ 11 ]. Some of these tasks might be completed with different types of eHealth tools, including phone calls, blood pressure telemonitoring, emails, websites, smartphone applications and SMS [ 12 ].

The current paper evaluates the ability of a set of written educational materials to inform patients regarding adherence to anti-hypertensive medications. The analysis was performed on material introducing angiotensin converting enzyme inhibitors (ACEI) and thiazide/thiazide-like diuretics, the most popular first-line anti-hypertensive class agents in Poland. The materials, in Polish and English language versions, were designed to be downloaded from the national website for the NMS [ 13 ].

Study design and participants

The study was performed as an observational survey with Polish patients. It received ethical approval from the Bioethics Committee in Poznan (Poland) (KB 108/23). The study sample comprised a randomly-selected group of adults visiting pharmacies or healthcare centres. The inclusion criteria comprised an age of at least 18 years, and the ability to read the presented materials. No history of chronic disease including HTN was necessary. The study was performed over four months from February 1 to May 31, 2023.

The educational materials were created according to the current summaries of product characteristics (SmPCs), guidelines and recommendations [ 7 , 14 , 15 ]. They were then subjected to preliminary review by an interdisciplinary team of physicians and pharmacists, and evaluated with regard to their language content. All materials and their graphic design (Canva Pro) were prepared by the authors of the paper.

The materials consisted of leaflets introducing five classes of first-line hypertensive drugs: thiazide/thiazide-like diuretics, angiotensin converting enzyme, angiotensin II receptor antagonists, calcium channel blockers and beta-blockers. The readability of the language (Polish version) was evaluated according to the Plain Language Index (PLI) available at https://logios.dev/ ; the tool evaluates the text with regard to simple Polish language [ 16 ].

In detail, the PLI index measures ten style features, with 10% points being available for each feature. The material exceeds the PLI threshold of ≥ 40%. However, it is important to note that the algorithm does not verify the substance of the text. The following categories were evaluated by the PLI index: (1) FORMAL (whether the language style is formal and official); (2) TERMS (two-word SPECIALIST EXPRESSIONS: noun + adjective); (3) TOP100 (most frequent words in the text); (4) DWORDS (difficult – rare and long words); (5) PRON (pronouns in the text); (6) N/V (nouns/verb ratio); (7) GRAM (inadequately-used grammatical forms); (8) ASL (sentence length); (9) SENDER (how often the sender reveals their “presence” in the text, by using the words: “me”, “mine”, “our”); (10) RECEIVER (how often the sender addresses the recipient directly, by using the words: “you”, “your”, “take”).

The material, regarding HTN treatment, was then tested in an observational trial. The participants were informed of the nature of the study and that participation was voluntary, confidential and anonymous. All gave their consent to take part. They were asked to read the material, and then complete the test (see below). The participants received an individual five-minute consultation to explain the purpose of the survey and how to complete the documentation. The knowledge test was completed twice, i.e. before being presented with the material (PRE-TEST) and after reading it (POST-TEST). In addition, at the end of the study, the participant completed a questionnaire about their overall rating of the material and various aspects, such as its presentation and readability. Although the participants were not given a time limit to familiarize themselves with the material or to complete the questionnaire, the researcher recorded the time spent reading the leaflet, as well as any comments about the overall comprehensibility of the proposed material. The participants familiarized themselves with the educational material and completed all the questionnaires at the survey location, i.e. community pharmacies or healthcare centres. Only fully-completed questionnaires were included in the analysis.

Instruments

a) The educational material comprised several paragraphs concerning the following topics: the criteria for the diagnosis of HTN, blood pressure monitoring, HTN therapy management. It also focussed on a particular therapeutic agent, its mechanism of action, indications, side effects, special warnings, information for special groups of patients, such as pregnant or nursing mothers, as well as the proper usage of the medication. The material was designed with the possibility of personalization, as it provided a space to complete the patient name, medication brand name and dosage according to general practitioner (GP) recommendations, as well as additional pharmacist information. The final version of the material, including the preliminary language check and comments from the participants, is given in Appendix B (Figures B1 − B5).

