Supporting appropriate Polypharmacy in the West of England

Supporting appropriate
Polypharmacy in
The West of England
13 December 2018
@weahsn
#WestPolypharm

• AHSNs work in partnership with our member organisations
and industry.
• We are uniquely placed to support the NHS in increasing its
contribution to improve patient outcomes and generate
economic benefits.
• We identify best practice in healthcare and drive the
adoption and spread of innovation for a healthier nation.
What is an Academic Health Science
Network?

The West of England AHSN area
2.4 million citizens
Three STP healthcare systems:
A. Gloucestershire
B. Bristol, North Somerset
and South Gloucestershire
C. Bath, North East Somerset,
Swindon and Wiltshire
www.weahsn.net

• Appropriate Polypharmacy
• Improvements in Medication Safety
• Medicines Transfer of Care processes
• Diagnosis & Treatment of Atrial Fibrillation
AHSN Medicines Optimisation Work
Programme - supporting:

• To consider and understand the key issues and challenges in
achieving optimal polypharmacy.
• To share and reflect on the local experiences, progress and
achievements to date, from both a system wide & individual
practitioner perspective.
• To consider how best to support and further improve appropriate
polypharmacy within & across WEAHSN healthcare systems.
Polypharmacy Workshop aims:

www.england.nhs.uk
Steve Brown
RMOC Meds Optimisation Oversight Group and AHSN
MO Programme Board: update on polypharmacy
December 2018

www.england.nhs.uk
• Policy – Medicines Value Programme
• Care homes (MOCH)
• RMOC
• WHO Medication Safety
• AHSN MO Programme Board
• Review of NHS Overprescribing
7
Polypharmacy – some of what’s going on!

www.england.nhs.uk
The Medicines Value Programme has been
set up to respond to these challenges
The NHS wants to help people to get the best
results from their medicines – while achieving
best value for the taxpayer
Savings will be reinvested in improving patient care and providing new
treatments to grow the NHS for the future
The NHS policy framework that
governs access to and pricing of
medicines
1
The commercial arrangements
that influence price
2
Optimising the use of
medicines3
Developing the infrastructure
to support an efficient supply
chain
4
A whole system approach….
• NHS England, NHS
Improvement, NHS Digital,
Health Education England
• Regional offices link with
STPs, ICSs, CCGs, and
providers
• Nationally coordinated with
AHSNs, Getting It Right
First Time, NHS Right Care
and NHSCC
Following the Next Steps on the NHS Five Year Forward View and Carter Report

www.england.nhs.uk
• 240 Pharmacists and technicians working
across care settings to support care homes
o Medicines optimisation (including deprescribing)
o Care home systems and staff (reduce errors, waste)
o Antimicrobial stewardship
• Training pathway
o HEE commissioned training provider – CPPE
o 600 Pharmacists and Pharmacy Technicians
o Independent Prescribing
• Infrastructure
o Networks, Digital, Data & Metrics, Polypharmacy Support
Care Homes Offer to STPs

www.england.nhs.uk
Regional Medicines Optimisation Committees
Purpose and scope:
• Monitor and support implementation of
national advice and guidance
• Provide and disseminate resources to
support and accelerate implementation
• Consider the implications of new ways of
working and technological innovations
• Provide consistent advice on medicines
optimisation
• Reduce duplication
• Horizon scan to identify challenges /
issues to benefit from a system-wide
approach
• Supported by the Specialist Pharmacy
Service: www.sps.nhs.uk
4 RMOCs set up to lead, chaired by
regional medical directors

www.england.nhs.uk
WHO Global Patient Safety Challenge –
Medication without harm
• Overall aim - Reduce the level of severe, avoidable harm related to
medications by 50% over 5 years, globally
• 3 Early Priority Actions
• Polypharmacy
• High risk situations
• Transitions of care
• 4 domains
• Patients
• Medicines
• Healthcare professionals
• Systems and practices of medicines

www.england.nhs.uk
The burden of medication errors
Medication errors can include prescribing, dispensing, administration and monitoring errors. Medication
error can result in adverse drug reactions, drug-drug interactions, lack of efficacy, suboptimal patient
adherence and poor quality of life and patient experience
An estimated 237
million medication
errors occur in the
NHS in England every
year
68.3 million errors (28% of total)
cause moderate or serious harm
The estimated NHS costs of
definitely avoidable ADRs are
£98.5 million per year,
consuming 181,626 bed-days,
causing 712 deaths, and
contributing to 1,708 deaths
EEPRU report - PREVALENCE AND ECONOMIC BURDEN OF MEDICATION ERRORS IN THE NHS IN
ENGLAND November 2017*
WHO Global Patient Safety Challenge – Reduce the level of severe, avoidable
harm related to medications by 50% over 5 years, globally
3 early priority actions: polypharmacy, high risk situations, transfers of care

