2. @PharmSafe
@Improve_Academy
#WeStopMeds

3. Setting the Scene Ageing population Multi-morbidity More frailty
Poly-pharmacy
Side effect burden

4. Multimorbidity is the norm @≥75
n (%)
Mean number of conditions
2 or more conditionsc: n (%)
 45-54
4489 (16.1)
1.19
1302 (29.0)
 55-64
5938 (21.4)
1.63
2412 (40.6)
 65-74
5827 (21.0)
2.09
3068 (52.7)
 ≥75
3254 (11.7)
2.53
2125 (65.3)

5. Polypharmacy facts and figures
3 million people in the UK will have a long term condition managed by polypharmacy by 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. 16% increase in risk of medication error with each additional medicine. 6% of admissions to hospital are drug related. 50% of medicines are not taken as prescribed.

6. 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 Jun;24(6):637-46

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

8. 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:

9. PROBLEMATIC POLYPHARMACY
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

10. 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

11. Changes to GMS contract: July 2017
Identification and management of patients with frailty
Appropriate tool to identify patients with moderate/ severe frailty
Patients with severe frailty: annual medication review +/- ask about falls. Provide other clinically relevant interventions.
Consent to activate their enriched SCR

12. 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.

13. Our Approach
Q.I.
Provide tools
Identify barriers

14. 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

16. NHS Scotland, Kings Fund (England), NHS Wales, PrescQIPP NHS Programme
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

17. The STOPP tool used with eFI
67/77 STOPP criteria from Gallagher et al (2008) STOPP/START tool developed as a free to access/use SystmOne protocol.
S1 STOPP protocol helps clinicians systematically identify potentially inappropriate prescribing in high risk populations
Pilots sites show effectiveness when STOPP protocol used is to generate possible STOPP recommendations which are then considered in the context of a clinically led (MDT informed) person-centred holistic medication review face to face with patient

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

19. We want to measure the reduction in inappropriate prescribing……which is difficult.
So we will track deprescribing
A prescription item is deprescribed when it is removed from the patient’s list of repeats. (our definition!)

20. National Polypharmacy Indicators
Used as an indication of effect on ‘inappropriate prescribing’
Average number of unique medicines per patient.
Percentage of patients prescribed 8/10/15/20 or more unique medicines.
Percentage of patients with an anticholinergic burden score of 6/9/12 or greater.
Multiple prescribing of anticoagulant and antiplatelet medicines.
Percentage of patients prescribed two or more unique medicines likely to cause kidney injury (DAMN medicines).
Percentage of patients prescribed two or more unique medicines likely to cause kidney injury (DAMN medicines), one of which is an NSAID.

21. Anticholinergic Burden – National metric
Local searches and patient lists produced by:

22. Results so far
Graph produced by QI Software from

23. And more
Graph produced by QI Software from

24. Detailed analysis of our results. Our story of polypharmacy reduction.
Next steps
Detailed analysis of our results.
Our story of polypharmacy reduction.
Our story of QI.
The story of our Data.
Effects on national polypharmacy metrics.
Planning for spread and scale.

25. @Improve_Academy #WeStopMeds
t: ; e:
@Improve_Academy
#WeStopMeds