‘You would rather not fill your body with pills’—patient perspectives on polypharmacy and medication reviews by pharmacists in general practice

Abstract

Introduction

Polypharmacy is widespread. The demographic shift toward older patients receiving multiple medications increases risk and drug-related problems in these patients.

Objective

To investigate patient perspectives on polypharmacy and the experienced effects of medication reviews by pharmacists in general practice.

Methods

Twenty-two semi-structured interviews with patients with polypharmacy (>5 medications) from 6 different general practice clinics in the North Denmark region. The interviewees were from the intervention arm of a randomized clinical trial and had received a medication review with a pharmacist in addition to the usual annual check-up in general practice. Participants were interviewed at baseline (no later than 2 weeks after the medication review) and again at follow-up (6 months after the medication review). The interviews were transcribed verbatim and thematically analyzed with an inductive approach.

Results

The patients’ narratives show that they face many difficulties in their everyday lives, making it hard for them to live up to society’s ideal of what it is to live a healthy life. The interviewees were generally positive toward the intervention and felt comfortable having a pharmacist conduct the medication review in their usual general practice clinic. Some interviewees gained more insight into their medication from the review.

Conclusion

Patient narratives give a comprehensive understanding of the challenges of polypharmacy. Having pharmacists conduct medication reviews in general practice could ensure more time and focus on patients and their medication management. The combined knowledge of physicians, nurses, and pharmacists regarding thorough polypharmacy management is recommended.

Introduction

The number of people aged over 60 is increasing due to economic, scientific, medical, and technological progress. One challenge related to this development is that older people have an increased risk of multimorbidity, and more are becoming patients with polypharmacy [1]. There is not yet a universal definition of polypharmacy, although it is commonly agreed to refer to patients who receive and use more than five different kinds of medicine simultaneously [2–4]. A patient with polypharmacy is exposed to many different medication prescriptions, and this increases the risk of drug-related problems with adverse events [5–7]. It is estimated that 5–30% of hospital admissions are because of drug-related problems [8–13]. Receiving multiple different medications increases the risk of drug-drug interactions [14–16] and potential problems with medication adherence, especially in older patients. It should, therefore, be the goal that all patients receive only the most appropriate and targeted medication [4,17–19]. Being a patient with polypharmacy can cause emotional distress and can be experienced as a burden that affects patients’ quality of life, which is illustrated in a study from the northwest of England. The study showed that some patients with polypharmacy feel that the routine of taking medication interrupts their lives in terms of restrictions on social activities, outings, and holidays [20].

In 2017, the World Health Organization (WHO) launched an initiative called Medication Without Harm, which addressed the increasing number of patients with polypharmacy and medication errors, and became a theme for WHOs third Global Patient Safety Challenge [21]. WHO’s key point for polypharmacy management involves the combined knowledge of physicians, nurses, pharmacists, and other healthcare professionals and the systematic involvement and empowerment of patients [22]. Patient medication reviews undertaken by pharmacists have been recommended as ways to improve both the quality of prescribing medicine to older people and reduce the risk of drug-related problems [6,23].

Although there is extensive knowledge about how people with multimorbidity live and manage their everyday lives [24–28], we found few studies that focus on how people deal with the emotional and social effects of living with polypharmacy, with or without multimorbidity. Nor is there much knowledge on how patients with polypharmacy experience medication reviews conducted by pharmacists within a general practice setting. This study addresses those gaps.

Methods

Context

The Danish healthcare system is public and free of charge for all citizens, almost all of whom are listed with a general practitioner [GP] who is paid by capitation and fee-for-service reimbursements [29]. The standard procedure for patients who receive many kinds of medication in Denmark is to attend an annual check-up in general practice [30], which can include a medication review where the GP or practice nurse reviews the patient’s medication to determine if the treatment is still appropriate and, if anything is unnecessary, to see how it can be reduced or discontinued [31]. However, the increasing number of older people and people with more complex illnesses results in increased pressure in general practice, resulting in insufficient time for the GP to do thorough medication reviews with every patient with polypharmacy [1,32,33]. This could, therefore, present as an opportunity to remove a task from the GP and give it to other healthcare professionals within general practice.

