Programmes to address polypharmacy and high-risk medication

In the iSIMPATHY (implementing Stimulating Innovation Management of Polypharmacy and Adherence Through the Years) project,⁹ reviews were carried out in different settings including hospital in-patient, out-patient clinics and GP practice settings. This built on the work of the EU-funded SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly) project which spent two years studying polypharmacy management in Europe.² Case studies in nine EU countries were used to determine how programs to manage polypharmacy and adherence were implemented using change-management tools such as Kotter’s eight steps and PESTEL and SWOT.

In addition to a literature review, a benchmarking survey across the EU and a modified Delphi approach were used to establish an EU-wide consensus on how to address polypharmacy and a recommendation on what should be measured to demonstrate improvement.^78,79,80 From this, the key areas of consensus were around potential gain arising from polypharmacy management, strategic development, strategic change management, indicator measures, awareness raising and person-centred polypharmacy reviews.

In iSIMPATHY, a total of 6,481 people had a medicines review.⁹ The average age of those reviewed was 72 years and 53% were female. An average of six long-term conditions were recorded per person. The project pharmacists made an average of 11 interventions per review which included education, medicines reconciliation, medication changes and monitoring.

 

Key findings from the iSIMPATHY evaluation

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A number of key benefits were obtained by utilising the 7-Steps approach. Interventions made were graded for clinical significance, with 82% being classified as clinically significant and 968 (4%) potentially preventing major organ failure, medication-related harm or incidents of similar clinical importance. Recommendations were accepted in 94% of interventions. The average number of medications reduced from 12 to 11, with 91% of the reviews resulting in more appropriate medication use, therefore decreasing the likelihood of medication-related harm. Inappropriate medications were stopped (i.e. deprescribed), reduced or altered to improve appropriateness.

The changes in number of medications and improvement of appropriateness will minimise medication waste which is important to achieve both climate and sustainability strategies of the three jurisdictions. With respect to health inequalities, the criteria for review means that those from more deprived communities will benefit from reviews at younger ages due to a higher prevalence of multiple long-term conditions.

Individual experience was captured through Patient Reported Outcome Measures (PROMs). They reported large improvements in understanding, with over 90% reporting post-review that they fully understood their medicines and potential problems with them, compared with 16% pre-review. They reported reduced side effects, with 64% pre-review, reducing to 38% post-review. Improvements were also reported in people’s ability to perform their usual activities and in some parameters of medicines adherence. They also reported decreased pain, discomfort, anxiety and/or depression following these reviews.

Many people and carers were very appreciative of the opportunity to engage in reviews and very positive about the experience:

“No-one has ever sat down with me and taken time to go through all my medicines with me.”

“…huge improvement walked for half an hour this morning used to have to stop every few minutes because of the dizziness.”

 

The Scottish national polypharmacy programme implements the learnings from programmes such as SIMPATHY.² Projects such as PINCER⁴¹ and DQIP⁴² resulted in one to two medicines reduced per person, as well as an improvement in safety and quality indicators. The priority population were those over the age of 75 years, chosen to utilise the available resources. This generated an average net saving of 150 euros per person per annum, after considering the cost of staff for the reviews.² There were additional indirect benefits in the form of cost avoidance due to fewer adverse reactions and hospital admissions.

Another example of a program to address inappropriate polypharmacy is the study conducted in the Basque region.⁸¹ This study used the multidisciplinary SIMPATHY methodology to minimise inappropriate polypharmacy in a population of 360,000 citizens. This approach, with pharmacists and clinicians reviewing people with five potentially inappropriate medicines, resulted in statistically significant reductions in potentially inappropriate polypharmacy across primary and secondary care settings.