Title: Identifying, understanding and addressing problematic polypharmacy within multimorbidity in primary care
Funder: Department of Health and Social Care

Abstract: BackgroundPolypharmacy for people living with multiple long-term conditions (multimorbidity) is an increasing global priority. With an ageing population, more people are living multimorbidity, often necessitating polypharmacy or using multiple medications. This is despite medications and clinical guidelines often being designed to treat single conditions in isolation. Medications carry obvious benefits, yet problematic polypharmacy is linked to adverse consequences including patient safety concerns, poor patient experience and wasted resources. About 10% of medicines prescribed to patients are inappropriate, costing the NHS over 1 billion. Better approaches are needed, with current interventions failing to improve outcomes. Currently, the main approach to identify polypharmacy uses a simple count of drugs, which carries limited value as it ignores individual patient characteristics and multimorbidity. There is an opportunity to improve the identification of problematic polypharmacy through developing a measure that accounts for patient factors and clinical diagnoses. AimTo identify, understand and address problematic polypharmacy within multimorbidity in primary care Research Questions What are the patient, professional and organisational factors associated with problematic polypharmacy? Can a Polypharmacy Assessment Measure improve the identification of patients with potentially problematic polypharmacy? What opportunities exist to improve patient care through addressing problematic polypharmacy within multimorbidity in identified patients?Methods Quantitative analyses of population-based linked electronic health records will use multilevel regression to identify predictors for polypharmacy. This will inform the development of a Polypharmacy Assessment Measure (PAM) to highlight potentially problematic polypharmacy through adjusting for individual factors and multimorbidity clusters. This will be constructed through calculating the discrepancies between the observed and expected count of prescribed medications, thereby identifying unexpected levels of prescribing. Validation will explore the association of PAM with high-risk prescribing and adverse outcomes. A qualitative study will sample patients with a range of PAMs to understand potentially problematic polypharmacy in practice and explore practitioner views on the utility of the PAM. This will incorporate semi-structured interviews with up to 12 patients and 12 practitioners (GPs and clinical pharmacists) informed by practitioners conducting retrospective case note reviews (contrasting patients with different PAMs) to stimulate accounts of everyday work. Thematic analysis will utilise constant comparison methods and incorporate Systems Thinking as a sensitising framework. Three participatory co-production workshops will incorporate nominal group technique methods and involve expert stakeholders including patient, carer, pharmacy, medical, organisational and commissioning representatives. Structured rounds of discussions will integrate both quantitative and qualitative findings from above, leading to recommendations at patient, professional and organisation levels to address problematic polypharmacy. This will embed my research in translational pathways to impact. Recommendations will inform the design of an intervention that incorporates the PAM along with guidance for optimising medicines use, in preparation for feasibility testing at the post-doctoral phase.Summary and impactThis project combines data driven techniques with organisational, practitioner and patient perspectives to improve the identification of problematic polypharmacy and co-produce improvement solutions for everyday practice. It intends to deliver a step-change in the way polypharmacy is tackled to help deliver the NHS Long-Term Plan by harnessing digital tools to maximise medicines optimisation.

Lay abstract: BackgroundPeople are living longer, with more people having multiple long-term conditions (multimorbidity). These patients are usually treated with several different medicines taken together, known as polypharmacy. Half of people over 65 in the UK take at least five regular medicines each day and almost a quarter take more than seven. Medicines help people, but taking too many medicines can be a burden on patients and may cause problems. About 10% of medicines prescribed are considered to be inappropriate, costing the NHS an extra 1 billion every year. We do not fully understand why this happens. In some cases, patients are prescribed medicines that they no longer need. However, where medicines are recommended, medicines for one condition can affect other conditions and some combinations can worsen side effects and drug reactions. For some people, the balance between benefits and harms mean it would be better to stop certain medicines. We need to identify who these people are, to better understand their situation and to produce solutions to help them.AimTo identify, understand and help people with multimorbidity in primary care who are taking too many medicines.Methods I will look at a large collection of health records across the country to: Identify patient, practice and national factors that are linked to many medicines being prescribed together Calculate the difference between the number of medicines prescribed compared to the number we expect for each individual patient Estimate the proportion of people taking risky combinations and the possible harms of this I will use this to develop a tool to identify patients who may be taking too many medicines. To understand how difficult decisions may lead to patients taking too many medicines, I will use the tool to identify patients who are at high risk of harm, compared to low risk and: Interview these patients to talk about their experiences with medicines and understand how they make decisions Ask GPs and pharmacists to look at the medical notes for these patients. Then interview them to understand their decision making I will hold three combined workshops with GPs, pharmacists, patients, carers and organisational representatives to: Produce recommendations for patients, professionals and organisations to improve how we manage patients taking too many medicines Design a more comprehensive way of helping patients Support the introduction of NHS Structured Medication Reviews within GP practices, providing guidance on targeting individuals who are most likely to benefitImpactBy better identifying patients who are taking too many of medicines and understanding why this is happening, we can reduce the use of inappropriate medicines for those already at risk and for future prescriptions. This would improve quality of life, reduce harms from side effects and drug reactions.Patient and public involvementCo-production will underpin the work, building on the involvement of patients and the public in developing this project through multiple workshops. Four public contributors will join the steering group, ensuring the solutions focus on what matters most to patients and carers and addressing diversity, equality and inclusion.DisseminationTo share findings and increase the relevance of my work: Patient, carer and public partners will lead on blogs, newsletters and social media and run a dedicated workshop to share findings and discuss next steps. They will support wider links to established patient groups throughout (e.g. our local PRIMER group, Age UK). As the GP in charge of improving digital systems and prescribing within my practice, I will hold a series of professional meetings with GPs, pharmacists and healthcare staff through existing local connections. Several academic papers will be presented to medical journals and at national and international conferences.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE