Multi-morbidity and associated polypharmacy present a significant and increasing challenge to patients, carers and healthcare professionals. Drug interactions, adverse drug events and non adherence can cause harm and lead to hospital admissions, especially in people living with frailty. Across a general practice population, it is difficult to predict which patients are most at risk from their medicines. 'At risk' patients often only present after a catastrophic event (e.g. fall or acute kidney injury) has already occurred. Pro-actively identifying such vulnerable patients is essential to minimise harm and prevent avoidable hospital admissions.
West Hampshire CCG (WHCCG) Medicines Optimisation team devised the Polypharmacy Risk Identifier Tool (PRIT) for this purpose. PRIT is a macro-enabled spreadsheet populated with data from the GP clinical system (SystmOne and EMIS Web - see PRIT image and anonymised outputs attached for both systems) that identifies patients most at risk from polypharmacy, either by virtue of the nature (e.g. high-risk) or the number of medicines currently being prescribed and the individual's clinical scenario. The screening tool allocates each patient in the practice a score; patients with high scores can be prioritised for a comprehensive medication review. Medication review enables patients to make informed decisions about stopping medicines, in order to maximise benefit and minimise harm.
GP Clinical Systems contain a wealth of information which can be used for risk stratification to improve patient care. However, without a means of sifting through the data, it is difficult to target healthcare interventions to the most needy. By drawing on evidence-based practice, the PRIT pulls together a series of clinical system searches to identify the following: patient details, age, GP, residential status, functional status (e-Frailty Index), number of repeat medications; high-risk drugs (e.g. causing falls, hypoglycaemic attacks, bleeds) and high-risk clinical scenarios. This allows identification of vulnerable patients living with frailty and polypharmacy for comprehensive medication review by the clinical pharmacists working in GP surgeries.
The spreadsheet tool is simple to use and integrates with the existing GP clinical system at the practice. It enables clinical pharmacist resource to be targeted at those patients who would derive most benefit from medication review. By specifically deprescribing unnecessary medicines, patient outcomes and experience are improved and avoidable harm is reduced. Whilst primarily a quality and safety initiative, the financial benefits to the health economy of reduced prescribing/ monitoring of medicines in terms of cost and workload for NHS staff are considerable, although difficult to measure on a large scale.
Patients are the main beneficiaries of the project: enhanced outcomes and experience, reduction of harmful polypharmacy, avoidance of adverse effects, minimising drug interactions, reducing avoidable hospital admissions.
Healthcare professionals also benefit: prioritising workload of clinical pharmacists; saving time for GPs and Practice Nurses and duplication of effort in practices; maximising efficiencies; systematic rather than opportunistic prioritisation; saving time and money for dispensing Community Pharmacists
The healthcare economy as a whole benefits by reduced prescribing costs, monitoring costs, reduced ambulance call-outs, decreased hospital admissions.
Falls are common in the older population and are recognised to be associated with considerable morbidity, immobility and mortality. Approximately 30% of people aged 65 years or older have a fall each year, increasing to 50% in people aged 80 years or older. With a population of just over half a million and around 70,000 patients over the age of 75 years in WHCCG, systematically prioritising medication reviews and identifying patients prescribed medicines that can cause falls is essential. The PRIT technology enabled 12,500 of the most vulnerable patients to have a comprehensive medication review and this resulted in targeted deprescribing of over 4,000 problematic medicines.
The NHS Business Services Authority has recently produced polypharmacy comparators and dashboards. Compared to its neighbours within Wessex and nationally, WHCCG is performing well on a number of indicators (e.g. Average number of unique medicines per patient; Percentage of patients prescribed 15 or more items and aged over 75 years; Percentage of patients prescribed a medicine likely to cause kidney injury (so-called 'DAMN' drugs)). NHS England has also published the first suite of medication safety indicators which show WHCCG in a good light compared to its peers.
