This document summarizes guidance on improving polypharmacy and mindful prescribing through multidisciplinary collaboration. Key points include: 1) Rates of multimorbidity and polypharmacy are projected to rise significantly in Scotland, increasing costs and risks. 2) A multidisciplinary model is proposed involving health boards, clinicians, pharmacists, patients, and decision support tools to conduct regular medication reviews targeting high-risk patients. 3) The goal is to improve understanding of medications, discontinue those no longer valid or causing harm, and sustain safe, effective, and person-centered care associated with medicines through a multi-professional approach.

1. Polypharmacy & mindful prescribing
Alpana Mair Therapeutic Partnership Lead

2. Multimorbidity in Scotland-Would
require an extra £3.5 billion 2031
• 62% projected rise in
over 65s 2006-31
• 144% projected rise in
over 85s 2006-31
• Increased prevalence of
LTC, esp COPD and
Diabetes
• 24% projected rise in
older people admitted as
emergencies by 2016
Audit Scotland
Mercer, Guthrie, Wyke:
Scottish School of Primary Care

3. Increase in polypharmacy
Pr. Bruce Guthrie, Dundee

4. Multidisplinary across Health boards
with Patient Representation
• Model of Care
• Materials to Aid Decision Support and Person
Centred Information
• Identification of Patients and Data for
Improvement
• Engagement and Infrastructure to Sustain
Model

6. Who is the guidance for?
• Health boards to inform how best
to deliver
• Tools are for health boards to put
into a pack for clinicians
• Advises on what is currently
delivered under QOF- Med level 2

7. Which patients to target?- iSPARRA
• Patients that have a 40-60% risk of admission in last 12
months
• Over age 75
• Taking 10 or more Medicines in BNF categories including
a High Risk medication
• In a care home
• Then 65+ or 5-9 BNF Categories

8. Drug Review Process- A4 summary with links
Nu
CRITERIA / References / Further reading
PROCESS/GUIDANCE
CONSIDERATIONS or Examples
Is there a valid and Identify medicine and check that it does
e.g. PPIs- minimum dose to control symptoms should
current have a valid and current indication in
be used- risk of c.difficle and fracture
1 indication? Is the this patient with reference to local
e.g quinine use- see MHRA advice re safety
dose appropriate? formulary. Check the dose is
e.g. long term antibiotics
appropriate (over/under dosing?)
Is the medicine Is the medicine important/essential in e.g. Medications for Heart failure, medications for
preventing rapid preventing rapid symptomatic Parkinson’s Disease are of high day to day
2 symptomatic deterioration? If so, it should usually be benefit and require specialist input if being
deterioration? continued or only be discontinued altered. review of doses may be appropriate
following specialist advice. e.g. digoxin
Is the medicine If the medicine is serving a vital e.g. thyroxine and other hormones
fulfilling an replacement function, it should
3 essential continue.
replacement
function?
-Is the medicine Contraindicated drug or Strongly
causing: high risk drugs group? consider
-Any actual or potential stopping
ADRs?
Poorly tolerated in frail Consider
-Any actual or See High Risk Drug section e.g is the patient on a high
patients? For stopping
potentially serious risk combination “ triple Whammy”
4 guidance on frailty
drug interactions? Ref. “STOPP” List
see
BNF Sections to Target
Gold National Framework
Particular side effects? May need to
consider
stopping
Is the medicine For medicines not covered by steps 1 to 4 Ref. Drug Effectiveness Summary
effective for this above, compare the medicine to the Ref NNT/NNH
5

9. NNT and NNH- drug effectiveness
tables
• The ‘Number Needed to Treat’ (NNT) is a
measure used in assessing the effectiveness of
a particular medication, often in relation to
reduction in risk over a period of time. The NNT
is the average number of patients who require to
be treated for one to benefit compared with a
control in a clinical trial.
• ‘Number Needed to Harm’ (NNH) is a related
measure which is the average number of people
exposed to a medication for one person to suffer
an adverse event

10. Outcomes so far…..
• Highland • Multidisplinary
• approach
Tayside
• GP, Pharmacist,
• Lothian Geriatrician
• Forth valley

11. Data Collection and evaluation
• Number of patients reviewed from list given
by iSPARRA and CHI numbers
• Number of high risk medications stopped and
why
• Medications started
• Cost benefit

12. Next Steps
1. Guidance document will be reviewed after 6 months for
revisions June 2013
2. Development of iSPARRA to help track changes in medication
and potentially other health outcomes
3. Development of indicators as PIS data develops
4. Development of coding for polypharmacy reviews nationally
5. Analysis of Scotland wide data for Polypharmacy
6. patient tools to help them actively take a role in polypharmacy
reviews
7. Development of tools for the clinicians undertaking
polypharmacy reviews
8. Development of IT systems to enable extraction of data from GP
prescribing systems by national read codes.

