The AHSN 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, Utilising the 7-step Polypharmacy Tool to Guide a Multi-Disciplinary Team Meeting for Hyper Polypharmacy Review, can be viewed here. For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/

1. Utilising the 7-step Polypharmacy Tool to Guide a Multi-Disciplinary Team Meeting
for Hyper Polypharmacy Review
Kayleigh Davison, Lead Senior Clinical pharmacist, kayleigh.davison@nhs.net
Patients were identified using the EPACT2 data available for the practice from the
NHSBSA analytics dashboard website (1). The patient identifiable data was requested and
provided via EPACT2 support. Patients were reviewed using the Scottish 7-Steps
polypharmacy framework (2). This document was completed in advance by the Senior
Clinical Pharmacist, then used to frame the discussion for an MDTM for the patients.
The MDT for the polypharmacy reviews consisted of the named GP, salaried GP, nurse
practitioner with Sp. Diabetes, respiratory nursing team, practice nurse, health care
assistant and Clinical Pharmacist’s. The polypharmacy review document was circulated
prior to the meeting. The drug interactions were included if it was classed as moderate
to severe via BNF grading.
After the MDTM, the patients were allocated to the most appropriate member of the
team to manage the ongoing care plan- dependent on the speciality area – e.g. if a
respiratory concern was the highest priority, the respiratory nurse would begin the care
plan and then transfer the patient to the next colleague to continue the plan.
Introduction
1. NHSBSA. 2022, ePact2, NHSBSA. NHS. Available at: hiips://www.nhsbsa.nhs.uk/access -our-data-products/epact2 (Accessed: December 16, 2022).
2.NHS Scotland, 2022. The 7-Steps medication review, NHSScotland. Available at: hiips://www.polypharmacy.scot.nhs.uk/for -healthcare-
professionals/principles/the-7-steps-medication-review/ (Accessed: December 16, 2022).
3. Kantor ED, Rehm CD, Haas JS, et al. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA. 2015;314(17):1818–
31.
4. Slater, N. et al. (2017). Factors associated with polypharmacy in primary care: a cross-sectional analysis of data from The English Longitudinal S.
BMJ Open. 8(3). [Online]. Available at: https://bmjopen.bmj.com/content/8/3/e020270 [Accessed 16 December 2022].
Aims Methods
The primary aim of this project was to review hyper polypharmacy patients
within a general practice setting through an MDTM (multi disciplinary team
meeting) to certify appropriate prescribing aligned with clinical
management plans.
Polypharmacy – usually described as taking more than 5 medications- is a growing
concern with estimates that 25-40% of adults over 65years will fit into this definition
(3). Hyper polypharmacy – described as taking 10 or more medications(4) - is
concerningly also becoming a more frequent sight in general practice. With the
current clinical guidelines available, a single condition focus is often embedded within
patient management. Consequently, a variety of clinicians with individual agenda’s
can unilaterally treat patients unintentionally within the constraints of a 10minute
appointment.
Safety Concerns identified – Themes identified within step 4
Contraindicated Interactions Clinical Monitoring
14
4
6
7 7
0
2
4
6
8
10
12
14
16
1
Number
of
identified
interventions
Theme Identified
Medication Review - Themes identified within step 3
Long term use not recommended Poor compliance Poor results Inappropriate prescribing Other
A total of 26 patients were highlighted as receiving 'hyper polypharmacy’ of over
15 medications. At the point of data collection 16 patients have been reviewed
within the MDTM utilising the 7-step tool to guide the discussions. 38 medication
review interventions were highlighted. Figure 1 shows graphically the reason for
medication review organised by theme. The most common theme, with 14
interventions, linked to inappropriate long term medication being prescribed. This
included mainly quinine and furosemide for ankle oedema, however, tramadol for
a knee operation 10 years prior was also flagged during the review.
Results
28 medication safety concerns were identified through step 5 of the 7-step
framework. Figure 2 below highlights most of the safety concerns were drug
interactions or clinical safety concerns.
The two identified contraindications were a) sildenafil with a nitrate co-
prescribed and b) nicorandil with hydrocortisone. Clinical safety concerns were
similar for some patients: high dose opiate with known respiratory disease;
propranolol prescribed in diabetic and asthmatics; post myocardial infarction and
no ace inhibitor or angiotensin receptor blocker. One patient was identified with
multiple safety concerns regarding the prescribing of quinine; known cardiac
condition, co-prescribed amitriptyline, tramadol and theophylline.
After MDTM and follow up appointments, 39 medications have been stopped.
Initially the average number of regularly prescribed medications in this cohort
was 19. After this project the average number of medications regularly
prescribed was 16.
The MDTM to review hyper polypharmacy patients with over 15 medications provided a
platform to engage different specialities within the general practice to enhance patient
care. The 7-step polypharmacy framework provided a structured approach to the
meeting to allow concerns with a medication focus.
The results indicate the importance of reviewing hyper polypharmacy patients given the
high numbers of identified medication review and safety concerns. The complexity of
this cohort of patients’ medication regimes can lead to inappropriate medication being
started or continued if not appropriately reviewed. The MDTM allowed a platform to
share knowledge and management plans across the clinical teams to enhance co-
operative team working across the general practice.
It is important to also state this was not a deprescribing review- although there was a
high proportion of medication stopped - medication was also commenced inline with
guidance if there was a clear indication e.g. ace inhibitor commenced post myocardial
infarction.
To conclude, MDTM structured by the 7-step polypharmacy guide for hyper
polypharmacy patients can provide appropriate clinical management for patients’
conditions by ensuring only appropriate prescribing of medicines.
Discussion & Conclusion
Poor results was documented if treatment was not to target for the diagnosis e.g.
a raised cholesterol level or elevated BP despite therapy compliance.
Inappropriate prescribing was observed in 4 patients, where one patient had 2
antispasmodics, 5 laxatives and 2 opiates within their 24 regular medication list.
Figure 1: Medication review Themes
Figure 2: Safety concerns identified
References
Kayleigh Davison
Lead Senior Clinical
Pharmacist Practitioner