Interventions for those with polypharmacy

A systematic review concluded that preventable medication-related harm remains a frequent and enduring serious problem, causing severe or potentially life-threatening outcomes in over a quarter of all preventable harm cases.³⁵ The risk is particularly high in inpatient care settings, geriatric care, specialised care settings, intensive care and emergency departments.³⁶ A person-centred approach to address their needs enables self-management. Involving individuals in decisions has been shown to address up to 15% of harm.³⁷ Public involvement is also important in changing policy³⁸ as well as nudge theory to support behaviour change, human factors, and change management for a scalable, sustainable solution to preventable medication-related harm due to inappropriate polypharmacy.

A rapid review of nine systematic reviews including international studies on polypharmacy³⁹ assessed the burden of problematic polypharmacy. While all systematic reviews showed an improvement in reducing inappropriate polypharmacy, the impact on other outcomes was mixed and the quality of the evidence was variable. From a safety perspective, Page et al. found no evidence to suggest that deprescribing increases the risk of adverse outcomes,⁴⁰ suggesting deprescribing following a medication review is a possible way to reduce inappropriate polypharmacy. This adds an important contribution as one of the challenges when addressing inappropriate polypharmacy is confidence by prescribers to reduce or stop medication originally intended for long-term use, for fear of harm to the individual. 

NHS Scotland introduced a person-centred programme for medication review to address inappropriate polypharmacy. This drew on work from indicators developed by Pirmohamed et al. (which identified a list of high-risk medications),²⁹ the pharmacist-led information technology intervention for medication errors (PINCER trial),⁴¹ and the Data-Driven Quality Improvement in Primary Care (DQIP) programme.⁴²

The DQIP programme evaluated indicator-based case finding and decision support, combined with education and financial incentives for medication review. This was a cluster randomised controlled trial and included 34 general practices in Scotland. The DQIP intervention significantly reduced high-risk prescribing (of NSAIDs and antiplatelets) by 37% and reduced associated emergency hospital admissions (for gastro-intestinal bleeding by 34%, for heart failure by 27%, and for acute kidney injury by 14%). The PINCER trial showed that a pharmacist-delivered information technology intervention substantially reduced the frequency of a range of clinically important prescription and medication monitoring errors. Related qualitative work showed the acceptability of the PINCER intervention to general practices, and staff valued the additional educational input and support provided by the pharmacist. 

Problematic polypharmacy is not just a technical problem but a relational challenge. Medication review is not a ‘one-off’ activity, but an ongoing collaborative process characterised by small, incremental changes.⁴³

Translation of learning from these safety prescribing programmes in Scotland was achieved by inclusion into national polypharmacy guidance,²⁵ by adopting the key recommendations from SIMPATHY and using the 7-Steps medication review process. This is supported by a suite of 69 indicators to identify individuals most at risk and 27 polypharmacy outcome indicators at a national level to show the improvements in reduction of medication-related harm.⁴⁴

A rapid review of polypharmacy guidelines and studies was undertaken in November 2023. These were reviewed to consider any additional evidence and insights, and support the person-centred approach to address inappropriate polypharmacy, appreciating that there may need to be additional therapy to achieve therapeutic objectives, for example to improve symptomatic control for heart failure. This ensures that the focus is on improving patient outcomes with medicines. The outcomes since then of the iSIMPATHY project have provided the validated methodology to achieve this.⁹ Studies are needed to explore the potential of pharmacogenomic interventions to improve the outcomes of people with multimorbidity where multiple medications are indicated. This could be undertaken in the context of a medication review.

There is the need to address barriers and support facilitators to deal with the change management methodologies outlined in both SIMPATHY² and iSIMPATHY.⁹ Key tools such as PESTEL (Political, Economic, Social, Technological, Environmental and Legal) and SWOT (Strengths, Weaknesses, Opportunities and Threats) can be used to highlight these, as well as Kotter to ensure implementation.^2,9,45,46