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Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of 'prescribing' and the 'prescribing process' and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for ...

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of 'prescribing' and the 'prescribing process' and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for ...

Introduction: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, 'Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY', which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter's eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

Background. - The Highlands and the Western Isles are the two most remote and rural areas of Scotland, with many medical practices in areas where pharmacies would not be viable. Recent regulations state that that dispensing medical practices in these areas must receive pharmacist support for patients who would benefit. Objective. - This study aimed to evaluate pilot services, which centred on the provision of patient centred pharmaceutical care. Methods. A realist type evaluation was conducted by an independent research team comprising collecting quantitative data around what occurred during the consultation followed by interviews with purposive samples of staff (n = 14) and patients (n = 18). Results. - A total of 873 medicines related issues were identified in 473 patients reviewed, with the main issue being 'inappropriate dose, frequency, duration'. Just under half (39.7%) of issues were managed by the pharmacist without any medical input. Interviews indicated a high level of appreciation, although there was an increase in workload for some staff. While the need for telephone based pharmacist consultations for some patients was understood, there was a preference for face to face. All were supportive of continuing and extending the service. Conclusion. - The clinical pharmacist service was both needed and valued highly by staff and patients. In Scotland, this aligns with the Government vision and action plan, 'Prescription for Excellence', that by 2023 all patient facing pharmacists will be independent prescribers with those in remote and rural areas entitled to 'equity of access to such expertise'.

Background: In Scotland, there has been significant investment in pharmacy teams in general medical practices over recent years, aligned to current government policy. Objectives: To characterize the national pharmacy workforce including activities undertaken, perceived competence and confidence, as well as perception of integration of the intervention. Methods: A cross-sectional survey of all pharmacists and pharmacy technicians in general practices. Survey items were demographics, activities undertaken and experiences. The NoMAD tool (Improving the Normalization of Complex Interventions) was included as a measure of perspectives of implementation. Post-piloting, a questionnaire link was sent to all pharmacists (n = 471) and pharmacy technicians (n = 112). A total NoMAD score was obtained by assigning 1 (strongly disagree) to 5 (strongly agree) to each item. Results: Responses were received from 393 (83.4%) pharmacists and 101 (91.8%) pharmacy technicians. Three quarters of pharmacists (74.6%) and pharmacy technicians (73.3%) had been qualified for over 10 years. Two-thirds of pharmacists (68.4%) were independent prescribers, with three quarters (72.3%) currently prescribing. Respondents worked in a median of two practices and were providing a range of activities including medication/polypharmacy reviews, medicines reconciliation, prescribing efficiencies and training. Respondents reported high levels of competence and confidence (median 8, scale 0–10 highest). Median NoMAD total score (scale 20–100 highest, Cronbach's alpha 0.89) was 80 for pharmacists and 75 for pharmacy technicians, P ≤ 0.001. Conclusions: The general practice pharmacy workforce in Scotland is experienced, well-qualified and integrated within general practices, delivering a range of activities. These findings have implications for workforce planning and future education and training.

Purpose: To investigate tigecycline prescription and patient outcomes in the Kingdom of Saudi Arabia (KSA). Methods: A retrospective observational study was conducted in three KSA government hospitals, between January, 2013 and May, 2014. The patients were identified from electronic prescription records; data were retrieved by trained researchers. Results: Thirty-seven patients who received tigecycline were included (mean age, 52.5 years; range, 17 92); 51.4 % were female. Tigecycline was prescribed for sepsis (59.5 %), pneumonia (21.6 %), and/or intra-abdominal infections (13.5 %). The majority of the patients (86.5 %) were prescribed tigecycline in intensive care unit (ICU) and the remaining patients were in the general medical ward. APCHE II score at the beginning of treatment was 16.8 ± 4.3, indicating severe disease. Susceptibility testing revealed 22 different bacterial pathogens, most commonly Acinetobacter baumannii (20 patients) and Klebsiella pneumoniae (14 patients). A significant proportion (56.7 %) was polymicrobial and 16.2 % involved suspected resistant pathogens. Sixteen patients recovered (5 on tigecycline alone, 5 with additional antimicrobials, and six switched to alternatives) while 21 patients died (nine on tigecycline alone, 12 with additional antimicrobials). Conclusions: The study revealed that tigecycline prescription was conducted according to marketing authorizations and national guidelines. Infection severity/stage and comorbidities may influence patients' response, and explain some of the poor outcomes.

