The 2012 the National Polypharmacy Guidance was the basis for a Lothian-wide polypharmacy reviewproject. Over a 4 year period 9,199 polypharmacy reviews were carried out by the pharmacy team. This resulted in 10,813 medicines being stopped (an average 1.2 medicines per patient) of which 25% were high risk medicines.In addition 2,436 doses were reduced, 384 doses increased, 1,278 medicines started and 753 medicines switched. The average cost saving per patient was £100 per year.This project had its limitations in that all reviews were paper-based and relied on GPs acting on recommendations made by the pharmacist (70% uptake).
The pharmacy team, in line with the ethos of the national guidelines for polypharmacy review, progressed this work to a multidisciplinary team (MDT) setting to further improve the pharmaceutical care, and reduce the risk of medicines-related harm, in the frail elderly population. The MDTconsisted of a Consultant geriatrician, a registrar, GP in training, a GP, pharmacists and care home staff.The MDT reviews resulted in an increase in the cost saving per patient per year (£560 per patient per year in one care home) as GPs were generally more confident in stopping inappropriate medicines with consultant input.These meetings proved to be anexcellent environment for learning and highlighting the application of the national polypharmacy guidance. This MDT approach however was only occurring in a small number of care homes in South Edinburgh.
Based on the success of these MDT polypharmacy reviews and the increase in the pharmacy workforce withinprimary care the SW pharmacyteam, with approval from the 17 SW Edinburgh GP practices, agreed to work towards annual MDT reviews of all 11 Care Homes within the locality.In addition the SW locality GP’s agreed to trial extending this MDT polypharmacy review approach to all housebound patients greater than 75 years of age and on greater than 10 medicines on repeat. Not all GPpractices were responsible for a care home so extending the MDT reviews to thehouseboundmeant all practices within SW Edinburgh could gain experience in polypharmacy review in the frail elderly.An invest to save project bid was successful and funding was received for for a six month period.
Results: The care home reviews are on target for an annual reviewas 5 out the 11 care homes were reviewed in the six month period.
In addition a total of 7 GP practices had a multidisciplinary review of their frail elderly housebound patients ( housebound results: 169 patients reviewed, 162 medicines stopped of which 40% were high risk, 113 dose/formulation changes and 20 medicines started)
In summary the MDT polypharmacy reviews have contributed to changing the culture of prescribing in the frail elderly within primary care.A quality improvement bid has also been submitted by one of the practices to answer the question “Does targeting polypharmacy reviews in the frail elderly reduce admissions to hospital?”
These quotes sum up how the project went beyond just polypharmacy reviews:
“I thought it was an excellent opportunity to have protected time to properly review and rationalise all the medications from an evidence based perspective, with the expert help of the geriatrician and yourselves. Would be very happy to have further sessions as it will improve patient safety in the longer term.”
“I’ve found this a really good project and I’ve really enjoyed getting out and meeting some of the pharmacists and GPs. I think it goes beyond polypharmacy in that it is bridging links between secondary and primary care”
“although my housebound review savings have worked out at £173.97 per patient per year I really feel that this figure doesn’t matter- as we have stopped some drugs that could cause harm and that is just not quantifiable. Also some visits have been really worthwhile just for an opportunity for the patients to discuss their medicines”