The current study forms part of an intervention by The Quality Unit for General Practice in the North Denmark Region (Nord-KAP). The intervention involves pharmacists visiting general practices and educating nurses on medication. The pharmacists conduct medication reviews with patients with polypharmacy and make intervention plans for the patients, that get approved or declined by the patients’ GP. The general practice nurse attends the medication reviews with the pharmacist to learn about medication and to provide information about the patient’s medical history.

The intervention took place in nine general practice clinics and was conducted as a randomized controlled trial (RCT) with a 6-month follow-up. There were 523 patients with polypharmacy included in the RCT; 243 in the intervention group, and 280 in the control group. The intervention group received a medication review with a pharmacist and their usual practice nurse attending, along with usual care for patients with polypharmacy, which is an annual check-up. The control group received the usual care (the annual check-up). The RCT was pre-registered at clinicaltrial.gov (ClinicalTrials.gov Identifier: NCT04945447).

Interviews

The present study is an interview study with patients from the intervention group of the RCT, all of whom had attended a medication review with a pharmacist. Choosing only those patients who had participated in the medication review with a pharmacist allowed us to investigate how the review itself was perceived by patients, thereby getting firsthand impressions and outputs, which we could not have had from patients from the control group.

The inclusion strategy was to recruit female and male patients of different ages with polypharmacy. The inclusion criteria for the participating patients (interviewees) were that they received more than five different medical drugs, besides antibiotics and skin remedies, were aged 18 or over, were in continuous medical treatment, and were enrolled in one of the participating general practice clinics. The interviewees were recruited randomly from six of the nine general practice clinics in the RCT during the medication review itself if there was time left after the review. If not, the first author contacted randomly selected patients by phone after they had attended the medication review. Even though one of our inclusion criteria was patients aged 18 or over, none of the patients who received a medication review were that young, and only patients in their 40s and older were in a position to attend the interviews.

Data collection methods

The study consists of semi-structured interviews with 12 patients from the intervention group. Ten interviewees were interviewed at baseline, within two weeks of the medication review, and again at follow-up, 6 months after the medication review. The authors chose to interview the patients at baseline, so the patients could remember the medication review in detail and their health status before the review. In that way, it was possible to gain insight into the interviewees’ experiences with the medication review itself and into how it was to live with polypharmacy before the medication changes started to kick in. The follow-up interview allowed the opportunity for additional insights on whether the interviewees experienced changes in their health following the medication review, and how they might have learned something from the review. Two interviewees were only interviewed at baseline since the first author had lost contact with them 6 months after the medication reviews. However, data from the baseline interviews were still used in the analysis, resulting in a total of 22 interviews. After preliminary analysis of the first 12 interviews, the authors agreed that data saturation had been reached as patterns were repeating in the final few interviews [34]. The first author conducted all the interviews and each one lasted 30–40 min. The interviewees decided where the interviews would be held. Due to illness and COVID-19, eight of the baseline interviews and four of the 6-month follow-up interviews were held over the phone, and the rest were held in person. The follow-up interview with the last interviewee [interviewee 12] was held 10 months after baseline due to maternity leave. The interviewees comprised five men and seven women (Table 1).

Table 1.

Interviewee information and interview times (in months).