www.england.nhs.uk
1. Patients
Medicines Safety
Programme
• Improved shared decision making, including when
to stop medication
• Improve information for patients and families, and
access to inpatient medication information
• Encourage and support patients and families to
raise any concerns about their medication
Set up following the recommendations of the Short Life Working Group
• Improved shared care between health and care professionals
• Training in safe and effective medicines use is embedded in
undergraduate training
• Reporting and learning from medication errors
• Repository of good practice to share learning
• New defences for pharmacists if they make accidental
medication errors
• The accelerated roll-out of hospital e-prescribing and
medicines administration systems
• The roll-out of proven interventions in primary care such as
PINCER
• The development of a prioritised and comprehensive suite of
metrics
• New systems linking prescribing data in primary care to
hospital admissions
• New research on medication error to be encouraged
2. Medicines
• Increase awareness of ‘look alike sound alike’ drugs
and develop solutions to prevent these being
introduced
• Patient friendly packaging and labelling
• Ensure that labelling contributes to safer use of
medicines
3. Healthcare professionals
4. Systems and practice

www.england.nhs.uk
Reducing medicines waste
• In 2016, 1.1bn prescription items were
dispensed in the community in England.
An average of 2.7m items a day
• The 2010 report Evaluation of the Scale,
Causes and Costs of Waste Medicines,
produced by York Health Economics
Consortium and School of Pharmacy
University of London, estimated the
national figure of pharmaceutical waste
to be £300m
• Much of this waste will be tackled
through implementing the principles of
medicines optimisation, particularly
through the NHS RightCare programme,
and through the deployment of
pharmacists and pharmacy technicians
in general practice and care homes,
working with patients to review their
medicines

www.england.nhs.uk
Polypharmacy ‘Problematic polypharmacy’ - prescribing of multiple
medicines inappropriately, or where the intended benefit is not
realised
• Average no. of prescription
items per head in 2016 was
20, compared to 14.8 in
2006
• De-prescribing medicines
in a controlled way reduces
the risk of medicines
related complications and
this requires clinical
medicines reviews
• NHS England’s care home
vanguards have reduced
these risks and the NHS is
rolling out the Enhanced
Health in Care Homes
Framework and developing
a medicines optimisation in
care homes schemeOctober 2017 data: patients prescribed 10 or more unique medicines
• 5.15% of ALL patients
• 8.19% (aged 65 and over); 9.76% (aged 75 and over); 10.46% (aged 85 and over)

www.england.nhs.uk
Deprescribing
• www.deprescribing.org (guidelines,
EMPOWER brochures, other
resources e.g. Medstopper,
CaDeN, research summaries etc.)
• www.deprescribingnetwork.ca for
general public website
• Follow us on Twitter:
@deprescribingnet,
@deprescribing, #deprescribing
Learning from Canada - initiatives
being considered:
• English Deprescribing Network
(EDeN)
• Deprescribing guidelines

www.england.nhs.uk
PRACTICE
What we do on the
ground driven by
polypharmacy
prescribing
comparators
PUBLIC
Shift in public
consciousness toward
shared decision
making and person
centred prescribing.
Flattening of the current
trajectory of increase in
volume of items
prescribed in primary care.
Cultural shift in public
awareness that multiple
medicines in older age
may cause harm
All high risk patients identified
and known to practices
Percentage of high risk patients
are called for medication
review.
Public fully aware and engaged
with the drive to reduce
inappropriate polypharmacy
Alignment with local and
national stakeholders so roles
and responsibility to tackle
polypharmacy are clear.
All CCG fully trained in ePACT 2 and Polypharmacy Prescribing
Comparators
Practices using comparators to call in the highest risk patients
B
A CONTEXT
•A person taking ten or more meds is 300% more likely to be admitted to hospital (1))
•6.5% of hospital admissions are for adverse effects of medicines this rises to 17% in the over 65 age group.
•Poor public awareness of the harm caused or the impact on health services from problematic polypharmacy
•Between 1999 and 2012, the percentage of the population that received at least one medication prescription increased from 64.5% to 69.2.
•The percentage of patients receiving prescriptions for one to four unique agents declined from 45.6% to 42.1%.Meanwhile, the percentage receiving five to nine and ten or more unique agents
increased from 14.1% to 17.5% (and 4.7% to 9.6% respectively. (2)
C D E
with these
INPUTS
we will carry out the
following
ACTIVITIES
to deliver the following
OUTCOMES
with these long term
IMPACTS
High risk patients recalled and inappropriate polypharmacy addressed
Savings made from
stopping inappropriate
medicines identified and
realised.
Patients open up about their
medicines and their ability to
cope
Each AHSN hosts an annual local event to bring prescribers, patients,
specialist clinicians, Commissioners, social care ect together to shape
local strategy on polypharmacy ( based on data)
Medicines Optimisation - Polypharmacy
Enabling activities to support
above:
POLICY
Policy supports
practice to fully
address polypharmacy
Improved patient outcomes and
experience. Reduced pill
burden and fewer meds related
admissions
All unnecessary medicines
stopped and impact measured.
All CCGs utilising polypharmacy comparators to prioritise local actions on
polypharmacy
Systems across the sector interfaces support identification of patients with
high pill burden or at risk from harm from polypharmacy
Roll out of “me and my medicines” and patient medication charter as
enablers for change. Communications plan.
Public engagement plan developed in collaboration with Graham
Prestwich and others including Age UK, Carers UK etc.
Practices trained in the principles of holistic , person centred medication
review.
An annual joint NHSE AHSN RMOC event to bring policy and practice
together to share issues and develop actions
Synergistic relationship with policy makers and RMOCs to address
perverse incentives and barriers in the current system
Reduction in inappropriate
polypharmacy (ave number
of medicines per person
over 75 flattens or declines)
Alignment of regulation,
contracts, training, public
perception and funding to
support reduction in
inappropriate polypharmacy
Full public drive to have
shared decision making
as part of normal
consultations
Reduction in avoidable
admissions due to
polypharmacy.

