Introduction: Polypharmacy – i.e. the use of multiple medications – is correlated with increases in mortality, adverse drug events, falls, length of hospital stay, and rates of re-admission among the elderly. Polypharmacy has also been linked with non-adherence, and issues concerning the quality of care for this group of patients have been documented. To identify areas relevant to care provision from the perspective of the patients, our objective was to explore medication-related experiences in polypharmacy patients.
Methods: We systematically searched PubMed, Embase, and CINAHL up to June 2018 for primary qualitative studies about patient experiences with polypharmacy. Studies were appraised for their methodological quality by applying the Critical Appraisal Skills Programme (CASP) checklist for qualitative research, and data were extracted and synthesized using the meta-aggregation approach.
Results: We included 11 qualitative studies, representing 451 patients with polypharmacy and a wide range of chronic conditions. Overall, most items of the CASP checklist were reported in the studies. We extracted 113 findings, we synthesized these into 17 categories, and we developed five interrelated syntheses: 1) Polypharmacy patients are a heterogeneous group in terms of needing and appraising information, 2) The importance of adherence is self-evident but difficult to achieve, 3) Decision-making about medications is complex, 4) Multiple relational factors affect communication between patients and doctors and can prevent patients from disclosing important information, and 5) Polypharmacy affects patients’ lives and self-perception, and the challenges with polypharmacy are not only related to the practical issues of medication-taking.
Discussions/Limitations: Through this systematic review, we identified a plethora of medication-related experiences of polypharmacy that demonstrates the complexity and different needs of polypharmacy but also the shared challenges experiences by this patient population. Even though two researchers carried out the screening and sifting of articles, the quality appraisal, and the development of the categories and syntheses, the data extraction was carried out by a single researcher, which could have biased the results. However, we have applied the approach of meta-aggregation, which dictates a transparent reporting of findings, categories, and syntheses, making our analytical process clear to the reader.
Conclusion/Lessons learned: Polypharmacy has widespread consequences and poses many challenges for the patient. Challenges include difficulties in organizing medication-intake, navigating the healthcare system, and interacting with healthcare professionals. In addition, polypharmacy has a stigma attached to it and impacts the self-perception of patients. All these factors can potentially affect patients’ ability to follow medication regimens and influence their quality of life. It is central that healthcare professionals consider patient experiences to limit the negative effects on adherence, health, and well-being.
Suggestions for future research: Given that most of the included studies were of older patients with polypharmacy (60 years or older), future research should cover the entire age spectrum, as younger people with multimorbidity constitute a high number of the multimorbidity population. Also, research is needed into the effect of stigmatization on medication-related behavior, and ways to reduce the societal stigma of medication- and disease-related factors.

1. An introduction:
An ageing population, together with a greater awareness for atrial fibrillation (AF) screening, have increased the worldwide prevalence of AF. AF patients are known to have increased risk of heart failure and stroke, translating into greater mortality and lower quality of life. Current clinician-centric care based in tertiary hospitals may not be able to cope with this rising tide of AF. Much deliberation amongst health policymakers to move care of AF patients from acute settings to the community. The integrated care model together with the utilisation of Advanced Practice Nurses (APN) and technological tools, have been proposed as a possible solution.

2. Short description of practice change implemented:
In Singapore, the government polyclinics provide subsidised primary health care, outpatient medical care, health screening and pharmacy services. In September 2018, a novel Nurse-led Integrated Chronic care E-enhanced Atrial Fibrillation (NICE-AF) clinic was implemented in one of the polyclinics. The NICE-AF clinic is led by an APN. She works in collaboration with a Family Physician and has tele-consultations with a Cardiologist from a tertiary hospital. Stable chronic AF patients are referred to this clinic. AF management is optimised through technological tools such as a computerised decision support tool and educational resources. The NICE-AF clinic also receives priority listing for radiological investigations in the tertiary hospital.

3. Aim and theory of change:
Care for AF patients has conventionally been managed in hospitals’ outpatient specialist clinics. Commonly, AF patients have other chronic comorbidities. Hence, the NICE-AF clinic serves to integrate chronic care management. The Chronic Care Model guides the design of the clinic. The aim of the implementation is to improve clinical and patient-reported outcomes.

4. Targeted population and stakeholders:
Targeted population is patients living with AF. Stakeholders are policymakers, health administrators, physicians and advanced practice nurses.

5. Timeline:
Two years.

6. Highlights:
Preliminary findings has shown a great improvement in healthcare providers’ adherence to AF management protocol with the use of the computerised decision support tool. Initially, patients were apprehensive about seeing an APN for their AF condition. However, patients’ attendance for follow-up visits have been good and patients’ level of acceptance with the APN improved with time.

7. Comments on sustainability:
Sustainability of the NICE-AF clinic requires the patients and stakeholders to experience and see the value it brings to care.

8. Comments on transferability:
Great potential precursor to other clinics devised to optimise chronic disease management in the community.

9. Conclusions:
Preliminary findings found greater adherence to AF management protocol and patient satisfaction. No significance change was observed in clinical outcomes, AF knowledge, and medication adherence.

10. Discussions:
Despite the lack of improvement observed in most outcomes, the preliminary findings were heartening as it demonstrated that the NICE-AF clinic was not inferior to hospital outpatient services.

11. Lessons learned:
Patients in Singapore are accustomed to physician-centric hospital-based specialist care. The role of integrated care in the community requires greater publicity. With more time and exposure to such models of care, patients’ acceptance and trust will improve.