Title: Addressing the polypharmacy challenge in older people with multimorbidity: an in-depth ethnographic case study of experiences and practices to inform medicines optimisation in primary care.
Funder: Department of Health and Social Care

Abstract: BACKGROUND Mutlimorbidity, the co-existence of two or more ongoing medical conditions is common. It is often accompanied by polypharmacy, the co-prescription of four or more medications. Managing polypharmacy is demanding for patents/carers and complex for clinicians as health systems and the research that informs healthcare largely assume a single disease' model. Polypharmacy is a common cause of error, adverse drug reactions and hospital admissions, and is costly and wasteful to the NHS (approximately half the medicines prescribed for long term conditions are unused). Patients who are prescribed ten or more items of medication are at particularly high risk. Medicines optimisation' emphasises the importance of understanding patients' priorities for their care, but we know little about how polypharmacy and medicines optimisation' play out in practice for patients and clinicians. This qualitative study will explore the experience of polypharmacy in multimorbidity: the work that it demands of patients/carers/social networks; how health systems support or challenge polypharmacy; how professionals manage the complexity of polypharmacy to identify principled best practice' responses and translate practice into evidence'. AIMS To improve patient care by:Examining patients' experience of polypharmacy to discern elements of safe, high-quality prescribing and those that might lead to harmful/wasteful polypharmacyUnderstanding how polypharmacy is sustained/upheld/challenged within lay and professional networksAnalysing medication review' consultations to understand how medicines optimisation' and de-prescribing' is successfully negotiatedUsing participatory approaches to develop evidence-based e-learning materials, recommendations for high-quality prescribing in multimorbidity, and patient engagement resourcesWorking with established networks to disseminate findings/learning materials/ patient resourcesRESEARCH QUESTIONSWhat is the patient experience of polypharmacy in multimorbidity?What does polypharmacy mean for patients and carers?How are patients' lives with multimorbidity shaped by practices of managing medicines?How is the managing of medicines shaped by contingencies of living with multimorbidity? How do the practices of patients/carers/health professionals and wider systems of care support appropriate' or challenge inappropriate' polypharmacy and with what consequences for care quality and safety?How can insights from longitudinal patient case studies inform improvements in professional practices/service delivery and public awareness of polypharmacy?PLAN OF INVESTIGATION There are four work packages (WP1-4). Data analysis from WP1-3 will draw on linguistic ethnographic approaches informed by relevant social theory, informing development of outputs in WP4. WP1- Longitudinal ethnographic observation (in patients' homes and health settings) of a purposive, maximum variety sample of 30 patients, age 65 years or older, living at home with multimorbidity and prescribed 10+ medications. CHAR(13) + CHAR(10) Patients will be recruited from two contrasting research localities. Exploration of patients' knowledge, experience, practices, routines, strategies and sense-making around medicines-taking. Data will include interviews, fieldnotes, photographs and relevant documents relating to medicines-taking, building detailed case narratives. WP2 - Ethnographic study of professional practices relating to polypharmacy, including shadowing of key staff and gathering relevant documentation. Video-recording and micro-analysis of medication review' consultations. WP3 - Elicit professional accounts of medicines optimisation' including video-elicited feedback to identify critical moments' in the consultation. Video-reflexive ethnography groups to explore professional concerns/challenges/strategies. WP4 Co-design/dissemination of clinical e-learning materials and patient engagement resources. POTENTIAL BENEFITS TO PATIENTS AND NHS The research will:Make patients' treatment burden' visible and enable reduction in this burden in ways that are acceptable to patients and cliniciansIdentify where there are opportunities to avoid: unnecessary/unwanted treatments; vulnerabilities to error/waste; misunderstandings, and identify responses to thisExamine, develop and disseminate a principled good practice' approach to polypharmacy, informed by case examplesDevelop evidence-based e-learning resources for cliniciansIncrease patient engagement with the polypharmacy challenge through co-design/dissemination of patient resources