Interviewee information				Interview times
Interviewee number	Gender	Age at follow-up interview	Profession	Baseline	6 months follow-up
1	Female	70s	Retired	February 2022	August 2022
2	Female	50s	Working full time	February 2022
3	Female	80s	Retired	February 2022	August 2022
4	Male	60s	Early retirement	February 2022	August 2022
5	Male	40s	Working full time	February 2022	August 2022
6	Female	70s	Retired	February 2022	August 2022
7	Male	70s	Retired	June 2022	December 2022
8	Female	50s	Early retirement	May 2022	December 2022
9	Male	70s	Retired	May 2023
10	Male	70s	Retired	January 2023	June 2023
11	Female	50s	Working part time	January 2023	June 2023
12	Female	70s	Retired	June 2023	April 2024

A semi-structured interview guide was used, enabling the possibility of unforeseen perspectives to come forward and opportunities to follow the participant’s train of thought [35]. All the interviews were audio recorded on a Dictaphone and transcribed verbatim.

Data processing and data analysis

The authors analyzed the data with an inductive approach and conducted a thematic text analysis [35], which offers the opportunity for emergent themes and a flexible approach to analyzing qualitative data. The interviews were transcribed verbatim by the first author, and a medical student, and by the AI transcript program Whisper Transcription (https://openai.com/index/whisper/). The AI-generated transcripts were read and validated by the first author. The first step of the analysis was data familiarization through reading and re-reading all the transcriptions to get the first ideas. The initial codes were generated by highlighting words and phrases and taking notes, and later by using the software program Nvivo13. This was primarily done by the first author with collaboration and input from the remaining authors. Then the search for themes began and some of the initial codes became main themes while others were dropped. The authors considered whether the themes appeared to form a coherent pattern. When satisfied with the candidate themes, we re-read the entire data set to see if the themes worked, to code any additional data that had been missed earlier, and to make sure the themes fit with the overall research aim. The final themes were made in vivo coding, meaning that the interviewees’ citations appear as theme headings [35]. Themes 1–3 were informed by follow-up interviews and the fourth theme was informed by a baseline interview. See Figure 1 below for themes, codes, subcodes, and their relationships.

Figure 1.

The figure illustrates the final four themes (in blue), the codes (in white), and sub-codes (in purple) from the data analysis. The dotted lines represent which themes and codes are connected, and which subcodes are connected to which codes.

Researchers’ characteristics and reflexivity

The first author is a PhD student with a background in health promotion and psychology, she has a humanistic and health-oriented approach and is fundamentally interested in citizen/patient perspectives. Furthermore, she has experience with interviewing citizens/patients from earlier studies and her education. The second author is a professor and GP with an interest in implementing new technologies to improve workflow in general practice. The third author is an assistant professor in health economics and is particularly interested in how introducing new healthcare initiatives creates value for patients and the healthcare system in general. The fourth author is a professor and doctor in medicine with an interest in healthcare initiatives that create value for patients in the healthcare system and in the context of general practice. The final author is a senior researcher with a particular focus and expertise in qualitative research methods and is also interested in patient perspectives in general practice settings.

Theoretical approach

Psychologist Jerome Bruner argues that the way people act is associated with the world they live in and the contexts in which they participate. The self is created and re-created through the narratives people tell, and Bruner explains how the narratives are linked with the canonical, which relates to society providing a canon or a law to make sense of what other people are doing. Bruner argues that telling others about oneself is influenced by what we think others want to hear, or how ‘the self’ should be [36] and, therefore, canonical expectations of what is normal and a good way of living influence how people narrate their lives [36,37]. In this paper, we try to unfold the experiences of living with polypharmacy through the lens of narrative theory and we illustrate how the narratives told by the interviewees about their everyday lives were influenced by the canonical expectations of what an ideal healthy life is in society today.