www.england.nhs.uk
MO INN - Polypharmacy
Metrics
Process measures
• Being developed jointly with NHS England MV Team – initial tranche
discussed with MV Programme Board – Feb 2018
• AHSNs should develop their 3 key priority measures based on the
national Polypharmacy prescribing comparators and on the priorities of
their local CCGs.
• Agreed measures will be submitted to the AHSN MO Programme Board
and monitored.
• Individual target areas can be measured via the polypharmacy
prescribing comparators.

www.england.nhs.uk
Polypharmacy – Roll-Out
2018/19 Process measures Comments
KSS • Process measures
being developed by
AHSN Network
with NHS England
Medicines Value
Team.
• Likely to start with
narrow, relatively
straightforward
measures and
become more
sophisticated over
time.
Four AHSNs active.
Any other AHSNs
interested in joining
second wave in 19/20?
HIN
Y&H
Wessex

www.england.nhs.uk
Review of NHS
Overprescribing
20

www.england.nhs.uk
Review of NHS
Overprescribing
21

www.england.nhs.uk
Review of NHS
Overprescribing
22

www.england.nhs.uk
• Policy – Medicines Value Programme
• Care homes (MOCH)
• RMOC
• WHO Medication Safety
• AHSN MO Programme Board
• Review of NHS Overprescribing
Questions?
23
Polypharmacy – some of what’s going on!

Mark Gregory, Lead Pharmacist
West of England AHSN
Polypharmacy prescribing comparators

• Cumbria STOP-START 2007 (STOP-START 2 /2015)
• NHS Scotland. Polypharmacy guidance 2012 /2015/2018
• The King’s Fund: Polypharmacy and medicines optimisation 2013
• Guidance for Prescribing in the Frail Elderly: All Wales Medicines Group 2014
• PRESQIPP OSAMU guidance 2012 /2015
etc…
• USA: Beers criteria – first published 1991
• Canada: IPET – first published 1997 www.deprescribingnetwork.ca/ https://deprescribing.org/
• Australia: A practical guide to stopping medicines in older people. BPJ 2010; (27)
• Medstopper www.medstopper.com
• RxISK Polypharmacy Index https://rxisk.org/tools/polypharmacy-index/
etc…
What to do – lots of guidance ….

• Drivers of and barriers to de-prescribing
•  Polypharmacy correlation to increased risk of hospital admissions
• De-prescribing especially in elderly plus wider meds optimisation groups
• Should be a routine mind set & process
• Shared decision making / Individual patient centred
• Language used with patients - ‘de-prescribing’/cost reduction/negative vs
positive - medicines needs change; compliance & ADRs/safety benefits
• Obligations to address inappropriate polypharmacy
Appropriate polypharmacy improves patients outcomes; extends life expectancy;
improves quality of life.
Lots of useful key points ….

The challenge is implementation …
Why are patients on so many
medicines?
There are lots of reasons to
start them
But ineffective mechanisms to
stop them

• Local monitoring and evaluation – numerous approaches
• National Polypharmacy indicators – epact2
• Uses primary care prescribing data (no 2care or OTC)
• Analysis at individual patient level new from 2018
• 92% prescriptions can be accurately linked to NHS number
• 75% prescriptions can be accurately linked to patients age
• Accuracy will increase further as usage of Electronic
Prescribing increases
Assessing Progress

General format of epact2 dashboard indicators

• High degree of data accuracy (although not yet 100%)
• Aimed at helping to identify variations (warranted/unwarranted?) in
practice and highlight areas for prioritising focus
• However ‘the indicators only indicate’ ….
• Comparators are not the solution to addressing inappropriate
polypharmacy
• The solutions require the application of multi-professional &
multi-faceted approaches
• Indicators will be further developed by the BSA based on use &
feedback
Considerations for interpretation

BSA
Polypharmacy
Comparator
Definition:
‘Unique
Medicines’
Chapter
Number
BNF Chapter Name
‘unique’
medicines
1 Gastro-intestinal 
2 Cardiovascular 
3 Respiratory 
4 Nervous system 
5 Infections X
6 Endocrine system 
7 Genito-urinary 
8 Malignant disease 
9 Blood & nutrition 
10 Musculoskeletal 
11 Eye X
12 Ear, nose &
oropharynx
X
13 Skin X
14 Vaccines X
15 Anaesthesia X
16 Emergency treatment
of poisioning
X