Funding: iNOVA4Health-UID/Multi/04462/2013, a program financially supported by Fundação para a Ciência e Tecnologia/Ministério da Educação e Ciência, through national funds and co-funded by FEDER under the PT2020 Partnership Agreement is acknowledged. This work was supported by Fundação para a Ciência e Tecnologia (IF/01097/2013 to C.N.S.), by The Scottish Government Rural and Environment Science and Analytical Services Division (A.F. and D.S.), and BacHBerry FP7-KBBE-2013-613793 (R.M., A.F., C.J., I.C., G.G., R.R.-R., J.P., A.M., C.D., D.S. and C.N.S.). T.F.O. was supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Center for Nanoscale Microscopy and Molecular Physiology of the Brain (CNMPB), and is currently supported by the DFG under Germany's Excellence Strategy—EXC 2067/1-390729940. ; Plants are a reservoir of high-value molecules with underexplored biomedical applications. With the aim of identifying novel health-promoting attributes in underexplored natural sources, we scrutinized the diversity of (poly)phenols present within the berries of selected germplasm from cultivated, wild, and underutilized Rubus species. Our strategy combined the application of metabolomics, statistical analysis, and evaluation of (poly)phenols' bioactivity using a yeast-based discovery platform. We identified species as sources of (poly)phenols interfering with pathological processes associated with redox-related diseases, particularly, amyotrophic lateral sclerosis, cancer, and inflammation. In silico prediction of putative bioactives suggested cyanidin-hexoside as an anti-inflammatory molecule which was validated in yeast and mammalian cells. Moreover, cellular assays revealed that the cyanidin moiety was responsible for the anti-inflammatory properties of cyanidin-hexoside. Our findings unveiled novel (poly)phenolic bioactivities and illustrated the power of our integrative approach for the identification of dietary (poly)phenols with potential biomedical applications. ; publishersversion ; published

Diets rich in (poly)phenols are associated with a reduced reduction in the incidence of cardiovascular disorders. While the absorption and metabolism of (poly)phenols has been described, it is not clear how their metabolic fate is affected under pathological conditions. This study evaluated the metabolic fate of berry (poly)phenols in an in vivo model of hypertension as well as the associated microbiota response. Dahl salt-sensitive rats were fed either a low-salt diet (0.26% NaCl) or a high-salt diet (8% NaCl), with or without a berry mixture (blueberries, blackberries, raspberries, Portuguese crowberry and strawberry tree fruit) for 9 weeks. The saltenriched diet promoted an increase in the urinary excretion of berry (poly)phenol metabolites, while the abundance of these metabolites decreased in faeces, as revealed by UPLC¿MS/MS. Moreover, salt and berries modulated gut microbiota composition as demonstrated by 16S rRNA analysis. Some changes in the microbiota composition were associated with the high-salt diet and revealed an expansion of the families Proteobacteria and Erysipelotrichaceae. However, this effect was mitigated by the dietary supplementation with berries. Alterations in the metabolic fate of (poly)phenols occur in parallel with the modulation of gut microbiota in hypertensive rats. Thus, beneficial effects of (poly)phenols could be related with these interlinked modifications, between metabolites and microbiota environments. ; C.B., C.N.d.S., C.O. were funded by ANR (ANR-13-ISV1-0001-01) and FCT (FCTANR/BEX-BCM/0001/2013). D.B. was funded by the Austrian Science Fund (FWF P26127-B20) and European Research Council (Starting Grant: FunKeyGut 741623). D.S. and A.F. acknowledge support from Scottish Government: Rural and Environment Science and Analytical Services. We also acknowledge the Investment for the Future program ANR-11-IDEX-0003-01 within the LABEX ANR-10-LABX-0033 (C.B., C.O.), Fundação para a Ciência e Tecnologia financial support of A.G. (SFRH/BD/103155/2014) and C.N.d.S. (IF/01097/2013). iNOVA4Health Research Unit (LISBOA-01-0145-FEDER-007344), which is cofounded by FCT through national funds, and by FEDER under the PT2020 Partnership Agreement, is acknowledged.

