@PharmSafe @Improve_Academy #WeStopMeds

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

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) https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3335-z

Polypharmacy facts and figures 3 million people in the UK will have a long term condition managed by polypharmacy by 2018 . 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.

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. 2015 Jun;24(6):637-46

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

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:

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

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

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

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.

Our Approach Q.I. Provide tools Identify barriers

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

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

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

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

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!)

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.

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

Results so far Graph produced by QI Software from

And more Graph produced by QI Software from

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.

@Improve_Academy #WeStopMeds www.improvementacademy.org Sarah.de-biase@yhahsn.nhs.uk t: 01274 38 3904; 07739140659 e: academy@yhahsn.nhs.uk @Improve_Academy #WeStopMeds