Available for all patients or ≥65 or ≥75 or ≥85 years old:
1. The average number of unique medicines prescribed per patient
2. Percentage of patients prescribed ≥8 or ≥10 or ≥15 or ≥20 unique medicines
3. Percentage of patients with an anticholinergic burden score of ≥6 or ≥9 or ≥12
4. Percentage of older patients prescribed medicines likely to cause Acute Kidney Injury
DAMN (Diuretics/ACI&ARBs/Metformin/NSAIDS) drugs.
5. Percentage of patients prescribed a NSAID and ≥ 1 other unique medicines likely to
cause kidney injury (DAMN drugs)
6. Percentage of patients prescribed multiple anticoagulant regimes
epact2 Prescribing Polypharmacy Comparators

Available for all patients or ≥65 or ≥75 or ≥85 years old:
1. * The average number of unique medicines prescribed per patient
2. * Percentage of patients prescribed ≥8 or ≥10 or ≥15 or ≥20 unique medicines
3. * Percentage of patients with an anticholinergic burden score of ≥6 or ≥9 or ≥12
4. Percentage of older patients prescribed medicines likely to cause Acute Kidney Injury
DAMN (Diuretics/ACI&ARBs/Metformin/NSAIDS) drugs.
5. * Percentage of patients prescribed a NSAID and ≥ 1 other unique medicines likely to
cause kidney injury (DAMN drugs)
6. Percentage of patients prescribed multiple anticoagulant regimes
epact2 Prescribing Polypharmacy Comparators

AHSN comparators
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Average Number of Unique Meds 75+

AHSN comparators
0
1
2
3
4
5
6
7
Average Number of Unique meds 85+ yrs

AHSN comparators
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
% 8+ unique meds of all 85+ yrs

AHSN comparators
0.00%
0.01%
0.02%
0.03%
0.04%
0.05%
0.06%
0.07%
% ACB score 9+ of all 85+

AHSN comparators
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
1.40%
1.60%
% NSAID & 1+ DAMN of all 1+ DAMN 85+ yrs

CCG comparators
0
5
10
15
20
25
30
35
40
% 8+ unique meds & 85+ yrs

CCG comparators - trends
15
17
19
21
23
25
27
% 8+ medicines of all 85+ years
Glouc
Harrogate & Rural
BANES
BNSSG
Swindon
Wiltshire
National

CCG comparators
0
5
10
15
20
25
30
35
40
% 8+ unique meds & 65+ yrs

CCG comparators
0
0.5
1
1.5
2
2.5
% NSAIDS & 1+DAMN & 85+ yrs

CCG comparators
0
0.5
1
1.5
2
2.5
3
3.5
% NSAIDs & 1+DAMN & 75+ yrs

CCG comparators
0
0.05
0.1
0.15
0.2
0.25
% patients ACB score 9+ & 85+ years old

GP Practice Level Comparators
0%
10%
20%
30%
40%
50%
BANES
BANES
BANES
BANES
BANES
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
BNSSG
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Gloucestershire
Swindon
Swindon
Swindon
Swindon
Swindon
Wiltshire
Wiltshire
Wiltshire
Wiltshire
Wiltshire
Wiltshire
Wiltshire
Wiltshire
Wiltshire
% Patients 85+ years on 8+ unique medicines

• West of England AHSN healthcare systems relatively good on all current
epact2 polypharmacy comparators
• Individual CCGs positions also relatively good on most indicators
• Evidence of recent improving trends illustrated
• Significant variations at GP practice level for all systems indicating scope for
further improvements
• National polypharmacy comparators a useful basis to highlight areas to
consider for prioritisation/focus & monitor progress
• Emerging evidence of significant positive change in practices that focus on
improving their polypharmacy indicators – SMART objectives
Conclusions

Gloucestershire
Polypharmacy Update
13.12.18
Sian Williams, Clinical Pharmacist
Dr Hein Le Roux, Frailty Lead GP

Key Elements of Gloucestershire Approach
• Promotion of key national polypharmacy guidance
• Development of additional local guidance involving
engagement across primary & secondary care
• Identification of target patient groups
• Inclusion in local primary care incentive schemes
• Encouraging prescribers sharing of implementation
experience and learning

Developing Successful Local Experience
2015/16 – localised initiatives:
• Gloucestershire Hospitals Trust – PIDE project
• Gloucestershire CCG – Pharmcare project
• Individual locality initiatives
• All achieved positive results in terms of measures of
increased appropriate polypharmacy eg. Anticholinergic
burden reductions, deprescribing in elderly.
• Potential benefits of countywide initiative recognised.

Included in Prescribing Incentive Scheme
2016 - Elderly & Polypharmacy focus:
Practices required to undertake ‘proactive polypharmacy
reviews’ considering the principles of de-prescribing for
patients:
– aged 70 years or above AND on 6 or more oral repeat
medicines
– of which at least one of their repeat items must be either:
a bisphosphonate; or an anticholinergic; or a statin, or a
oral NSAID.

Continued in Prescribing Incentive Scheme
2017 – Frailty focus added:
Practices required to undertake ‘proactive polypharmacy reviews’
considering medicines optimisation and de-prescribing principles for
patients:
– with high frailty scores AND on 6 or more oral repeat medicines
of which
– at least one should be for the treatment of either; diabetes; or
hypertension; or a form of primary prevention.
• 2018 – frailty focus continued with supporting guidance …..