b) Specific knowledge test. This quiz included thirteen questions intended to verify that the participants understood the proper use of the hypotensive medications (thiazide/thiazide-like diuretics or angiotensin converting enzyme inhibitor) given in the material. The first six questions (questions 1 to 6) required the participants to indicate one answer out of four. The next two multiple-choice questions required them to choose from eight possible answers, with more than one answer being correct (questions 7 and 8). Finally, the next five questions were true/false statements, with the study participants indicating one of three options: true , false or I do not know (questions 9 to 13) (see Appendix A ).

c) A questionnaire for subjective appraisal of the educational material. The tool contained three sections. The first consisted of five multiple-choice questions about age, gender, place of residence, education and history of chronic disease. The second included eight statements about the attitudes of the respondent toward the proposed educational material, including its readability, sufficiency of provided information, comprehensibility and presentation; the responses were based on a 5-point Likert scale. The respondents were also asked to subjectively rate their knowledge about hypotensive medication before and after reading the leaflet. The possible responses were arranged on a five-point scale ranging from “strongly disagree” (1 point) to “strongly agree” (5 points). The Likert Scale was proposed as it allows respondents to self-report the extent of their agreement or disagreement with a statement; such an approach might reveal subtle differences in subjects’ opinions, instead of a simple “yes” or “no” answer. The last section included two open-ended questions about participant comments concerning the educational material.

The knowledge test and the subjective appraisal of the material did not require information about the health of the respondent (quality of life, chronic disease management or well-being). However, one question enquired into any history of chronic disease, with the aim of differentiating the patients into subgroups for further analysis, i.e. subjects with history of HTN and the remaining ones.

All the materials were provided in Polish and were translated into English. The knowledge test was constructed randomly and subjectively by a seven-member panel comprising interdisciplinary academic experts with relevant expertise and experience within Pharmacy education (panels: pharmacotherapy, pharmaceutical care, drug information and communication), as well as community pharmacists with experience in patient counselling. The panel proposed a list of 25 common questions about the indications, contraindications, side effects, special warnings and proper usage of hypotensive medications; these were prepared according to their prior experience with non-adherent patients who may had misunderstood other informative materials such as patient information leaflets (PILs). Finally, this list was shortened to 13 that were included in the final version of the knowledge test. Any disagreements regarding the selection or interpretation of questions were resolved through verbal discussion until consensus was reached.

To test the questions and reduce the risk of any misunderstanding or misinterpretation, the materials and instruments were pre-tested on a sample of 10 randomly-selected respondents from the target population. Their responses were used for further clarification of the materials before the beginning of the survey and hence were not included in the subsequent analysis.

Data analysis. The results were analysed with STATISTICA 13.1 software (StatSoft Polska Sp. z o.o. 30–110 Kraków, Poland). Selected categorical socio-demographic variables were compared with the chi-square test. To identify participant attitudes toward the material, the non-parametric Kruskal–Wallis one-way analysis of variance was used to compare the mean ranks for quantitative responses (1–5 points), according to a set of covariates (e.g., history of HTN).

For each question in the knowledge test, any change in understanding about anti-hypertensive drugs associated with the learning material was assessed with the Cochrane Q-test. For this purpose, an individual correct response, given by a particular respondent in the PRE- and POST-TEST, was awarded 1 point, and an incorrect answer with 0 points. The total score achieved by a particular respondent, before and after reading the material, was presented as a percentage of possible correct answers, where 100% indicated a flawlessly completed test. The absolute difference between total scores achieved before and after reading the material was calculated, and then analysed using one-way analysis of variance (ANOVA) or Kruskal–Wallis one-way analysis of variance, with post hoc comparisons according to subgroups, e.g. male vs. female. The normality of the distribution of a parameter was checked with the Shapiro-Wilk test, and the homogeneity of variance with the Brown-Forsythe test. Correlation analyses were performed using the non-parametric Spearman’s test. A P -value of less than 0.05 was considered statistically significant.