In our analysis of the narratives, we are also inspired by anthropologist Cheryl Mattingly who argues that through narratives it is possible to get a personal perspective and insight into how it is to live with illnesses, which makes narratives well suited to the task of unfolding the phenomenological perspective of being ill and how bodily pain can shape a person’s life [38]. Mattingly introduces the term ‘chronic homework’, which refers to how patients with chronic illness (or their family members) are expected to manage their illnesses in their own homes [39]. The homework is exemplified by taking or giving medicine, administering injections, doing different exercises, and being aware of side effects, which are all elements reflected in the narratives of the interviewees in the present study. Being a patient with polypharmacy often relates to protracted illnesses, and therefore the chance of returning to ‘normal’ or to how one ‘used to be’ health-wise is slim. Personal identity becomes directly linked to the pain and stigma that comes with being ill [40]. Mattingly argues that narratives can create insights into people’s worlds and provide examples for possible futures. Furthermore, narratives can give coherence to all the negative aspects of being ill [40].

Finally, to further explore the burden of taking multiple medications and living with different illnesses, we are also inspired by medical sociologist Aaron Antonovsky’s theory of sense of coherence (SOC). SOC is associated with the health promotion field and the term salutogenesis, which focuses on the origins of health rather than disease. SOC theory relates to how people cope with and overcome stressors and challenges, and these abilities form our resistance resources [41]. A strong SOC is related to good health, good quality of life, and contributes to aging well [42]. In this study, the theory of SOC enables us to understand what the interviewees experience as stressors and what makes them feel a sense of coherence.

Results

Four themes were identified during the data analysis. The first theme is represented by the citation: ‘I am a set of Chinese porcelain, I cannot endure anything’. The second theme is: ‘I realized that the medication I receive is not crazy, there is more to it’. The third theme is: ‘The GP can’t be up-to-date with all the new medicine’; and the final theme is: ‘I know that I would be better off not taking any medication, but I have to have quality of life’.

‘I am a set of Chinese porcelain, I cannot endure anything’

The interviewees described different difficulties related to being a patient with polypharmacy, such as expensive medicine, new upcoming illnesses, long and multiple drives to general practice, and side effects, all stressors that can be difficult to overcome. Furthermore, interviewee 11 mentioned being very sleepy and having trouble remembering words and expressing herself after a stroke; she also finds everyday tasks difficult to overcome due to back pain:

For example, if I’m at home dusting, I sweat so much that I need to change all my clothes, like, just hanging the laundry, but I don’t know where it comes from… as soon as I feel the pain I start to sweat… I don’t respect myself anymore as the person I am because I cannot provide anything anymore… It’s always him [points to her husband] who does everything, he does most around here… He walks the dogs, he is the one cooking, he is the one cleaning.

The narrative indicates that interviewee 11 views being productive, providing, and contributing to the household as an important part of life. By saying she doesn’t respect herself anymore, she expresses a sense of failure to live up to the ideal way of living, but her illnesses make it difficult for her to accommodate all her former tasks. Her narrative indicates, however, that she tries to live up to the norm by keeping a part-time job, which is very important to her even though she needs several breaks during her 2-h shift and is not on the best of terms with her boss. Keeping a job is also important for interviewee 7 even though he retired years ago:

I’m driving for a grocery store. I started when I retired… I want to continue until… well as long as I can lift the things I need.

The citation indicates that interviewee 7 views having a job as part of his identity and could be linked to him being an inveterate contributor to society. Trying to live up to the norm also shows in interviewee 11’s narrative:

I have four dogs that I would like to be able to walk, but as soon as I’m in the street I’m already tired in my back and then I just want to go home… I do have my laundry, I take care of that.

As argued by Bruner, the canonical expectations of a good way of living influence how people narrate their lives [36,37], which is reflected in interviewee 11’s narrative. She implies that she tries to live up to the norm by doing or trying to do the physical things she was able to: working, walking a little, and doing her laundry. She expresses a sense of pressure, however, from the health care professionals at her general practice:

I just feel like, “you must walk, you must walk” they say, yes but like I can’t.

The previously mentioned sense of failure could be strengthened by the pressure interviewee 11 feels from the healthcare professionals’ nudging and her experience of society’s general canonical expectations of what it is to be healthy and active. The power of society’s view on good health is also prominent for interviewee 10, who lives with various illnesses but still says that his health is fine and mentions in the same sentence that he continuously walks to prevent weight gain.

