Polypharmacy - What next? (planning for Wessex) Conference 30th March 2017 'Polypharmacy Prescribing Comparators' Opening Presentation by Clare Howard, Clinical Lead

1. Medicines Optimisation
Polypharmacy Prescribing Comparators
Workshop 30th March 2017
Clare Howard FFRPS FRPharmS
Clinical Lead

2. Polypharmacy
Is it real?
• In 2002, there were 617 million items dispensed, in 2012, there were 1,000.5
million (an increase of 62%)
(1)
• In 2015, 1,083.6 million prescription items were dispensed overall, a 1.8 per cent
increase (19.1 million items) from 2014. This is an increase of 50.4 per cent
(363.4 million) on the number dispensed in 2005; 720.3 million items
(2)
• The average number of prescription items per head of the population in 2015 is
19.8, compared to 19.6 items in the previous year and 14.3 in 2005 (2)
• One third of over 75’s now take at least six medicines (3)
So what?
• A person taking ten or more meds is 300% more likely to be admitted to hospital
(4)
• 6.5% of hospital admissions are for adverse effects of medicines this rises to 17%
in the over 65 age group.
• 30 – 50% of people do not take their medicine as intended by the prescriber.
• Over 70% of hospital admissions for adverse reactions to medicines could be
avoided.

3. Medication Safety
But we aren’t getting it right…
Evidence from primary care shows
• 1 in 20 prescription items has an error and 1 in 550 is
serious(5)
• In 2013, there were over 1 billion prescription items
dispensed in England. Therefore this equates to 1.8
million serious errors(3)
• Adverse drug reactions account for 6.5% of hospital
admissions and over 70% of the ADRs are avoidable.
• Over 50% of errors were in 4 disease classes,
antiplatelets, NSAIDs, diuretics and anticoagulants5

4. Polypharmacy- it is not new!
“We dislike polypharmacy as much as it is
possible, and we would never exhibit a remedy
of any kind unless we had a scientific reason for
so doing and unless we were prepared to defend
our method of treatment.”
W Newnham, Provincial Medical and Surgical Journal, 1848

5. Polypharmacy prescribing
indicators - the story so far….
Wessex AHSN workshop November 2015.
Metrics identified as a key starting point.
No point developing just for one locality?
Why not engage NHS BSA and HSCIC and
develop some national measures? RPS also
working on this?
So we held a small workshop. GPs, Pharmacists,
BSA, RPS, HSCIC and others.

6. Initial suggestions for
Polypharmacy prescribing indicators
• 1. Average number of items per patient by CCG/ Practice
• 2. Average number of items per ASTRO PU by CCG/ Practice
• 3. Can you do average number of items in patients over 75?
• 3. Can you do average number of items in patient over 65
• 4. Number of patients on 10 or more meds over 65
• 5. Number of patients on 10 or more meds over 65
• 6 Number of patients on 4 or more meds over 65
• 7. Number of patients on 4 or more meds over 65
• 8. Number of patients on 20 or more meds over 65 and 75
• 9. Spend on top 10 drugs in STOPP part of STOPP start tool by CCG
(controversial - but it was the exploratory phase!) in the over 75s
• 10 Anticholinergic burden score in over 75s by CCG/ Practice
They have changed a bit since this first list...

7. For each indicator we asked..
• Is it useful?
• Is it valid? (are there any health warnings)
• How would you use it?
• What other data sources might make it more
meaningful?
• In or out? i.e should it be included in the final
polypharmacy measures?
• Any other measures that the group could
suggest?

8. BSA and HSCIC
worked their magic….

9. ALL – AHSN WORKSHOP
Positive response
Feedback
Nothing like these indicators currently
Greater emphasis on utilisation of EPS to
increase accuracy ✔
Some tweaks to the measures ✔
Set out the limitations. ✔

10. Limitations
• Historically, prescribing information was derived from the reimbursement
processes for dispensed medicines. However, the BSA is now able to
capture extra information that undoubtedly adds value to prescribing
measures.
• The NHS number can now be linked to prescription items. In this way, we
are able to demonstrate much better the quality of prescribing in key
areas.
• The polypharmacy prescribing comparators are the first suite of measures
to take advantage of this development. Currently, 92% of all prescription
items can be linked to an NHS number with an accuracy of 99%. Age and
date of birth can be linked to 73% of items with an accuracy of 99%. As the
utilisation of electronic prescribing (EPS) increases, the coverage and
accuracy of this data will increase.
• Therefore, CCGs are encouraged to drive up the uptake of EPS. To
support this improvement, EPS levels have been included at the start of
these comparators.