A total of 401 patients completed the survey, i.e. with a 100% response rate; these were randomly allocated to the thiazide/thiazide-like diuretic (D) and angiotensin converting enzyme inhibitor (A) group. More detailed demographic characteristics of the study participants are presented in Table A1 (Appendix A ). Of the group, 32.8% reported a history of HTN and were reading material about thiazide/thiazide-like diuretics, while 29.0% were reading about angiotensin-converting enzyme ( P  > 0.05, difference between groups). None of the other covariates, including age, gender and education, differentiated the subgroups.

Language readability

After adjustment, the readability, grammar and structure of the proposed educational material were found to be suitable for specialist texts (i.e. ≥40% PLI) (Table A2, Appendix A ).

The knowledge test

The median time for learning the leaflet was six minutes (IQR; 6, 8), the knowledge test was completed within less than 10 min (pre-and post-test), and the approximate time spent on the survey was 20 min. The percentage scores obtained in POST-TEST and PRE-TEST are presented in Table A3 (Appendix A ). A significantly higher percentage of correct answers was found in the POST-TEST than the PRE-TEST ( P  < 0.001) with the exception of Question 6.

The median score achieved before reading the leaflet was 46.8% (IQR; 31.2, 60.0) for thiazide/thiazide-like diuretics, and 43.7% (31.2, 56.2) for angiotensin-converting enzyme inhibitors; this value increased significantly in the POST-TEST to 86.7% (73.3, 93.3, P  < 0.001 – vs. PRE-TEST) and to 75.0% (62.5, 81.2, P  < 0.001 vs. PRE-TEST).

Patients noted a subjective improvement in coping with the hypotensive drug (Fig.  2 ). No significant difference in basic knowledge about hypotensive drugs i.e., the PRE-TEST value, was found between the patients with a history of HTN and those without ( P  > 0.05) (Table A3, Appendix A ). Both hypertensive and normotensive respondents indicated that the educational material improved their knowledge about hypotensive medication (Fig.  3 ). No significant difference in the increase in total test score, and hence understanding, was found between hypertensive and normotensive patients ( P  > 0.05). The final outcome did not appear to be influenced by any other sociodemographic covariates ( P  > 0.05) (Table A4, Appendix A ).

The results of knowledge test before and after learning the materials (median and 25th − 75th quartile)

The knowledge about a drug in the subjective opinion of respondents (median and 25th − 75th quartile) ( a – d )

The patients with a history of HTN required a significantly longer median time to read the leaflet ( P  < 0.05). In both groups, i.e., thiazide/thiazide-like diuretics, and angiotensin converting enzyme inhibitor, participants with only primary or vocational education needed a significantly longer time ( P  < 0.001).

The educational material – appraisal

The participants found the educational material to be clear and well-presented, and provide sufficient information about medications for HTN. The overall rating of the educational material according to a 5-point Likert scale is given in Table A5 (Appendix A ). The final outcome was not differentiated by sociodemographic covariates ( P  > 0.05) (Table A6, Appendix A ). A significant correlation ( P  < 0.01) was found between the total score awarded by a particular respondent and the percentage improvement in leaflet understanding (Fig.  4 ).

Linear regression for the percentage increase in total score achieved in the knowledge test as a function of the overall rating of the educational material − given by each individual respondent ( a – b )

Our study presents a pioneering example of educational materials that community pharmacists can use as an additional tool when performing NMS. The role of community pharmacists has evolved for years in the US and some European countries, and now exceeds the traditional dispensing of medicines; however, in Poland, the process of implementing patient-centred approaches including structured counselling or medicine reviews has generally been very slow. For example, an NMS was only officially introduced in January 2023 [ 4 ]. Pharmacists attribute the reluctance to implement the service to the low availability of supporting materials, together with the need to develop relationships with GPs and the lack of payment structure.

Our findings indicate that the prepared leaflets successfully informed patients about their medications, with an approximately 35% higher score in the POST-TEST. Such evidence-based and critically-evaluated educational materials can support medication adherence by helping the patient make the decision to take medicines, and empower management of chronic therapy, as demonstrated in other studies on patients with asthma, diabetes or rheumatoid disorders [ 17 , 18 , 19 ]. As adherence is best ensured by multifaceted interventions, patient education should be accompanied by other approaches e.g., simplification of treatment regimens, and communication between patients and their health care professionals, follow-up and monitoring [ 10 ].

