The Health Innovation Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Assessing the outcomes of structured medication reviews, can be viewed here. For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/

1. Discussion
Nearly two thirds of the SMR cohort had at least one medication-related intervention during their review,
which suggests the right people were targeted. The most common intervention was to stop a medicine. This
was, perhaps, to be expected. That said, these patients are complex and there can be hesitancy among
them to change what they consider to be a combination that keeps them ‘on an even keel’. If the first contact
a clinician has with a patient is to conduct a medication review, and the patient does not feel anything is
wrong, it is important to establish a relationship of trust. At times, agreeing with a patient to continue poten-
tially risky combinations of medicines can establish that relationship better than trying to force through
changes for which the patient isn’t prepared. The hope then is that once the relationship is established, the
patient can be more receptive to recommendations at future reviews.
Reason for having an SMR
The most common reason reported for a patient having an SMR was polypharmacy. Some patients may
have been eligible for other reasons, but there was no requirement to record more than one reason. The
second most common reason was for the patient being housebound. This cohort of patients was targeted
during flu season – when the pharmacist visited patients at home to administer a flu jab and conducted an
SMR at the same time. Other common reasons were for being on anticoagulation, for a high anticholinergic
burden and for severe frailty.
Medication changes made
There were a wide variety of medicines stopped during SMR consultations. The most common BNF catego-
ry for a medicine stopped was cardiovascular, with antihypertensives being the most common subcategory.
These medicines have a quantifiable effect (ie, blood pressure) so making the case for patients to stop them
is quite simple, when their BP is lower than necessary.
The second most common subcategory was anticholinergics used for lower urinary tract symptoms. The risk
associated with anticholinergic combinations was one of the reasons for doing an SMR. Anecdotal experi-
ence from conducting SMRs suggests these medicines often have an initial effect, but not a long-lasting ef-
fect. Given that you can trial without these medicines without any risk of mortality or morbidity, they are often
a good place to start when deprescribing.
Vitamins were another common medicine stopped during SMRs – particularly folic acid. Folate deficiency is
usually treated in two to three months. Due to the low risk of them causing harm, consideration of stopping
them is often overlooked. Again, trialling without them is easily done and creates no risk for patients.
Antiplatelets were another subcategory commonly stopped. This was, in part, because aspirin was previous-
ly prescribed for diabetic patients to prevent cardiovascular disease. Despite the recommendation for this
use having changed, many patients have continued to have them prescribed – and such use is identified
during an SMR. The other time that antiplatelets were stopped was when dual antiplatelet therapy was be-
ing used beyond its intended duration. Historically, if the intended duration of treatment was not made clear
on the repeat prescription, dual antiplatelets could easily be continued for longer than intended.
In total, the NHS cost of these medicines (according to the Drug Tariff in December 2021) was £856.59 per
28 days. Extrapolated across a calendar year, this would have generated a saving of £11,135.67 to the NHS
drug budget.
Further NHS savings will be generated through fewer dispensing fees for pharmacies. At present, the dis-
pensing fees for 112 prescriptions would total at £100.80. Assuming prescriptions were all for 28 days, this
would generate an additional saving of £1,310.40 per year.
Outcomes
Between 1 October 2020 and 20 September 2021, 233 pa-
tients received an SMR at Boughton Medical Centre. Of
these, 6 had either died or left the practice at the time of
analysis. During those SMRs, 142 patients (63%) had one
or more medication interventions. The following interven-
tions were recorded:
• Medicine stopped due to being inappropriate – 80
• Medicine stopped due to side effects – 4
• Medicine stopped due to being ineffective – 11
• New medicine started – 20
• Dose increased – 7
• Dose decreased – 82
• Other medication advice given – 1
The reason documented for those patients having an SMR
is shown in the chart to the right.
Of the 85 patients for whom no medication intervention was
recorded during their SMR appointment(s), the following
referrals occurred:
• Weight management programme – 3
• GP – 2
• Blood test – 6
• Social prescribing service – 10
Medicines started
Only 12 patients had a new medicine started and 8 had a
medicine switched to a direct equivalent. Medicines started
included aspirin, metformin, PPIs and statins. Those
switched included inhalers, anticoagulants, antihyperten-
sives, calcium and vitamin D. There is no read code used
for a ‘medication switch’, so it is likely some were not identi-
fied (particularly if done during a follow up consultation).
The impact on drug spend was minimal. Most switches
were to lower cost alternatives (except for when warfarin
was switched to a DOAC) and all medicines started were
low-cost generics.
Aim
To analyse the outcomes occurring during SMRs conducted for patients registered in a single general prac-
tice and analyse the reasons for the SMRs being offered in the first place. Outcomes will include those that
are drug related, along with those involving referrals to other clinicians or for blood tests.
Objectives
• Record the reason why each SMR was offered
• Record and analyse the BNF category of each medicine that was stopped, started, increased and
decreased during each review
• Calculate the financial impact of any medication changes that occur during those reviews
A period of time was selected so that approximately 200 patients are included – as this was a manageable
workload for analysis while also being large enough to identify trends.
Assessing the outcomes of structured medication reviews
By Gareth Malson, lead pharmacist, Chester East PCN
Category of
drug stopped
No of pa-
tients Drug subcategories
Antihyperten-
sives 13
ACE, ARBs, beta blockers, calcium-
channel blockers, thiazides
Other cardiac
drugs 19
Antiplatelets, DOACs, ezetimibe,
statins, nitrates, nicorandil, fibrates,
furosemide
Gastric meds 8
Domperidone, PPIs, hyoscine, laxa-
tives
Pain meds 10
Opiates, NSAIDs, Movelat gel,
pregabalin, tricyclic antidepressants
Urology meds 15
Anticholinergics, mirabegron, PDE5
inhibitor
Diabetes meds 3
Metformin, repaglinide, DPP4 inhibi-
tors
Bone meds 11
Bisphosphonates, calcium and vita-
min D, alfacalcidol
Vitamins and
iron 20
Vitamin B co strong, vitamin B12,
vitamin D, folic acid, iron, thiamine,
pyridoxine
CNS meds 7
Antidepressants, antihistamines,
benzodiazepines, melatonin
Creams 2 Topical steroid, Doublebase cream
Eye drops 3 Hyloforte, Xailin
Respiratory
meds 1 Saline amps
Category of
drug reduced
No of
patients Drug subcategory
Antihyperten-
sives 3
Alpha blocker, beta blockers, calcium
-channel blockers
Other cardiac
drugs 16 DOACs, nicorandil, nitrates, statins
Gastric meds 14 Gaviscon, PPIs
Pain meds 29
Gabapentin, opiates, pregabalin,
tricyclic antidepressants
Urology meds 1 Anticholinergics
Diabetes meds 2 Metformin
Bone meds 3 Calcium and vitamin D
Vitamins and iron 2 Iron, thiamine
CNS meds 8
Antidepressants, antihistamines,
benzodiazepines, duloxetine, zopi-
clone
Respiratory meds 5 Carbocisteine, inhaled corticosteroids
HRT 1 Premarin