An often-repeated feature of the interviews is that physical health-related difficulties that are connected to the interviewees being patients with polypharmacy, seem to stand in the way of practicing a healthy lifestyle. Interviewee 12 wants to go for walks and feels lonely but for physical health reasons, she is afraid to go to the retirement home where she has been invited to join different groups. She explains:

I have been thinking about going over to the retirement home… but last winter I got pneumonia five times because I also had chronic-obstructive-pulmonary-disease – the non-smoker kind, so I’m afraid to go such places. I have hunted high and low everywhere for a friend who wants to go for walks with me.

She also tried to do a workout once, but it did not last:

As I said to her [the trainer] I’m a set of Chinese porcelain I cannot endure anything.

The narrative reflects interviewee 12’s understanding of the ideal way to practice health – by being active and working out – but, like interviewee 11, her state of health makes it difficult to live up to her own and the canonical expectations of what a healthy lifestyle is. The narratives of interviewees 11 and 12 indicate a need to find coherence about why they cannot live up to the norms of an ideal lifestyle. The narratives hint that both interviewees have a low SOC, where their illnesses become life stressors that they have not found ways to overcome. Interviewee 12 also feels lonely, which she indicates is one of the reasons it is difficult for her to overcome the stressors associated with being a patient with polypharmacy. Concerning Mattingly and Lawlor’s point on narratives reflecting a person’s perspective on how bodily pain can shape a person’s life [39], interviewee 11 feels like she has changed a lot compared to how she was before taking all the different kinds of medication to relieve her back pain:

Before I was the one making the jokes, now I can sit for hours without saying a peep… I used to like making people laugh, but I also used to be a happy girl.

Interviewee 11’s narrative indicates that her social interactions and general mood have changed drastically since her back pain started. Furthermore, as argued by Mattingly, interviewee 11’s bodily pain becomes linked with her personal identity, such that she feels like it has changed her completely in a very negative way.

Some interviewees expressed opposite views, feeling that their health and need for medication did not correlate with or alter how they viewed themselves. A few would not call themselves sick even though they have chronic illnesses and/or multiple other illnesses and were therefore taking many different kinds of medication. For example, interviewee 3, an 80-year-old woman, stated:

Well I don’t call myself sick, I do have diabetes, yes, I do have that. I do have a chronic illness for which I need medication, but I don’t have any serious illnesses.

Interviewee 3’s statement suggests that for her there is a difference between needing medication for having a chronic disease and being seriously ill, which could indicate that the canonical understanding of being ill equates to feeling sick and being in bad shape physically, which some of the interviewees felt they were not.

‘I realized that the medication I receive is not crazy, there is more to it’

Most interviewees had lived with their illnesses for many years before participating in the intervention. Even though the broad definition of being a patient with polypharmacy is taking five or more different kinds of medication a day, many interviewees mentioned receiving a lot more than five different kinds. One interviewee takes 15 pills, another one, 17, and a third, 31 pills every day. The number of medications and different illnesses correlates to the amount of work the patient is expected to do at home [38]. In the baseline interviews, when the first author asked the interviewees what medication they received, half of them had trouble remembering the names or were unfamiliar with all the medication they received.

For example, interviewee 1, a 79-year-old woman, responded:

I don’t have it right here. Just a moment, I can’t remember – I get a lot of medication.

Likewise, interviewee 8, a 56-year-old woman, responded:

That’s a good question what it is I receive right now. It’s the thing with pronouncing the names, right? - I know the packages.

Having trouble remembering all the different kinds of medication could make it challenging to have control and be aware of the potential problems with drug-drug interactions, which is a risk among patients with polypharmacy [5–7]. Similarly, interviewee 2 could not keep track of all the different kinds of pills herself. Therefore, in contrast to most of the other interviewees, she did not intend to keep track of her own medication, she fully relied on her GP to do so.