Each registered medication provides an information insert in its package, i.e. the PIL, which includes relevant data for use. Worryingly, only a third of patients fully understand the leaflet, while less than half usually read it [ 20 ], thus raising concerns of impaired disease management and reduced medication adherence. The materials proposed in our survey have been designed to support education about new medication, and feature simplified language and content. The latter covers various topics, including the basic and crucial aspects of blood pressure monitoring and HTN therapy management, as well as basic data on the product such as dosage, mechanism of action, indications, side effects, special warnings, information for particular groups of patients including pregnant or nursing mothers, special warnings and precautions.

Instead of sections introducing recommended dose and dosage schedules, the material provides a space that can be completed by the pharmacist according to the GP’s recommendations to indicate the dosage for an individual user. Many patients indicate that anxiety arising from reading about potential side effects can influence their withdrawal from treatment or reduce adherence [ 20 ]. Hence, the section introducing medication side effects has been shortened, with the assumption that the pharmacist can use additional materials for healthcare professionals e.g. SmPC, to provide a more personalised service when counselling the patient.

The first finding is that the material significantly improved patient knowledge about the hypotensive medication. This was true for all items except question no 6, introducing the situations where the patient should stop taking the drug immediately. Interestingly, the respondents were more likely to indicate that the patient must not discontinue the medication under any circumstances (60%), rather than discontinue when experiencing any of the noted serious side effects (swelling of the face, lips, mouth, tongue or throat, difficulty in breathing). In addition, the percentage of correct answers did not increase significantly after learning the material, emphasizing the need to discuss this aspect of drug safety with patients rather than provide written materials.

This was also true regarding awareness of the most frequent adverse effects of hypotensive medication. Patient knowledge about the side effects of hypotensive medication was relatively poor – even after reading the leaflet (≈ 50% of correct answers in POST-TEST), compared with the other sections. For example, asthma was regarded as the most frequent adverse event for ACEI (33%), probably due to mistakenly associating dry cough with asthma; this item could be explained more clearly by the health care professional. In addition, 10% indicated that oedema (swelling) was an adverse event for the thiazide/thiazide-like diuretics, which might indicate a misunderstanding in the mechanism of action: diuretics increase excretion of water and sodium by the kidneys, which can reduce oedema and lower blood pressure.

Although the respondents did not require any history of HTN to take part in the current survey, the participants were sorted into hypertensive and normotensive subgroups for analysis. Among the former, the median time for hypotensive therapy (since the diagnosis) was calculated as eight years. Interestingly, the comparative analysis did not reveal any significant differences in basic knowledge, i.e. before learning the material, regarding the rationale for hypotensive therapy, proper usage, overdosage or precautions for the hypotensive medicine. The analysis did not include any questions regarding mechanisms of action or side effects, which were specific to individual therapeutic groups, but focused on the basic rationale for anti-hypertensive therapy and general rules for its proper management.

The HTN patients only obtained higher scores when they were asked about the proper drug supply (swallowing with at least half a glass of water, question no 10). Surprisingly, they provided incorrect responses to question 1, i.e. that the hypotensive drug “sometimes lowers and sometimes decreases BP” (question no 1) (11%), question 2, i.e. what to do when missing a dose (38.4%), or question 6, when experiencing serious side effects (65%) (see above). In addition, some respondents would give their drug to the other person experiencing the same symptoms (question 12) (7.1%). These gaps in patient knowledge about medication can result in poor medication adherence, which is a well-recognized contributing factor of uncontrolled hypertension [ 21 ]. This is supported by studies indicating less than 50% of adherence to treatment, expressed as proportion of days covered, in as many as half of the cohort of patients [ 22 ]. This concerns especially first-line pharmacotherapy agents like thiazide/thiazide-like diuretics and spironolactone [ 23 ], where the most common reasons for withdrawal could be adverse effects of medication or impaired quality of life [ 24 ].