Therapeutic Focussed Polypharmacy Reviews
2018 examples beyond frailty or elderly:
• Complex analgesic combinations, including high dose opiods and/or
‘gaba’ drugs
• Asthma & COPD – including multiple inhalers
• Opportunistic extended med reviews for patients identified for other
initiatives eg. high AC burden regimes; OTC med reviews; etc.
• Multimorbidity polypharmacy increasingly the norm

Gloucestershire Frailty Programme
& Polypharmacy Medicines Optimisation
Dr Hein Le Roux
Frailty Lead GP
Gloucestershire CCG

Gloucestershire Frailty Programme
• Two year development programme 2017-19
• System wide approach across County
• Care pathway review and development
• Central focus of Primary Care Offer
• Locality meetings & educational support
• Formalised frailty assessments/scoring/recording
• Encouraging regular MDT case reviews
• Builds on standard care & QOF requirements
• Medicines Optimisation a key component …..

Local Prescribing in Frailty Guidance
• Aimed at difference levels of frailty
• In addition to/beyond national guidelines
• Local clinical opinion and consensus based
• Expertise & credibility of local specialist
• Detailed guidance & 1 page summary sheet
• Baseline audit Q4 2017/18 – Implementation /re-audit
planned for Q4 2018/19

Gloucestershire Guidance Prescribing in Frailty

Level of frailty Therapeutic target Suggested actions
Rockwood 1-4
Generally able
 HbA1c 54-59
 BP 145/85
Appropriate to use third line agents
Reassess if worsening frailty
Rockwood 5-6
Modest frailty
 Control of symptoms
 HbA1c 60 – 85
 BP 160/90 and no postural
drop
Review metformin if eGFR <50 or low weight
Do not use third line agents unless to control
symptoms
Do not restrict diet if low wt or losing weight
Rockwood 7-9
Severe frailty
 Symptom control
 Avoid hypos
 HbA1C only to identify risk
of hypos (aim >65)
 Usually no BP Rx
Reduce treatment
Symptomatic drugs only – stop other drugs eg
statins, BP
Stop metformin if eGFR <30
Consider stopping sulphonlyurea or insulin (type
2)
Watch for falling weight
In EOL Type 1, give low dose once daily longacting
insulin
Diabetes

Level of frailty Therapeutic target Suggested actions
Rockwood 1-4
Generally able
 BP 145/85
 NNT 120/annum in >80’s
to prevent one TIA/stroke,
but takes 2 years for effect
Always measure lying and standing BP in >75’s
Review if reports a fall
Rockwood 5-6
Modest frailty
 BP 160/90 and no postural
drop
Stop alpha blockers if fall or dizzy
Stop calcium channel in heart failure/oedema
Stop thiazide if low sodium or urinary frequency
Rockwood 7-9
Severe frailty
 Usually no BP Rx Stop antihypertensives
Hypertension

Level of frailty Treatment guide Suggested actions
Rockwood 1-4
Generally able
• Usual Rx
• Medical Rx for stable
angina
Referral when unstable angina
Referral if uncontrolled on 2 drugs
Rockwood 5-6
Modest frailty
• Usually 1-2 anti-angina
drugs
• Usually aspirin and statin
• If uncontrolled and referral not wished, then
3rd drug added
• If asymptomatic , consider stopping one drug
(ISMN or calcium channel first to stop)
• If falling, consider stopping 1-2 drugs
Rockwood 7-9
Severe frailty
 Angina less likely if
immobile
• Stop aspirin & statin (NNT to prevent
ischaemic event 250/yr, and no sig reduction
in mortality)
• Stop angina drugs if asymptomatic
• B blocker at low dose
Angina / IHD

plus Local Frailty Podcasts
• Featuring - Drs Ian Donald & Hein Le Roux
• Approx 10 mins each for Frailty &
Prescribing/Diabetes/Delirium/Sepsis/Vascular Disease
• De-prescribing in frailty
• Gloucestershire Frailty Education Podcasts
• Available on G-care website at:
• https://g-care.glos.nhs.uk//

Local learning
• System wide engagement important
• Need to incentivise extended polypharmacy med reviews – de-
prescribing takes additional time
• Manageable approach required re associate workload
• Targeted approach more effective – specific patients grouping
and/or drugs
• Additional locally agreed supporting guidance useful
• Non Medical Prescribers involvement in reviews 
• Forums for local discussion & learning useful
Q4 18/19 reaudit will demonstrate our achievements ….

BaNES CCG
Polypharmacy update
December 2018

Care Homes
• LES for services to nursing & residential homes
– Nursing homes
• Weekly GP “ward round”
• Minimum 6 monthly medication review
– Residential homes
• 6 monthly medication review
• LES under review, to start April 2019
• Care homes pharmacists
• NHSE MOCH technicians
– To be recruited
– Clinical pharmacist support /mentor from RUH: ~2.5 hours/week

Other work
• Contractual medication review for severely frail
• MO team restructure
• Polypharmacy/frailty medication reviews:
– NHSE GP pharmacists
– Vulnerable elderly pharmacist(s)
– QIPP 2019/20 increase pharmacist hours +
technician

Our Mission: To Optimise the Health of the People of Swindon and ShrivenhamOur Mission: To Optimise the Health of the People of Swindon and Shrivenham
Using a Prescribing Incentive Scheme to encourage
polypharmacy medication reviews in Swindon CCG
Nikki Shaw and Paul Clarke
December 2018

Our Mission: To Optimise the Health of the People of Swindon and Shrivenham

Prescribing Incentive Scheme 201718:
Part A Engaging with CCG Medicines Optimisation Team to improve the
quality of prescribing
proposed annual payment
per registered patient (p)
3.1 Polypharmacy Reviews: patients over 75 on >15 repeat drugs to
undergo a detailed medication review (a template is available and
needs to be completed and returned). Evidence of review is required.
7.5
26 GP practices, with 3 clinical systems (predominantly SystemOne TPP and Emis)
Eclipse system used to estimate patient numbers (1879pts April 2017 - 1435pts Dec 2018) Range 8-205
pts / practice
Searches within the clinical systems to identify patients

Using templates:

http://www.polypharmacy.scot.nhs.uk/media/1157/7-steps-
to-appropriate-pharmacy.jpg

Local experiences and themes:
• Aspirin – is there a valid indication for prescribing? (and then stop the PPI!)
• Reviews of prophylactic meds such as statins/ bone protection agents in pts with a shortened life
expectancy
• Over treatment of bp and diabetes, Anti cholinergic burden e.g. meds for urinary incontinence no longer
needed, antihistamines trialled for itch
• All of the above contributing to falls and unsteadiness
• Continued need for sip feeds for under nutrition – regular MUST scores
• Supplements e.g. folic acid (trial without and repeat folate?) or thiamine and vit b cpd in patients with a
hx of alcohol dependence but have not drunk alcohol for many years. Iron supplements.
• PPIs started e.g. alongside an NSAID, which has now stopped
• Antibiotics UTI prophylaxis – little evidence after 6 mths (stop and test sensitivities if a UTI develops),
less evidence in CAUTI
• Eye lubricants – multiple preps and pf preps/UDVs when not needed
• Multiple topical medicines and barrier preps

Analysis of 201718 reviews
Of 26 practices:
• 18 practices submitted results
Of 14 practices:
• 493 pts reviewed
• Pre-review 6610 items (13.4 items / patient)
Items stopped, 885 = 13%

Useful Tools / References
 Polypharmacy guidelines for prescribing in Frail Elderly All Wales Strategy Group 2014
includes Medication review process flow chart
http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20%20Guidance%20for%20Prescribing%20in%2
0Frail%20Adults.pdf
 SPICT tool - Identifying patients with advanced illness http://www.spict.org.uk/
 Bishara, D et al (2016) Anticholinergic effect on cognition (AEC) of drugs commonly used in
older people. International Journal of Geriatric Psychiatry.
 Presqipp – polypharmacy and deprescribing e-learning
https://www.prescqipp.info/learning/
 Polypharmacy guidance and Realistic Prescribing 3rd edn, 2018
https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf

‘The right healthcare for you, with you, near you.’
Polypharmacy in Wiltshire
Alex Goddard

Information and understanding
• Evidence and clinical trial info
meaningless
• Lack of knowledge from most
prescribers (including
pharmacists!) when asked
• Developed simple guide for
interpreting evidence
(originally from NPC)
• Welcomed by prescribers

Guidelines and Workshops in 2015
• Worked with Dr Julian Treadwell, Clinical Fellow for Health Education
South West
• Developed ‘Rational Prescribing’ guidance
• to SUPPORT decision making
• not to TELL prescribers what to do or not do
• Workshops for GPs, nurses and pharmacist prescribers
• Over 100 GPs attended
• Useful resources shared with explanation of where they are most
helpful/relevant

Simple Clear ‘monographs’ with practical
considerations

Resources
• NHS Scotland Polypharmacy “app” / website:
http://www.polypharmacy.scot.nhs.uk
• Mayo Clinic Shared Decision Tools:
http://shareddecisions.mayoclinic.org/decision-aid-
information/decision-aids-for-chronic-
disease/diabetes-medication-management/
• The NNT
• http://www.thennt.com/home-nnt/
• Statins:
https://www.nice.org.uk/guidance/cg181/resource
s/patient-decision-aid-243780157
• AF/anticoag:
https://www.nice.org.uk/guidance/cg180/resource
s/patient-decision-aid-243734797
• Type 2 Diabetes Glycaemic Targets:
https://www.nice.org.uk/guidance/ng28/resources
• HRT Risk estimates:
http://pathways.nice.org.uk/pathways/menopaus
e#path=view%3A/pathways/menopause/benefits
-and-risks-of-hormone-replacement-
therapy.xml&content=view-node%3Anodes-
breast-cancer
(click topics and then to tables from
links on right of page)
• Cochrane Library:
http://www.cochranelibrary.com
• Evidently Cochrane blog:
http://www.evidentlycochrane.net