The main element of the intervention in the RCT was the pharmacist conducting a medication review with the nurse and patient present, and some of the interviewees mentioned that they had gained more knowledge about their medication after the review. For example, when asked about it, interviewee 3 responded:

I realized that the medication I receive is not crazy, there is more to it.

In addition to being reassured that the medication she receives is right for her, she also felt like she was reminded about her illnesses and what she was being treated for, which she thought was positive. On the other hand, some interviewees did not feel like they gained more knowledge about their medication from the review. When asked interviewee 6 said:

No it has not [given me more knowledge], I actually know quite a lot about it [medication]… I familiarize myself with it when I get it.

Likewise, interviewee 10, who used to be a nurse, also felt that he already knew a lot about medication, which indicates that the people gaining knowledge and insight are the patients who knew little about their medication before the medication review.

‘The GP can’t be up-to-date with all the new medicine’

The interviewees were positive toward the intervention and several mentioned not having any worries regarding proposed changes in their medication. Furthermore, many interviewees expressed feeling comfortable having the medication review done by a pharmacist, even though they had never seen the pharmacist before and usually had their medicine checked by their GP. Almost all the interviewees believed that pharmacists have more knowledge of new medication and drug-drug interactions than a nurse and a GP. For example, according to interviewee 5:

It is not certain that the GP accurately knows, he might know the medical aspect, but he may not know whether a new type of medicine has arrived… The GP can’t be up-to-date with all the new medicine; however, I have the impression that the pharmacist knows more about what’s new.

Despite these reflections, interviewee 5 also stated that he would only have complete trust in the pharmacist’s advice on his medication if his nurse or GP were involved. Interviewee 4 had trouble placing a pharmacist in a general practice setting, as he felt pharmacists belong in a pharmacy. The two interviewees’ narratives indicate reservations regarding pharmacists doing medication reviews that are usually performed by the GP or nurse alone. The reservations could be based on the historical societal canon that pharmacists work in pharmacies and GPs and nurses work in general practice clinics. Therefore, the two interviewees’ perspectives suggest that it could take time for some patients to establish trust and adjust to pharmacists being part of a general practice setting.

Other participants, however, when asked for their opinions on the collaboration between pharmacists and general practice, expressed hope for future cooperation to secure maximum knowledge on the different types of medication. Furthermore, interviewee 7 shared another point related to why future collaboration between pharmacists and general practice would be positive:

I think it [a collaboration] would create a feeling of safety among patients that might think: “Hm is that [the medication] right” because a GP has 100.000 things that they need to attend to or familiarize themselves with, where a pharmacist also has a lot of things, but it’s primarily related to how different medications affect your body.

For interviewee 7, it is the GP’s lack of time during a consultation: patients can feel pressure in terms of not having enough time to share their questions with the GP. This narrative indicates a need for more time for both GPs and patients and perhaps this need could be fulfilled by expanding the collaboration between pharmacists and general practice.

‘I know that I would be better off not taking any medication, but I have to have quality of life’

For some interviewees, a positive outcome of being included in the intervention and having a pharmacist conduct their medication review was that they were feeling better after having some of their medicines changed and/or reduced. At the 6-month follow-up interview, interviewee 8 happily stated:

I have a lot more energy… My grandson, he is 10 years old, he also says: “but Grandmom usually you cannot play around like this a whole afternoon”… At the same time, I’m feeling better in my body. My mood is also better now I’m going to the gym.