It is important to emphasise that our survey did not aim to assess the direct impact of the designed educational material on medication adherence. Nevertheless, recent data from hypertensive patients provide a good evidence that higher health literacy can be associated with better medication adherence, and even blood pressure control [ 25 ]. As such, regular patient education and counselling may address the gaps in knowledge indicated among the HTN patients in the present study, thus assisting them in making informed decisions regarding their care, and improving adherence. In general, this also highlights the need to involve Polish pharmacists in patient-centred activities.

The overall appraisal of the proposed material (amount of information, its presentation, readability) was positive. The language was checked and revised for better clarity and readability before the observational study. The participants had an opportunity to give their feedback regarding overall comprehensibility of the material. Some concerns regarded the terminology, and terms perceived as too technical were reworded; for example, ‘electrolytes’, were replaced by ‘potassium level’ or ‘sodium level’ as appropriate; the term for gout was explained by additional colloquial terms for this disease in Polish.

Interestingly, while overall appraisal was not influenced by covariates such as age, gender, education or history of HTN, respondents who gave higher ratings for the material tended to obtain better scores in the knowledge test. This result is in line with previous studies, where the participants claimed to have never ‘bothered’ to read the information included in the PILs for anti-hypertensive or diabetic drugs; their criticisms concerned the limited usefulness of the PIL due to poor readability (e.g., small font size), legibility, length, design, appropriacy of the content, and difficulty of technical language [ 19 ]. This might explain, at least partially, poor disease insight and non-adherence to HTN management [ 26 ]. The current observations also underline the need for comprehensive and “patient-friendly” educational leaflets as part of a wide spectrum of intervention tools aimed at counselling chronically-ill subjects.

The designed educational material was then used to train licensed Polish pharmacists. The six-hour online courses were performed by the present authors in cooperation with four Polish medical universities (Poznan, Lodz, Krakow, Lublin) and the Supreme Pharmaceutical Chamber and Polish Pharmaceutical Society. A total of 4000 pharmacists completed the certified course to perform the New Medicine Service. The course was aimed to (a) introduce the New Medicine Service as a form of pharmaceutical consultation; (b) present the standard operating procedures (SOP), together with the algorithm of service and proposed documentation; (c) present educational strategies for improving patient knowledge about diseases and treatment, including anti-hypertensive medications. The participants reported that they found the proposed material useful for effectively educating hypertensive patients about their disease and pharmacotherapy. Further studies have been planned to design and evaluate other materials that can be used by pharmacists to inform patients.

Limitations

The study has some limitations. The detailed analysis concerned only two subgroups of patients: those evaluating educational material for ACEI and for thiazide/thiazide-like diuretics. The materials concerning the remaining groups of antihypertensive agents (i.e., beta-blockers, calcium receptor antagonists and angiotensin type 2 receptor antagonist) were designed based on a similar scheme, including the language and layout. Also, many of the respondents had completed a high level of education (up to 42% of subjects); however, our findings do not indicate that education, or other demographic factors, influenced the final outcome in the survey.

Conclusions

The role of the pharmacist in caring for hypertensive patient encompasses medication management, education and counselling. This may concern self-monitoring of blood pressure, dietary modification, regular physical activity, as well as adherence to pharmacological treatment recommendations. Provision of adequate, appropriate and effective written educational materials, when integrated with other educational tool and interventions, and in cooperation with health care professionals, might increase the chance of successful disease management.

The materials designed for the present study successfully improved patient knowledge about anti-hypertensive medications, and were positively appraised with regard to their readability, sufficiency of provided information, comprehensibility and presentation. Polish and English language versions of the materials can be downloaded from the national website to support patient-centred activities performed by community pharmacists. However, our findings also indicate that patients with a history of HTN may have gaps in their knowledge about the disease and the treatment, indicating the need for more effective involvement by Polish pharmacists. Particular effort should be put into educating and counselling the patient about the safety profile of anti-hypertensive medications, and presenting management strategies for situations where they might experience any serious and/or life-threatening side effects. In Polish community pharmacies, these activities might be performed during drug dispensing, or as a part of an NMS or other pharmaceutical care services outside the dispatch room. However, the latter needs further financial support by the Polish government to make it a universal service.

Data availability

Data generated or analysed during this study are included in this published article and its supplementary information files.

