RESUMEN
BACKGROUND: Medication reviews have been introduced as healthcare interventions to decrease inappropriate polypharmacy in older patients, but implementation in practice is challenging. OBJECTIVE: This case study aimed to explore the events, actions and other factors that were involved in the implementation and sustainability of medication reviews in older patients by clinical pharmacists in Region Uppsala, Sweden. METHODS: A case study design informed by change management principles (Kotter) and normalization process theory, consisting of a review of published and grey literature, key informant interviews and focus group triangulation. Findings from additional literature review and interviews were integrated into a final thematic analysis. Ten healthcare professionals, managers and policy makers participated as key informants. The study included data up to 2015. RESULTS: Factors were identified across all Kotter's principles and normalization process theory domains, ranging from the first evidence on inappropriate polypharmacy in the 1980s until the creation of permanent clinical pharmacist positions in recent years. Examples of facilitating factors were a national focus on quality of care for the elderly, multiprofessional teamwork, key individuals with different professions, education, financial support and local evidence. Barriers included an unclear allocation of tasks and responsibilities, a lack of time and continuity, and a lack of a national plan for implementation, monitoring and evaluation. CONCLUSIONS: Multiple factors across the full range of change management and implementation principles were involved in the implementation and sustainability. A systems approach, including these factors, should be considered in similar future initiatives, both in Sweden and settings in other countries.