As well as talking about the positive changes in her lifestyle, interviewee 8 often mentioned being more aware of her medication and being a lot more social. She is now talking to people at the gym, doing water aerobics with other ladies, and cleaning alongside her cleaning help, and of course, laughing and playing a lot more with her grandson, which means a lot to her. Interviewee 8’s positive change indicates an improved ability to overcome the stressors related to her being a patient with polypharmacy, and her social interactions could be seen as her gateway to increased SOC and feeling better. After attending the medication review, interviewee 8 is not only feeling better, with more energy, and the ability to exercise a lot more, but she is also motivated to reduce even more of her medication in cooperation with her nurse. Reducing medication generally seemed to be the biggest goal for several interviewees. For example, when asked about their wishes regarding the effects of the medication review, interviewee 2 answered: ‘Well the dream scenario would be receiving as few pills as possible’. This urge for fewer pills rather than, for example, getting rid of side effects or improving quality of life, speaks to a possible consensus in society that taking a lot of pills is bad for you and if you can change it, you should. However, the urge could also be explained by a desire to reduce the practical burden of taking a lot of pills. Likewise, for interviewee 6:

I know that I would be better off not taking any medication, but I have to have quality of life right?… It can’t help saying, I’m going to stop taking this and go cold turkey, right? You can’t do that, I can bite back much, but not that much.

The narrative indicates that interviewee 6 is trying to justify why she is taking her prescribed medication, and the need to justify correlates to the power of the canonical expectations of what an ideal healthy life is—a life without illness and therefore a life without the need for medication.

Discussion

An outcome of the intervention was that the interviewees generally had positive experiences with the medication review with a pharmacist, and some of the interviewees could feel an improvement in their health, indicating increased SOC. A key finding was that most interviewees felt comfortable having a pharmacist conduct their medication review without the GP present. For one interviewee, however, the nurse or GP needed to be involved for him to have complete trust in the process. This need for the GPs involvement shows the importance of trust and the personal care relationship between patient and GP which is provided through a continuing provider-patient relationship [43,44], particularly when new procedures are introduced in general practice. In recent years, the UK has largely implemented the initiative of pharmacists conducting medication reviews and management of long-term conditions in general practice, and a qualitative patient-centered study from the UK shows positive results. One of the themes from the UK study is the high quality of interactions between patients and pharmacists, and the thoroughness of pharmacists during the consultation. Furthermore, pharmacists seemed much easier to access than GPs and had much reduced waiting times [45], which relates to the hope expressed by several interviewees in this study that GPs are often busy and that pharmacists could be better placed to deal with specific issues with medication, thus creating a feeling of safety among patients.

Another positive finding from our study was that interviewees who did not know much about their medication to begin with felt that they had gained knowledge and insight into their medicines and illnesses after the medication review, which was a positive for them. Other studies show similar results: in Aukland, Frankfurt, and the south of England, medication reviews by pharmacists have been shown to increase patient knowledge about medicines and health-related issues [2,46,47].

There are several negative aspects to being a patient with polypharmacy which have an impact, and all aspects have a great effect on how the interviewees live their lives, both in terms of what they are physically capable of, and also on their mental health and well-being. For some of the interviewees, illness and bodily pain are closely linked to their identities, making it difficult for them to overcome stressors. Nudging by healthcare professionals and societal expectations on how to live a healthy life also play a role in how some interviewees perceive themselves. Some of the narratives described in this study indicate that some patients with polypharmacy are not able to live up to the ideal of a healthy life and therefore express a sense of failure. This could be related to the consensus in society that good health is required to be a good and participating citizen, and that people are themselves responsible for achieving good health [47]. Illness can prevent people from working, which places an economic burden on the rest of society. Body maintenance, therefore, is viewed as a strategy to achieve society’s health ideal and be a good citizen [48]—a point that also emerged in some of the narratives from the interviewees about trying to stay active and the importance of having a job despite physical difficulties related to illnesses and polypharmacy.

The importance of social relationships was also apparent in the narratives of our interviewees. Human beings are social and therefore connections and relationships with other humans are important for aspects, such as security, joy, motivation, and social relationships can even be a gateway to recovery [49]. A study found that community social support, peer-to-peer support, friendly environments, and the possibility for social networking were identified as SOC-strengthening factors [49]. It can be difficult to overcome stressors related to polypharmacy and feel SOC if social relationships and joy are missing, which was the case for several of the interviewees in our study.