Elliott RA, Boyd MJ, Tanajewski L, Barber N, Gkountouras G, Avery AJ, et al. New medicine service’: supporting adherence in people starting a new medication for a long-term condition: 26-week follow-up of a pragmatic randomised controlled trial. BMJ Qual Saf. 2020;29:286–95. https://doi.org/10.1136/bmjqs-2018-009177

Article   Google Scholar  

Hovland R, Bremer S, Frigaard C, Henjum S, Faksvåg PK, Saether EM, et al. Effect of a pharmacist-led intervention on adherence among patients with a first-time prescription for a cardiovascular medicine: a randomized controlled trial in Norwegian pharmacies. Int J Pharm Pract. 2020;28:337–45. https://doi.org/10.1111/ijpp.12598

Elliott RA, Boyd MJ, Salema NE, Davies J, Barber N, Mehta RL, et al. Supporting adherence for people starting a new medication for a long-term condition through community pharmacies: a pragmatic randomised controlled trial of the new medicine service. BMJ Qual Saf. 2016;25:747–58. https://doi.org/10.1136/bmjqs-2015-004400

Waszyk-Nowaczyk M, Jasińska-Stroschein M, Drozd M, Dymek J, Stankiewicz A, Jędra A. Guidelines for performing new medical pharmaceutical service. Position of the team for the standardization of pharmaceutical care of the chamber of pharmacy and the Polish pharmaceutical society. Warszawa: Naczelna Izba Aptekarska; 2024, https://opiekafarmaceutyczna.nia.org.pl/ [Accessed 11 February 2024].

Waszyk-Nowaczyk M, Dymek J, Drozd M, Sierpniowska O, Stankiewicz A, Jędra A, et al. New medicine service as support for medication adherence by chronically ill patients. Farm Pol. 2023;79:281–8. https://doi.org/10.32383/farmpol/172894

Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, GBD-NHLBI-JACC Global Burden of Cardiovascular Diseases Writing Group, et al. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020;76:2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010

Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, ESC National Cardiac Societies; ESC Scientific Document Group. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227–37. https://doi.org/10.1093/eurheartj/ehab484

World Health Organization. Disease burden and mortality estimates. www.who.int/healthinfo/global_burden_disease/estimates/en [Accessed 4 June 2023].

Świątoniowska-Lonc N, Polański J, Mazur G, Jankowska-Polańska B. Impact of beliefs about medicines on the level of intentional non-adherence to the recommendations of elderly patients with hypertension. Int J Environ Res Public Health. 2021;18:2825. https://doi.org/10.3390/ijerph18062825

Milosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: a systematic review. Int J Pharm Pract. 2018;26(5):387–97. https://doi.org/10.1111/ijpp.12462

Jasińska-Stroschein M, Waszyk-Nowaczyk M. Multidimensional interventions on supporting disease management for hospitalized patients with heart failure: the role of clinical and community pharmacists. J Clin Med. 2023;12(8):3037. https://doi.org/10.3390/jcm12083037

Cavero-Redondo I, Saz-Lara A, Sequí-Dominguez I, Gómez-Guijarro MD, Ruiz-Grao MC, Martinez-Vizcaino V, Álvarez-Bueno C. Comparative effect of eHealth interventions on hypertension management-related outcomes: a network meta-analysis. Int J Nurs Stud. 2021;124:104085. https://doi.org/10.1016/j.ijnurstu.2021.104085

https://nowy-lek.pl/ [Accessed 11 January 2023].

Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European Society of Hypertension: endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41:1874–2071. https://doi.org/10.1097/HJH.0000000000003480

https://rejestry.ezdrowie.gov.pl/rpl/search/public [Accessed 2 February 2023].

https://logios.dev [Accessed 2 February 2023].

Raynor DK, Savage I, Knapp P, Henley J. We are the experts: people with asthma talk about their medicine information needs. Patient Educ Couns. 2004;53:167–74. https://doi.org/10.1016/S0738-3991(03)00126-5

Hill J, Bird H. The development and evaluation of a drug information leaflet for patients with rheumatoid arthritis. Rheumatology (Oxford). 2003;42:66–70. https://doi.org/10.1093/rheumatology/keg032

Lee DY, Armour C, Krass I. The development and evaluation of written medicines information for type 2 diabetes. Health Educ Res. 2007;22:918–30. https://doi.org/10.1093/her/cym048

State of the Nation Report. https://kssahsn.net/wp-content/uploads/2023/03/State-of-the-Nation-Report-FINAL.pdf [Accessed 8 August 2023].