11. ‘indicators only indicate’
Health Warning

12. So, the final data set
These comparators will be available at GP Practice, and CCG
level and will include measure such as…
• The average number of unique medicines prescribed per
patient. BNF Chapters 1-4 and 6-10
• Percentage of patients prescribed 8 or more unique
medicines, 10 or more unique medicines, 15 or more
unique medicines, 20 or more unique medicines
• Percentage of patients with an anticholinergic burden score
of 6 or greater, 9 or greater, 12 or greater
• Percentage of patients prescribed multiple anticoagulant
regimes
• Percentage of older patients prescribed medicines likely to
cause Acute Kidney Injury (DAMN Drugs)

13. Update March 2017
• The comparators specifications are written
• The final comparators were given final sign off by the
working group on 2nd Feb
• The data is available at Practice, CCG, Local Office,
AHSN, STP, Similar 10 CCGs and NHS England Area ,
Regional and National level.
• Patient-facing comms messages are broadly agreed.
• NHS-facing comms have been developed.
• Met with NHS Scotland to compare and for support.
• We have developed a short animated film “This is Mo”

14. Core Patient Messages…
• Polypharmacy is not about reducing medicines costs – it is
about making sure you are only on the medicines you need, to
live well and avoid unnecessary or unplanned visits to hospital.
• As you get older, medicines may no longer be appropriate for
you as your body changes. It may be time for a medication
review.
• Taking too many medicines increases your risk of going into
hospital.
• So – you should know your medicines. If not, speak to your
Pharmacist or GP.
• Don’t stop taking medicines without a review. Your local
Community Pharmacist can review how you use your medicines
and make recommendations to your GP. Ask them today.

15. Different patient groups….
Any messages need to be carefully worded to take into account some of the different
types of patient groups e.g.
• The well informed – who may have concerns that the NHS is trying to stop medicines
that they need.
• Those that don’t understand their medicines. There will be groups of patients who
take regular medicines but do not really have a good understanding of what they are
taking and why.
• Some patients will not take their medicines but will be scared or unwilling to tell their
GP that they regularly don’t take medicines that have been prescribed for them.
• Patients with Dementia will not necessarily be aware of their medicines and what they
are for and this may become more of a challenge as their symptoms increase.
• Carers, relatives and commissioned carers. These groups will require special
messaging.
• Patients with mental health problems. Here the messages will be about not stopping
medicines unless part of an agreed approach with their GP or another Health Care
Professional

16. Secondary messages
• Do your medicines work for you?
• Do you have a sense of what your medicines are supposed to do?
• Are you concerned that you have not received any medication
checks?
• Who do you talk to about your medicines? Have the conversation
with your GP and Pharmacist.
• Lots of people may prescribe medicines for you. But as you get
older, it’s important that you receive a whole-person review to
check those medicines are still effective and that you can take all of
those medicines safely.
• It’s important for patients to be honest about what medicines you
take regularly and those that you don’t. If you don’t want to take
your medicines tell your GP and Pharmacist.
• Unwanted medicines should be taken to a Pharmacy for safe
disposal.

17. Key stakeholders for
NHS communications
BSA will strongly support the NHS-facing comms
but key stakeholders have been identified as…..
RPS Age UK, Carers UK etc
RCGP Richmond Group of Charities
CCGs CCG Patient engagement leads (PPGs)
NHS England
Senior Pharmacists Healthwatch England
AHSN Network Healthwatch Local
AHSN MDs Media
DH ABPI

18. Can we identify those
most at risk?
A study found that 80% pf patients who were dispensed 15 or
more medicines had a potentially serious interaction on their
prescription.
Individuals with multiple medicines were more likely to
receive a medicine with anticholinergic activity.
In 2010, 23.7% were receiving an anticholinergic despite
evidence of harm.
Research suggests a link to increased mortality with the
number and potency of anticholinergics prescribed.
We plan to evaluate the comparators over time to validate
that they do identify those most at risk.

19. Resources
See
http://wessexahsn.org.uk/programmes/11/me
dicines-optimisation
https://www.cppe.ac.uk
http://www.kingsfund.org.uk
http://www.sign.ac.uk/pdf/p
olypharmacy_guidance.pdf

20. Thanks to the working group
Name Role/Organisation
Clare Howard Clinical Lead, Medicines Optimisation, Wessex Academic Health Science Network (Chair)
Graham Mitchell Information Services Manager, NHS Business Service Authority
Paul Brown Senior Pharmaceutical Adviser, NHS Digital
Neil Watson Clinical Director of Pharmacy and Medicines Management, Newcastle Hospitals NHS Foundation Trust
Vicki Rowse Programme Lead, Medicines Optimisation Wessex Academic Health Science Network
Julia Blagburn Senior Lead Clinical Pharmacist for Older People's Medicine and Community Health, Newcastle Hospitals NHS Foundation
Trust.
Michelle Trevett Senior Pharmacist NHS Dorset Clinical Commissioning Group
Dr Paul Mason GP and Prescribing Lead NHS Dorset Clinical Commissioning Group
Dr Lawrence Brad GP and RCGP Polypharmacy Lead
Dr Simon Flack GP and Locality Lead NHS Dorset Clinical Commissioning Group
Simon Cooper Head of Prescribing Support Portsmouth Clinical Commissioning Group
Katie Griffiths Medicines Safety Officer Dorset University Healthcare NHS FT
Catherine Armstrong Lead Pharmacist – Pharmicus, English Pharmacy Board Royal Pharmaceutical Society
Helen Kennedy Prescribing Analyst, Dorset Clinical Commissioning Group

23. Where next???
Trigger tool to
ensure a review
when patient is
about to go from
9-10 medicines
EVALUATION: Does this
data truly identify those
most at risk from harm?
How do we join up with
secondary care??
Tool that helps
the practice to
identify and
prioritise the
patients most in
need of review.
Let’s not get to 10
medicines in the
first place!
Research to
help us to stop
medicines
safely!