Lay abstract: BACKGROUNDMultimorbidity refers to the co-presence of two or more ongoing medical conditions. It is common, affecting most people over 65. Patients with multimorbidity are often prescribed four or more medications (polypharmacy'). Polypharmacy may be burdensome to patients, is a common source of error and is sometimes harmful - causing side effects and hospital admissions for example. Polypharmacy is also expensive and wasteful, since about half of prescribed medicines are unused. This research seeks to understand the experience of patients with multimorbidity who are prescribed ten or more medicines (this number may indicate a relatively high risk of adverse events), by following patients (and their medicines) over time. It will explore patients' understandings, beliefs and medicines routines, and their encounters with health professionals. This will include video-recording medication review' consultations to analyse how stopping medicines - when appropriate - can be successfully negotiated. Workshops with clinicians and pharmacists will inform the development of professional e-learning materials. A co-design process with service users will inform development of resources to encourage public awareness and debate about the scale and potential impact of polypharmacy. AIMS To build a detailed picture (case narratives') of polypharmacy in multimorbidity and improve patient care through:Detailed understanding of patients' experiences of polypharmacy.Documenting how patients' lives are shaped by managing medicines (and vice versa)Identifying elements of safe, high quality prescribing and those that may lead to harmful and/or wasteful polypharmacy Exploring how polypharmacy is sustained and/or challenged within lay and professional networksWorking with clinicians/pharmacists/patients/carers to:understand how decisions about optimising patients' medicines are worked throughdevelop e-learning resourcesdevelop patient engagement resources Disseminating research findings and professional/patient resourcesDESIGN AND METHODS The project hinges around detailed observation of the experience of 30 patients (c.15 from each of 2 GP surgeries) with multimorbidity who are prescribed ten or more medications. There are four work packages:Understanding patients' experience of polypharmacy6-8 interviews (per patient) in patients' homes over a 2-year period, encouraging them to tell their story' to discover how polypharmacy is experienced from patient (and carer) perspective.Additional data collection: photographs (e.g. of medicine storage); observational field notes of patients' encounters with the health service; documents (e.g. hospital discharge summaries)Monthly telephone contact will ensure continuity and identify key events. 2. Understanding professional behaviours in polypharmacy a. Interviews with key professionals involved in study patients' care exploring meanings/dilemmas/challenges in polypharmacy. b. Video-recording of medication review' consultations to discover whether/how opportunities to address inappropriate polypharmacy are negotiated.3. Exploring professional concerns a. Audio-recording of clinicians' feedback on their video-recorded consultations to identify key moments' in medicines decision-making b. Workshops: clinicians will watch video extracts, prompting inter-professional discussion about challenges/strategies for stopping medicines in potentially high-risk polypharmacy. The discussion will be recorded as data.4. Developing e-learning materials and patient resources a. Workshops with patients/professionals/stakeholders informing development of clinical e-learning resources. b. Co-design workshops with patients to develop patient engagement resources and raise awareness of polypharmacy issues WHY IS IT IMPORTANT? Analysis of the data will allow new insights into the experience and challenges of polypharmacy. The findings will inform development of evidence-based resources to increase clinicians' skill/confidence in managing polypharmacy, and patient resources to promote public understanding. It has potential to reduce medicines wastage and costs. PATIENT AND PUBLIC INVOLVEMENT The project proposal has been improved following discussions at two meetings with patients, additional e-mail feedback, and input from the appointed lay chair of the advisory group. Planned involvement includes:Advisory group includes 2 lay members and a lay chairPatient participation group to give feedback on:recruitment/participant information sheetsproject websiteinvitations to workshop/co-design activitieslay summary of final report Piloting of interviewsCo-designers of e-learning materials and patient resourcesDISSEMINATION Planned dissemination includes:Publicly accessible project website, maintained throughoutPublished academic papers (4)Conference presentations (5)Final project report and lay summaryE-learning materials (with RCGP, currently 61000 regular learners)Co-designed multimedia patient resourcesFinal project dissemination event, including invited stakeholders

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE