Summary of the example
The Safer Prescribing for Frailty project, supported by Harrogate & Rural District CCG medicines management team in partnership with Yorkshire & Humber AHSN Improvement Academy (funded by the Health Foundation), recruited 12 general practices from across North and West Yorkshire. Practices were enrolled onto an innovative primary care quality improvement programme combining behaviour change theory to Institute for Healthcare Improvement (IHI) method of quality improvement. They were provided with training and support in identifying patients with frailty and tools to actively manage polypharmacy. Learning workshops focused on cognitive barriers identified to deprescribing, patient concerns and how to address them, quality improvement activity measurement.
Over the 24 weeks of the project practices achieved a 6% reduction in the average number of prescription items prescribed to people with frailty.
Why we think it’s important
The population is ageing, with increasing incidence of people living with frailty. Frailty is a distinct health state which develops as part of the ageing process, approximately 10% of people aged over 65 years and 25 to 50% of those aged over 85 years have frailty. Frailty means that even minor events can trigger disproportionate changes in health status after which the patient fails to recover to their previous level of health. Active management of older people with frailty through the provision of preventative and individualised care can help avoid crisis events.
Problematic polypharmacy is a recognised burden on the health of people living with frailty. Being on 10 or more medicines is common for people with frailty and the combined side-effects and errors contributes to a 300% increase in hospital admissions when compared to a someone without frailty on less than 5 medicines.
GMS contractual arrangements require GPs to use an appropriate tool, e.g. electronic Frailty Index, to identify patients aged 65 and over who are living with moderate and severe frailty. The British Geriatrics Society (BGS) guidelines recommend GPs review medicines as part of a holistic medical review of older people with frailty.
Learn more about the example
Aims and objectives of the work
The aim of the project was to work with GP practices to reduce inappropriate* polypharmacy for people with frailty.
*inappropriate prescriptions were ‘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.’
- Improve medication review, and reduction in potential inappropriate prescribing for frail elderly.
- Improve knowledge and skills of primary care team in reference to deprescribing.
- Develop intervention specific to the setting for undertaking and improving medication reviews using evidence based tools and national guidelines.
- Train primary care teams in transferable Quality Improvement skills.
- Evaluate how psychological theory could be used to assess the barriers to deprescribing medications with older people at risk of severe frailty in primary care; and identify the factors contributing to deprescribing practice among primary care health care professionals.
The Training and Action for Patient Safety (TAPS) methodology was used to support practices reduce inappropriate prescribing in patients living with frailty. This included:
- Training in clinician behaviour change theory and tools.
- Training in change management and quality improvement techniques.
- Increased awareness of evidence based tools to support medication reviews e.g. STOPP/START and the Scottish polypharmacy guideline.
- Opportunities to learn and share good practice with fellow primary care practitioners.
- A package of on-going support from the Improvement Academy team including on-site visits.
The project used an understanding of the cognitive barriers to stopping medicines to enable GP practice teams to design, test and embed ways to better meet the medication needs of their frail populations.
The project had the following key components:
- A series of 4 learning workshops to be attended by members of GP practices.
- First – orientation
- Second – education, patient concerns, QI methods, cognitive barrier feedback
- Third – geriatrician presentation, patient perspectives
- Fourth – celebration event, practice teams feedback
- QI activity by the GP practice members using IHI model.
- Measurement of improvement using run-charts.
- Application of psychological theories to tailor improvement activity to overcome cognitive barriers in stopping medicines.
The programme was led by quality improvement and behavioural change experts from the Improvement Academy over a 24 week period. Following the training, the teams were supported to develop interventions to apply evidenced based tools to support deprescribing utilising the electronic frailty index to identify patients. The main measure used was the total number of repeat prescription items within each practice’s defined cohort. There was fortnightly monitoring of the impact of change over the project period.
Twelve GP practice teams, from five CCGs in Yorkshire and Humber, completed the 24 week programme. Ten teams carried out multiple plan-do-study-act (PDSA) cycles;- 2 teams provided a limited contribution.
When cognitive barriers were collated a broad range of barriers were identified. Lack of knowledge scored highest followed by environment. However, other barriers such as social influences and fear of consequences were also cited.
Interventions were GP practice specific and tailored to the specific barriers identified within that practice. However, there were commonalities across practices, including:
- Use of templates for recording medication reviews.
- Better use of available skills, particularly the optimal use of practice pharmacists for teams with access to one.
- Protected time for polypharmacy medication review consultations.
- Consideration of home visits for medication review consultations.
- Sharing learning within the wider GP practice team.
- Development of a ‘Gold Standard’ approach to medication reviews.
Aggregate data for the 10 teams demonstrated a ~6% (795 prescription items) reduction in the number of prescribed items (the improvement measure).
Determining whether stopping a medicine was inappropriate (by study definition) using routinely available data was not possible. Other concerns are that not all patient benefits would be shown by measuring reduced prescribing only as dose reduction also shows improvement in inappropriate prescribing.
To address these concerns a ‘deep dive’ into the records of one GP practice was undertaken by a senior pharmacist; notes of 74 of the 111 patients with frailty were audited (average age 83). The audit demonstrated an average saving of £69.27 per review with 30% medicines stopped being high risk in frail elderly patients. Of the medicines stopped, 17% reduced anticholinergic burden. Overall the project improved care for patients living with frailty by achieving more appropriate prescribing and improving the culture of prescribing in participating practices.
Links to the project outline, a summary of the impact and outcomes and the ‘Achieving Behaviour Change’ for patient safety toolkit are below.
A link to the final project report ‘Safe prescribing for frailty. A story of polypharmacy reduction in General Practice’ will be added when it is published.
National guidance, data and publications
The adverse outcomes associated with polypharmacy, especially in the older population, are well recognised. National guidance in Scotland, England and from NICE provide background and tools to address and manage the problems.
Assistant Director, Lead pharmacist for Dental Medicines Information and Pharmacovigilance, North West Medicines Information Centre