13. Patient Engagement
‘Safe to ask’

14. Authoritarian Physicians And Patients’ Fear of Being
Labelled ‘Difficult’ Among Key Obstacles to Shared
Decision Making
D.L. Frosch et al
Health Affairs May 2012 Vol 31 no.5 1030-1038

16. If you’re not part of the solution then you
are part of the problem….

17. “When you confront a problem you begin to solve it.”
Rudy Giuliani

18. ‘Given additional pain killers and not explained why’
‘I am still not sure about the medicine I am taking’
‘Given the wrong drugs to take home’
Lack of a shared mental model?

20. Improve Understanding
• What you are taking
• Why you are taking it
• When you should take it
• How you should take it
• How long you should take it for

21. Who needs to ask questions?
• Doctors, Nurses, Pharmacists and other
healthcare professionals.
– Why?
– Don’t they know what I take?
• Patients
– Why?
– What if I forget to ask when I see the doctor?

23. Make it easy

25. “Good ideas are not adopted automatically.
They must be driven into practice with
courageous patience”
Hyman Rickover
Jennifer.ross@nhs.net
@med_safety_bird

26. 180 day Rapid Cycle Improvement
Project in
Medicines Reconciliation
Dr Gregor Smith

27. One man may hit the mark, another
blunder; but heed not these
distinctions. Only from the alliance of
the one working with and through the
other, are great things born.
Antoine de Saint-Exupery

28. Background to 180d RCIP
• Commissioned by the Quality Alliance Board
• Five Boards (NHS Lanarkshire, Tayside, Highland,
Grampian and Forth Valley)
• Aims:
– Build on and accelerate the work in med rec
– Improve breadth clinical engagement
– Share learning between and beyond participating
Boards
– Develop capacity and capability for rapid cycle
improvement work

29. Project Measures
Admission Discharge
3. Current medicine list 3. Current medicine list
(using 2 or more sources) 4. Documented Changes
4. Plan 5. Demographics
5. Demographics 6. Allergy status
6. Allergy Status 7. Accurate interim
7. Accurate Cardex discharge letter

30. Medicines Reconciliation: Definition
The process of obtaining an up-to-date and accurate
medication list that has been compared with the most
recently available information and has documented any
discrepancies, changes, deletions or additions resulting
in a complete list of medications accurately
communicated

31. Project Structure and Process
• 3 phases: Scoping and Planning, Testing and
Improvement, Implementation and Assurance
• Weekly / bi-weekly calls
• Milestone meetings
• Strong links with Medicines Reconciliation Network and
hosting on their Community Site
• Problem sharing / solving; developing test strategies;
reporting and spreading successes or challenges

32. High compliance Project Pause
with 2 source over Festive Changeover
reconciliation and holiday junior medical
Reduced use staff: reduced
formation plan of ECS in 2 access to
source ECS
reconciliation
Consultant
spread and
junior audit
Introduction
Ward round
of new
pause; MDT
Consultant cardex
rounds; IDL
engagement
audits

33. Potential correlation between reduced
use of ECS and Accurate Medication
History

34. Medicines Reconciliation - Med. Rec. by Consultant
100
90
80
70
60
Acute Care
Ageing & Health
50
General Medicine
Surgery
40
30
20
10
0
Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12
Med Rec Audit Data 180 Day Project
100
90
80
70
Pergentage
60
50
Total
40
30
20
Total Take Audit
10
1
1
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
/2
0
0
1
1
1
2
2
1
1
1
1
1
2
2
3
3
3
3
0
1
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/1
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/0
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7
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8
5
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6
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9
6
3
6
3
0
7
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6
1
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0
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2
2
0
1
1
2
0
0
1
2
3
0
1
2
2
0
1
1
2
Week beginning
Total compliance Total accurate (%) Total

35. Learning and Recommendations
• Education and training
• QI capacity and capability
• Professional Leadership
• Clinical Quality Strategies
• Consultation
• Process and System Solutions
• eHealth
• Workforce

36. Mindful Prescribing
Empowering people to make informed choices,
providing innovative and holistic care using
appropriate decision support materials that enable meaningful conversations and anticipatory care planning
Effective
Safer Medicines Therapeutic
improving the communication Care
and reconciliation Using Risk Prediction tools to
of medicines at times of transition target specific cohorts of people
and administration of medicines for Chronic Medication Service,
for vulnerable people in hospital and community Medication Reviews and Stewardship,
and telehealth support for managing medicines
Sustainable Safe, Effective,
Efficient and Person Centred care
associated with medicines
requires a multi-professional
approach

37. Acknowledgements
Alexa Wall, SPSP Fellow, NHS Lanarkshire
Jane Ross, Improvement Advisor, HIS
Susan McGaff, Policy Officer, HIS
Jennie Ross, NHS Grampian
Dr Alison Graham, NHS Lanarkshire
Jason Leitch, Clinical Director, Quality Unit
Dr Anne Hendry, National Quality Lead
Carol Sinclair, Better Together Programme
And participants from all the Boards for their patience, diligence and
innovation
Gregor.smith@lanarkshire.scot.nhs.uk

38. Discussion Questions
 What examples of improvement work relating to
medicines are you involved in with your organisations?
 What gaps in the care related to medicines have you
identified?
 What approaches might NHSScotland take to accelerate
improvement in the care associated with medicines?