Feedback/Actions from Workshops
Stand back and not
rush in to prescribe
Be brave to
challenge patient
expectations
Courage to stop
medicines
Check compliance
before adding more
medicines
Be patient focussed
not guideline
focussed
Don’t over-
diagnose
Look at the
anticholinergic
effect
Use the Optimise
‘FDB’ button (within
TPP)
Use the resources
Familiarise myself
with NNT/ risk vs
harm in detail
Ensure colleagues
consider de-
prescribing in care
homes
Advise if dosette
box changes can
wait until next set of
trays

Current activity
• Shared searches within TPP SystmOne
• Identify pts on > 15 meds on repeat
• Identify pts on > 20 meds on repeat
• Part of Care Home LES to ensure 6 monthly medication review
(including START/STOPP criteria)
• POD to reduce waste and encourage appropriate review where
identified

Kate Davis
Principal Medicines Optimisation Pharmacist
BNSSG CCG
December 2018
Polypharmacy Initiatives
Sharing best practice
BNSSG CCG

Work streams in BNSSG CCG
• Prescribing Quality Scheme
• Practice based pharmacists undertaking reviews
• Close working with prescribing clinicians in practices
• Polypharmacy and targeted specific drugs
• Care Home Medication Reviews
• Current reviews
• Plans for New Care Home work
• STP Polypharmacy work stream

Patient Medication Reviews
• Anticholinergic Burden Score Review
• EMIS search for patients prescribed medicines with ACB score of 2 or 3 (286 patients
identified)
• 72% score of 6, 15% >7
• Types of medication reviewed and stopped included antimuscarinics and tricyclic
antidepressants
• 86% had reduction in score of ≥3
• Optimise Rx alert to support ACB score
• Polypharmacy reviews
• Medication review of patients prescribed highest number of items
• Reduce risk associated with problematic polypharmacy
• Searches for 10/15/20 meds
• 658 patients reviewed (8-43 medications)
• 76% recommendations agreed by GP
• 3.5% classified as possible prevention of hospital admission
• 18/19 prescribing scheme – medication reviews attached

Dosulepin review
• Review of all patients prescribed
dosulepin
• Switch to safer
alternative/discontinue/dose reduction
• >550 patients reviewed
• ~70% continued
• Switched to alternative/dose reduction
• Patient numbers continuing to fall
Quinine Sulphate for night cramps
• MHRA guidance in 2010
• 1083 patients identified (30 practices) –
leg cramps and >3 months
• 68 serious interactions identified
• 747 reviewed
• 374 trial discontinuation
• 224 quinine discontinued (80%)
Antibiotics for UTI prophylaxis
• All patients reviewed
• 1164 patients identified
• 779 antibiotics reviewed
• 51% stopped
• Good practice engagement
• Promoted UTI guidelines
• Good Antimicrobial stewardship, prevent AMR
and unintended SE
Amiodarone review
• Work currently underway
• Close working with secondary care
• Based on W Hampshire work
• Review and determine appropriateness –
deprescribing if no indicated.
• Continuation – ensure monitoring, AE,
toxicity, interactions
• Await results
• Included in latest NHSE consultation

Care Home Reviews
• Care Home with Nursing
• Medication reviews every six months by CCG employed pharmacist/care home
pharmacists
• Multidisciplinary desk top and care home review
• Recent data – 900 patients reviewed, 662 recommendations (79% agreed and
actioned)
• Use of STOPP/START tool, 219 meds discontinued, 75 dose changes
• Future work – NHSE Pharmacy Integration Fund
• 2 pharmacists and 2 technicians employed
• Care Home work in North Somerset starting in January 19
• Engage closely with Care Homes, GP practices and Community Pharmacies to
undertake medication reviews
• Aim to reduce inappropriate polypharmacy, medication related adverse events,
hospital admissions and improve quality of care for individual patients

STP Polypharmacy work stream
• Close working between BNSSG CCG, NBT, UHB and Weston General and Community
Pharmacy representatives
• Sharing of current project ideas
• Documentation produced for hospital pharmacists explaining deprescribing projects in primary
care
• Decision made to focus on a specific drug
• Proton Pump Inhibitors (Bye Bye PPI)
• Deprescribing algorithm designed by NBT specialist pharmacist, PIL explaining why and how,
Patient letter.
• Pilotted in other Trusts and primary care:
• Key areas to focus on:
• Secondary care review and deprescribing where appropriate
• Primary care review and deprescribing when appropriate
• Improvement in communication and documentation when initiating a PPI
(indication and duration of treatment)
• Pilot involving Community Pharmacies to support patients to manage
symptoms as they reduce/stop PPIs

Low Value Medicines
• Document and prescribing
highlighted to all practices
• Quarterly reports to individual
practices
• Reductions in items seen:
• Co-proxamol – 55%
• Dosulepin – 36%
• Trimipramine – 47%
• Liothyronine – 42%
• Omega-3 fatty acids – 70%
• 18 products identified in NHSE
document
• Now benchmark very positively – 4th
percentile

Future work
• Further roll out and launch of the STP PPI project
• Agreement of appropriate tools to use for Medication Reviews (current BNSSG
STOPP/START tool needs updating)
• Start Care Home work in Weston Area – evaluation of impact
• Work with our localities as they focus on Frailty and ensure involvement in
polypharmacy reviews to support this.
• Medication reviews based around Pain – updated chronic pain
guidelines/benchmark high in gabapentinoid prescribing
• Producing resources to support clinicians/patients to use medicines as a last
resort, encouraging lifestyle interventions through social prescribing.

National polypharmacy initiative:
sharing learning and best practice
Tony Jamieson, Director of Transformation
Yorkshire and Humber AHSN
@pharmsafe

Safer Prescribing for Frailty
Tony Jamieson Megan Humphreys
Director of Transformation Programme Manager
Y&H AHSN

Setting the Scene
Aging
populat
ion
Multi-
morbidi
ty
More
frailty
Poly-
pharma
cy
Side
effect
burden

What is frailty?
• Age-associated decline in physiologic reserve and
function across multi-organ systems leading to
increased vulnerability for adverse health outcomes
(Fried et al 2001)

Reduced functional reserve in frailty
Clegg et al. Frailty in elderly people. Lancet 2013; 381: 752–62

Polypharmacy facts and figures
• By 2018 3 million people in the UK will have a long
term condition managed by polypharmacy.
• A person taking ten or more medicines is 300% more
likely to be admitted to hospital.
• 1/3 of ≥ 75 year olds are taking at least six medicines.
• 6% of admissions to hospital are drug related.
• 50% of medicines are not taken as prescribed.

Frailty, polypharmacy and mortality
2350 French older people (70 years and older)
• Prevalence of Frailty was 17%
• 6x increased risk of death in frailty vs. robust and non polypharmacy (>5 drugs)
• 3x more likely to be on 5 drugs
• 6x more likely to be on 10 drugs
Herr M et al 2015 Pharmacoepidemiol Drug Saf. 2015 Jun;24(6):637-46

Oh dear
6 times more likely to be on 10+ drugs
Which means
300% more likely to be admitted to
hospital

We know which medicines cause the most admissions
In a 2004 UK study, the most common medicine groups
associated with admission due to ADRs were:
NSAIDs 29.60%
Diuretics 27.30%
Warfarin 10.50%
Angiotensin-converting-enzyme (ACE)
inhibitors
7.70%
Antidepressants 7.10%
Beta-blockers 6.80%
Opiates 6.00%
Digoxin 2.90%
Prednisolone 2.50%
Clopidogrel 2.40%

APPROPRIATE POLYPHARMACY
“Prescribing for an individual for complex conditions or
multiple conditions in circumstances where medicines
use has been optimised and where the medicines are
prescribed according to best evidence”
PROBLEMATIC POLYPHARMACY
“Prescribing of multiple medicines
inappropriately, or where the intended
benefits of medications are not realised”
King’s Fund, 2013

Think about the evidence
• Older adults with frailty often not in the trial
• Outcomes are not usually frailty specific e.g. falls,
fractures
• Trials are rarely about stopping drugs
• S/Es may not be highlighted
• The effects of drugs will be different in multimorbidity

Ambition
Reduce inappropriate prescriptions for people with
frailty.
Current practice is detrimental to the health of people
with frailty.
General Practice is the best place to change practice.
We wanted to use readily accessible Quality
Improvement methods to bring about change and leave
a legacy.

Reduce inappropriate prescribing
for patients with frailty.
What is inappropriate?
Any prescription for drugs or
appliances that is unnecessary (without
indication or benefit), unwanted (by
the patient) or unjustifiable due to its
risk/benefit ratio.

Our Approach
Q.I
.
Provide
tools
Identify
barriers

The behaviour:
De-prescribing medicines that are no longer of
benefit or that may be causing patient harm to
patients with a read code of frailty

Supporting appropriate Polypharmacy in the West of England

The Tools
• UK guidance from
NHS Scotland, Kings Fund
(England), NHS Wales,
PrescQIPP NHS Programme
• Evidence-based tools
1) STOPP/START tool
2) No Tears tool
3) Medicines Appropriateness Index

Our Quality Improvement project
Methodology based on Training and Action for Patient Safety. Slater et al 2012

Outcomes
We identified and addressed barriers to
changing prescribing behaviours.
There was a 6% reduction in prescriptions per
person.
The conversations with patients were reshaped.
Attitudes to prescribing for people with frailty
changed improving the culture of care.

Education
Barrier Buster
Measurement
Facilitation

We changed the culture of prescribing leading
to sustainable behaviour change.
Over 24 weeks our General Practice project
reduced prescribing costs
by £69 - £299 per patientyear.

Social prescribing video
View the video here.
Contact Tony: Tony.Jamieson@yhahsn.com

Polypharmacy:
how does it feel as a patient?
View Anne’s story here

Small group discussions
1. Addressing inappropriate polypharmacy, what
are the:
a) Challenges/learning
b) Opportunities
2. What are the gaps/unanswered questions that
could progress the research /evidence base?

• IT integration
• Patient empowerment
• Improved communication across the system
• Incorporating an understanding of the risks of over-
medication in training and education programmes of all
staff
• Patient communication toolkit
Themes arisen from group discussion

Supporting appropriate Polypharmacy in the West of England

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