Polypharmacy means receiving a lot of medication that patients cannot do without, and ‘chronic homework’ is the work of managing their medication to treat their illnesses at home [39]. For some of the interviewees, it was difficult to remember all the different types of medication they received, which could be linked to the interviewees’ biggest wish for the medication review, namely, to reduce their medication. This could also have something to do with canonical expectations about health: if good health is perceived as a life without illness or medication, then it could be argued that this intervention’s medication review placed our interviewees on the path to living up to society’s ideal since the focus of the review was to change for the better or reduce the patients’ medication.

Strengths and limitations

A strength of this study is that it gives specific insight into patient perspectives on medication reviews by pharmacists within a general practice setting, an area where knowledge is limited. The interviewees in this study were generally very positive toward the intervention. Some of them even felt better after the medication review, pointing out how their quality of life and physical activity had improved.

Our positive results could be influenced by the fact that all the interviewees were motivated to participate in the intervention and had agreed to attend the medication review. Additional insight could have been secured by involving patients from the intervention group who did not participate in the medication review and who dropped out of the intervention (six patients).

Due to illness and COVID-19, eight of the baseline interviews and four of the 6-month follow-up interviews were held over the phone, and the follow-up interview with the last interviewee [interviewee 12] was held 10 months after the baseline interview due to the interviewer being on maternity leave. It would have been ideal to have all the interviews conducted face-to-face since body language and facial expressions are missing from phone interviews. It would also have been ideal to have all the follow-up interviews conducted 6 months after the baseline interviews as planned.

The authors were transparent about the research method and informed the interviewees that the interviews were part of a PhD study and that the interviewer and first author was a PhD student. They also made sure the interview guide covered many different aspects of the intervention and what it is like to be a patient with polypharmacy. The interviewer, however, could have influenced the interviewees to be positive toward the intervention since she was affiliated with it.

The authors’ interest in implementing and introducing new technologies and initiatives to create value for patients and the healthcare system, in general, affected the decision to only include patients from the intervention group. This was to gain insights into the medication reviews by pharmacists firsthand. However, this decision excluded patients from the control group, who could have provided additional insights into being a patient with polypharmacy.

Conclusion

This study gives an in-depth understanding of some of the many challenges faced by patients with polypharmacy. Amid these challenges, some of the patients we interviewed stressed the importance of maintaining a job and being physically active, which implicitly allowed them to live up to the canonical expectations about being healthy and making a contribution to society. Patients with polypharmacy, and complex illnesses, however, are an increasing group, and therefore there is a need to increase efficiency in general practice, while at the same time making time and space for those patients who have the greatest need. One option to do so is to seek the benefits of greater collaboration between general practice and other healthcare professionals, such as pharmacists. The medication reviews by pharmacists investigated in this study were received positively by the patients, who were pleased to gain more knowledge about their medication, and some were also feeling better indicating increased SOC after the medication review. The patients felt comfortable having pharmacists conduct medication reviews within the context of general practice and this may be an example of how other healthcare professionals could contribute to increased focus on medication management possibly leading to reduced medication, and freeing up more of the GPs’ time to focus on clinical work.

Funding Statement

This work was supported by the North Denmark Region, M. L. Jørgensen and Gunnar Hansens Fond, The Quality Unit for General Practice in the North Denmark region.

Ethical approval

Ethics approval was deemed unnecessary according to the Danish national regulations, as it consists of self-reported data. Approval number: 2021-000438.

For further information on the national ethics committee of the North Denmark Region: Niels Bohrs Vej 30, 9220 Aalborg Ø. Phone number: +45 97 64 84 40. E-mail: vek@rn.dk.

Written informed consent was obtained from the interviewees. The study was carried out following Danish guidelines and regulations.

Disclosure statement

No potential conflict of interest was reported by the author(s).