Diets rich in (poly)phenols are associated with a reduced reduction in the incidence of cardiovascular disorders. While the absorption and metabolism of (poly)phenols has been described, it is not clear how their metabolic fate is affected under pathological conditions. This study evaluated the metabolic fate of berry (poly)phenols in an in vivo model of hypertension as well as the associated microbiota response. Dahl salt-sensitive rats were fed either a low-salt diet (0.26% NaCl) or a high-salt diet (8% NaCl), with or without a berry mixture (blueberries, blackberries, raspberries, Portuguese crowberry and strawberry tree fruit) for 9 weeks. The salt-enriched diet promoted an increase in the urinary excretion of berry (poly)phenol metabolites, while the abundance of these metabolites decreased in faeces, as revealed by UPLC–MS/MS. Moreover, salt and berries modulated gut microbiota composition as demonstrated by 16S rRNA analysis. Some changes in the microbiota composition were associated with the high-salt diet and revealed an expansion of the families Proteobacteria and Erysipelotrichaceae. However, this effect was mitigated by the dietary supplementation with berries. Alterations in the metabolic fate of (poly)phenols occur in parallel with the modulation of gut microbiota in hypertensive rats. Thus, beneficial effects of (poly)phenols could be related with these interlinked modifications, between metabolites and microbiota environments. ; C.B., C.N.d.S., C.O. were funded by ANR (ANR-13-ISV1-0001-01) and FCT (FCTANR/BEX-BCM/0001/2013). D.B. was funded by the Austrian Science Fund (FWF P26127-B20) and European Research Council (Starting Grant: FunKeyGut 741623). D.S. and A.F. acknowledge support from Scottish Government: Rural and Environment Science and Analytical Services. We also acknowledge the Investment for the Future program ANR-11-IDEX-0003-01 within the LABEX ANR-10-LABX-0033 (C.B., C.O.), Fundação para a Ciência e Tecnologia financial support of A.G. (SFRH/BD/103155/2014) and C.N.d.S. (IF/01097/2013). iNOVA4Health Research Unit (LISBOA-01-0145-FEDER-007344), which is cofounded by FCT through national funds, and by FEDER under the PT2020 Partnership Agreement, is acknowledged.

This research was funded by the European Union Framework Program 7, Project BacHBerry [FP7–613793]. The authors also acknowledge support from the Institute Strategic Programmes 'Designing Future Wheat' (BB/P016855/1), 'Understanding and Exploiting Plant and Microbial Secondary Metabolism' (BB/J004596/1) and 'Molecules from Nature' (BB/P012523/1) from the UK Biotechnology and Biological Sciences Research Council to the John Innes Centre and the European funded COST ACTION FA1106 QualityFruit. VT, PV and CM have also received funding from the European Union's Horizon 2020 research and innovation programme through the TomGEM project under grant agreement No. 679796. The funding bodies had no role in the design of the study, collection, analysis and interpretation of data nor in writing the manuscript. ; Background: Flavonoids are produced in all flowering plants in a wide range of tissues including in berry fruits. These compounds are of considerable interest for their biological activities, health benefits and potential pharmacological applications. However, transcriptomic and genomic resources for wild and cultivated berry fruit species are often limited, despite their value in underpinning the in-depth study of metabolic pathways, fruit ripening as well as in the identification of genotypes rich in bioactive compounds. Results: To access the genetic diversity of wild and cultivated berry fruit species that accumulate high levels of phenolic compounds in their fleshy berry(-like) fruits, we selected 13 species from Europe, South America and Asia representing eight genera, seven families and seven orders within three clades of the kingdom Plantae. RNA from either ripe fruits (ten species) or three ripening stages (two species) as well as leaf RNA (one species) were used to construct, assemble and analyse de novo transcriptomes. The transcriptome sequences are deposited in the BacHBerryGEN database (http://jicbio.nbi.ac.uk/berries) and were used, as a proof of concept, via its BLAST portal (http://jicbio.nbi.ac.uk/berries/blast.html) to identify candidate genes involved in the biosynthesis of phenylpropanoid compounds. Genes encoding regulatory proteins of the anthocyanin biosynthetic pathway (MYB and basic helix-loop-helix (bHLH) transcription factors and WD40 repeat proteins) were isolated using the transcriptomic resources of wild blackberry (Rubus genevieri) and cultivated red raspberry (Rubus idaeus cv. Prestige) and were shown to activate anthocyanin synthesis in Nicotiana benthamiana. Expression patterns of candidate flavonoid gene transcripts were also studied across three fruit developmental stages via the BacHBerryEXP gene expression browser (http://www.bachberryexp.com) in R. genevieri and R. idaeus cv. Prestige. Conclusions: We report a transcriptome resource that includes data for a wide range of berry(-like) fruit species that has been developed for gene identification and functional analysis to assist in berry fruit improvement. These resources will enable investigations of metabolic processes in berries beyond the phenylpropanoid biosynthetic pathway analysed in this study. The RNA-seq data will be useful for studies of berry fruit development and to select wild plant species useful for plant breeding purposes. ; publishersversion ; published

Background Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. Methods Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at >= 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. Results Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. Conclusion Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Background:- Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. Methods:- Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at - 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. Results:- Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. Conclusion:- Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ...

BACKGROUND: Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. METHODS: Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases. RESULTS: Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. CONCLUSION: Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives. ; Jennifer McIntosh and Albert Alonso contributed equally to this work.

BackgroundMultimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained.MethodsChange management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases.ResultsPolypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation.ConclusionWithin the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and ...

Background: - Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained. Methods: - Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework across cases. Results: - Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland and Uppsala) and included all care settings. There was agreement even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation. Conclusion: - Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and ...