Hamrahian SM. Medication non-adherence: a major cause of resistant hypertension. Curr Cardiol Rep. 2020;22(11):133. https://doi.org/10.1007/s11886-020-01400-3

Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, ESC Scientific Document Group, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104. https://doi.org/10.1093/eurheartj/ehy339

Schulz M, Krueger K, Schuessel K, Friedland K, Laufs U, Mueller WE, et al. Medication adherence and persistence according to different antihypertensive drug classes: a retrospective cohort study of 255,500 patients. Int J Cardiol. 2016;220:668–76. https://doi.org/10.1016/j.ijcard.2016.06.263

Fogari R, Zoppi A. Effect of antihypertensive agents on quality of life in the elderly. Drugs Aging. 2004;21:377–93. https://doi.org/10.2165/00002512-200421060-00003

Health literacy in. Relation to health outcomes in hypertension: a systematic review. J Atherosclerosis Prev Treat. 2022;13:109–18. https://doi.org/10.53590/japt.02.1040

Di Palo KE, Kish T. The role of the pharmacist in hypertension management. Curr Opin Cardiol. 2018;33:382–7. https://doi.org/10.1097/HCO.0000000000000527

Download references

Acknowledgements

The authors gratefully acknowledge the assistance of Professor Tomasz Piekot from Plain Polish Lab (University of Wroclaw), in the evaluation of the readability of the language.

This work was supported by the Medical University of Lodz [503/3-011-02/503-31-002].

Author information

Authors and affiliations.

Department of Biopharmacy, Medical University of Lodz, Muszynskiego 1, Lodz, 90-151, Poland

Magdalena Jasińska-Stroschein, Paulina Stasiak & Sylwia Cholewa

Department of Social Pharmacy, Jagiellonian University Medical College, Medyczna 9, Kraków, 30-688, Poland

Justyna Dymek

Department of Humanities and Social Medicine, Medical University of Lublin, Al. Racławickie 1, Lublin, 20-059, Poland

Mariola Drozd

Hospital Pharmacy, Independent Public Health Care Institution in Szczebrzeszyn, Zygmunta Klukowskiego 3, Szczebrzeszyn, 22-460, Poland

Olga Sierpniowska

Council of District Chamber of Pharmacy, Zeromskiego 77/6, Warsaw, 01-882, Poland

Artur Jędra

Lubusz Pharmacy Chamber Council, Wojska Polskiego 37, Pharmacy, Zielona Góra, 65-077, Poland

Agnieszka Stankiewicz

Pharmacy Practice and Pharmaceutical Care Division, Department of Pharmaceutical Technology, Poznan University of Medical Sciences, Grunwaldzka 6, Poznan, 60-780, Poland

Magdalena Nowakowska & Magdalena Waszyk-Nowaczyk

You can also search for this author in PubMed   Google Scholar

Contributions

MJ-S and MW-N designed the work; SCh, PS and MN performed data acquisition; MJ-S analysed and interpreted obtained data; OS, JD, MD, AJ, and AS designed the formularies and educational materials; MJ-S and MW-N have drafted the work. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Magdalena Jasińska-Stroschein .

Ethics declarations

Ethics approval and consent to participate.

All experimental protocols were approved by the Bioethics Committee in Poznan (Poland) (KB 108/23). Informed consent was obtained from all subjects.

Consent for publication

Does not concern.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Jasińska-Stroschein, M., Dymek, J., Drozd, M. et al. An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland. BMC Med Educ 24 , 521 (2024). https://doi.org/10.1186/s12909-024-05523-x

Download citation

Received : 02 November 2023

Accepted : 06 May 2024

Published : 10 May 2024

DOI : https://doi.org/10.1186/s12909-024-05523-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Anti-hypertensive therapy
• Medication adherence
• Pharmaceutical care
• New medicine service
• Written educational material

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]