Title: Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP)
Funder: Department of Health and Social Care

Abstract: Polypharmacy (prescribing multiple medicines to one individual) is widespread and growing in the UK; ~6% of adults take 10+ regular medicines. Although often clinically appropriate, polypharmacy may be problematic leading to a range of adverse outcomes. Despite recent national guidance, there is a lack of evidence for medication optimisation interventions that improve outcomes. The aim of this project is to develop and evaluate an intervention to optimise medication use for patients with polypharmacy in a general practice setting. The IMPPP intervention will be based in general practice involving GPs and pharmacists working together, drawing on the specific skills of each professional sensitive to the context of each practice. The intervention will comprise two key elements: (1) a model for conducting polypharmacy medication reviews (including pharmacist-GP collaboration and case finding) and (2) components to enhance professional engagement (education, practice feedback, financial incentives). These two key elements will be supported by an informatics tool integrated into practice clinical systems. We will conduct a 48-month 3-phase study adhering to the principles of the MRC framework for complex interventions: • Phase 1 (Development): Mixed-methods study in 2 Scottish Health Boards that are implementing novel informatics tools to support NHS polypharmacy reviews. Interviews with healthcare professionals (HCPs) plus patient focus groups will be used to understand implementation and their experience of polypharmacy review, and the strengths/limitations of the various intervention components. Epidemiological analysis of practice data will be used to explore the prevalence, variation and amenability to change in potentially inappropriate prescribing (PIP). These findings will inform the initial intervention design, which will then be refined in consultation with HCP and patient groups. • Phase 2 (Optimisation): Pilot-feasibility study in 5 Bristol-area GP surgeries to optimise the intervention in the English context. A formative qualitative process evaluation will examine initial adoption and intervention implementation, including likely barriers/facilitators to implementation which will be addressed prior to the full trial. We will also pilot/evaluate trial processes including collecting quantitative data on patient recruitment/retention. • Phase 3 (Evaluation): Multicentre cluster-RCT comparing intervention vs usual care. The primary outcome is the mean number of PIP indicators triggered per patient. Secondary outcomes include quality of life, health service use and treatment burden. A cost-effectiveness analysis will be conducted. A parallel mixed-methods process evaluation will be undertaken examining implementation to help explain the success or otherwise of the intervention, and to inform subsequent implementation in practice. This study will establish whether and how the IMPPP intervention is effective and cost effective. It will provide valuable insights into how to best implement case-finding and prioritisation for review in patients with polypharmacy, how GPs and pharmacists can best collaborate to meet patients’ needs, and the role of informatics in supporting case-finding and focused review. If effective, our intervention has the potential to improve health related quality of life, improve prescribing and reduce adverse medication effects and treatment burden in a growing and highly vulnerable population.

Lay abstract: Prescribing medicines is one of the most important things doctors do to treat illness and improve peoples’ health. The UK population is steadily ageing and people often have more than one health problem. This means more people are taking multiple medicines, which is called polypharmacy. Polypharmacy is common. It is often necessary to help a person keep well, but polypharmacy can also cause problems such as side effects or confusion about exactly what medicines are to be taken when. We need to find ways of improving the use of medicines in people with polypharmacy so we can reduce some of these problems. However, there is no good scientific evidence to help health care professionals decide how to most effectively do this. The aim of this project is to create an effective approach for improving the use of medicines in people with polypharmacy attending general practice. We will develop a new approach (called IMPPP) to improve how we manage polypharmacy. IMPPP has several parts to it. It will improve how GP surgeries organise reviews of medicines for patients experiencing polypharmacy. It will encourage better care by providing GPs with training, payments, and information about how well their practice is performing. It will use a new computer program to help GPs and pharmacists make the right decisions about medicines. Patients’ concerns and wishes about their medicines will remain central. We will base IMPPP on similar approaches our team has used in Scottish GP surgeries, called POEMS and DQIP2. Unfortunately, POEMS and DQIP2 are both developmental, so we cannot tell if they will be successful in improving care. In developing IMPPP, we will be able to use and improve upon what we have learned from POEMS and DQIP2. This project has 3 parts: 1. Firstly, we will speak to health care professionals and patients with experience of POEMS and DQIP2. This will tell us what they think of these existing approaches. We will use prescribing data gathered by the Scottish GP computer systems to help us understand which people with polypharmacy will benefit most from improved care. We will use this information to design the new IMPPP method, with the help of patients and other experts. 2. Secondly, we will test IMPPP in 3 Bristol-based GP surgeries. We will interview individuals in these surgeries to find out about any problems with IMPPP so we can improve it. 3. Thirdly, we will carry out a clinical trial in Bristol and Staffordshire. The trial will compare 27 surgeries using IMPPP to 27 surgeries using current, normal practice. We will check whether IMPPP results in improved medicines safety, less use of health services, and better quality of life and less burden of treatment for the patients involved. We will also check whether IMPPP is acceptable to patients and both doctors and pharmacists, and will find out the cost implications of IMPPP for the NHS. This research will provide us with valuable information about which people with polypharmacy might benefit most from having improvements made to their medicines, and tell us what approaches work best for improving the use of medicines in people with polypharmacy, including how GPs and pharmacists can work together most effectively to achieve this. If it works, it should be possible to use the IMPPP approach across the NHS, helping many people with polypharmacy. We will work closely with the public and other patient groups throughout this research, to make sure that we take on their views in the design of the IMPPP approach itself, the research more generally, and when publicising the findings.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE