(ID: 235) Can overprescribing in primary care be addressed by secondary care pharmacists? Evaluation of a proof of concept pilot

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them. Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis. Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication. SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Introduction Reducing overprescribing in primary care through targeted structured medication reviews (SMRs) is a national priority. Shared decision-making and a multidisciplinary team (MDT) approach to SMR are recommended for successful deprescribing (stop/reduce inappropriate medications) among older people, specifically those with frailty. Aim To develop a multidisciplinary medication review and deprescribing intervention in primary care for older people with frailty. Methods The intervention development involved two stages and was informed by the Medical Research Council framework for complex intervention. Stage one involved intervention planning and included: 1) a realist review of 28 articles that identified 35 context-mechanism-outcome (CMO) configurations for successful MDT medication review and deprescribing in primary care[1] and 2) a qualitative study with 26 primary care healthcare professionals (HCPs) including GPs, pharmacists, and advanced clinical practitioners, and 13 older people with polypharmacy and their informal carers recruited from two general practices within Wessex. Using the person-based approach, drawing on the COM-B model for behaviour change, and a normalisation process theory lens, the findings of these two studies informed the development of intervention’s guiding principles. Stage two involved intervention development based on six co-design online workshops with key stakeholders (n=25), including primary care HCPs recruited from across the South region, patient and carer representatives, and the research management team. The intervention guiding principles were presented in these workshops and possible intervention content, format and delivery were proposed, discussed and refined through an iterative process. Workshop data were analysed drawing on a rapid analysis method and a final version of the intervention was agreed. Results The final version of the complex intervention consisted of five main components based on findings from stages one and two: 1) Proactive identification of patients with frailty and polypharmacy for targeted SMR using the electronic frailty index embedded in primary care health systems and the UK national polypharmacy prescribing comparators, 2) HCPs preparation to conduct SMR through targeted education on deprescribing and identifying and prioritising high-risk medications for deprescribing using evidence-based deprescribing tool(s), 3) Preparing and educating patients and carers about the purpose of SMR and reasons for potentially stopping or changing medications (patient leaflet sent prior to SMR), 4) Conducting a person-centred SMR that includes in-person, phone or virtual appointments tailored to patient and carer needs and preferences, involving other MDT members based on their expertise, documenting and sharing any agreed changes with patients and other staff members, and 5) Tailored follow-up plans that allow continuity of care and management and include highlighting specific signs and symptoms for patients and carers to monitor following medication changes, and arranging further contact through text, phone or in-person follow-up appointment. Conclusion The use of multiple research methods has led to the development of a complex MDT medication review and deprescribing intervention for older people with frailty and drawing on behaviour and implementation theories could potentially maximise the intervention’s feasibility, acceptability and successful implementation. A mixed-method study in primary care is currently underway to test the feasibility and acceptability of intervention implementation, in preparation for a full trial.

Background Alcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new ‘holistic’ service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone ‘healthy living’ or ‘lifestyle’ question. Method Semi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery. Results SMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking. Conclusions Including alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.

SummaryObjectivesTo identify the number and characteristics of patients with polypharmacy receiving structured medication reviews (SMRs) and medication reviews in primary care in 2022, and to evaluate whether the provision of these services is equitable across different demographic and socio-economic groups.DesignCross-sectional study.SettingPrimary care networks in North West London, UK.ParticipantsAdults registered with a general practitioner (GP) and regularly prescribed at least five medicines or more.Main outcome measuresReceipt of at least one SMR and any kind of medication review during the study period (2022).ResultsAmong 515,042 adults regularly prescribed with medication, 167,482 were regularly prescribed at least five medicines, defined as polypharmacy. 53.3% (89,220) of these patients received at least one kind of medication review and 17.2% (11,954) of them received SMRs. Patients who were males, black, more affluent, and frailer, were more likely to receive medication reviews, while those who were males, less affluent, and frailer, were more likely to receive SMRs.ConclusionsAlthough polypharmacy was common in North West London, only about half of eligible patients received medication reviews, and only 17.2% received SMRs. Different distributions of medication reviews and SMRs by demographic and socio-economic characteristics may indicate inequities in the provision of these services. Policy makers should consider effective ways to incentivise the equitable provision of SMRs.

Introduction Problematic polypharmacy in older people living with frailty can cause harm due to adverse drug events and deprescribing (withdrawing inappropriate medication to manage polypharmacy and improve outcomes (1)) is one solution to mitigate this. Structured Medication Reviews (SMRs) have been commissioned in England to be conducted by Primary Care Network (PCN) pharmacists for which older people living with frailty are a priority group. SMRs are an ideal opportunity to deprescribe for this high-risk population and a person-centred approach is required to ensure deprescribing is safe, effective and acceptable to patients. However, the optimal deprescribing process has not been developed and tested in this context. Aim To develop a person-centred process for deprescribing for older people living with frailty which could potentially be implemented within SMRs in primary care. Methods We conducted qualitative research with older people living with frailty, carers and primary healthcare professionals to identify barriers and facilitators to deprescribing in this context in the North of England (2). We then used these findings and a “trigger film” of patients’ experiences to conduct Experience-based Co-design (EBCD), a multi-event process where older people living with frailty, informal carers and primary healthcare professionals came together to determine the key features of an ideal deprescribing process and identify priorities for a complex intervention to support the process. Following this, we presented the process model for feedback at the training day of a large multi-site primary care practice based (involving pharmacists, GPs and administrative practice staff) in the North of England and subsequently refined the model to integrate within their evolving SMR programme. Results The co-designed deprescribing process consisted of 3 phases: 1. Prior to the SMR consultation which involved case-finding of high-risk patients, case-note review for deprescribing eligibility and clinician planning for the consultation, inviting and preparing the patient for the consultation with written information (including what to expect during the medication review, and questions for patients about their medicines to reflect upon); 2. The consultation which included shared decision-making, agreement of plans to stop medicines, recording of decisions in the electronic health record, providing written information for patients on how to safely stop their medicines, safety netting and signposting to post-deprescribing support; 3. Post-consultation which involved evaluating patient experiences and organising follow-up and further review as needed. Key elements of the optimal process to ensure it was person-centred, were effective written and verbal communication for patients (during the entire process), shared decision-making and tailored support post-consultation. Conclusion We have developed a person-centred process for deprescribing for older people living with frailty and adapted it for implementation within nationally commissioned SMRs in England. Although the model is grounded in the requirements of multiple stakeholders, the final version requires evaluation. The next steps are to design and develop tools which can support our deprescribing process and to undertake feasibility testing in primary care.

ObjectivesThis study explored how Structured Medication Reviews (SMRs) are being undertaken and the challenges to their successful implementation and sustainability.DesignA cross-sectional mixed methods online survey.SettingPrimary care in England.Participants120 clinical pharmacists with experience in conducting SMRs in primary care.ResultsSurvey responses were received from clinical pharmacists working in 15 different regions. The majority were independent prescribers (62%, n=74), and most were employed by Primary Care Networks (65%, n=78), delivering SMRs for one or more general practices. 61% (n=73) had completed, or were currently enrolled in, the approved training pathway. Patient selection was largely driven by the primary care contract specification: care home residents, patients with polypharmacy, patients on medicines commonly associated with medication errors, patients with severe frailty and/or patients using potentially addictive pain management medication. Only 26% (n=36) of respondents reported providing patients with information in advance. The majority of SMRs were undertaken remotely by telephone and were 21–30 min in length. Much variation was reported in approaches to conducting SMRs, with SMRs in care homes being deemed the most challenging due to additional complexities involved. Challenges included not having sufficient time to prepare adequately, address complex polypharmacy and complete follow-up work generated by SMRs, issues relating to organisational support, competing national priorities and lack of ‘buy-in’ from some patients and General Practitioners.ConclusionsThese results offer insights into the role being played by the clinical pharmacy workforce in a new country-wide initiative to improve the quality and safety of care for patients taking multiple medicines. Better patient preparation and trust, alongside continuing professional development, more support and oversight for clinical pharmacists conducting SMRs, could lead to more efficient medication reviews. However, a formal evaluation of the potential of SMRs to optimise safe medicines use for patients in England is now warranted.

Providing Complementary and Alternative Medicine in primary care: the primary care workers’ perspective

Overprescribing proton pump inhibitors

Reducing polypharmacy and overprescribing in older people living with frailty is challenging. Evidence suggests that this could be facilitated by structured medication review (SMR) and deprescribing processes involving the multidisciplinary team (MDT). This study aimed to develop an MDT SMR and deprescribing intervention in primary care for older people living with frailty. Intervention development was informed by the Medical Research Council framework for complex intervention and behaviour change and implementation theories. Intervention planning included: 1) a realist review of 28 papers that identified 33 context-mechanism-outcome configurations for successful MDT SMR and deprescribing in primary care, 2) a qualitative study with 26 healthcare professionals (HCPs), 13 older people with polypharmacy and their informal carers. The intervention's guiding principles were developed and intervention functions proposed, discussed and refined through an iterative process in four online co-design stakeholder workshops. The final version of the complex intervention consisted of five components: 1) Proactive identification of patients living with frailty and polypharmacy for targeted SMR using routinely collected primary care data; 2) HCPs' preparation using an evidence-based deprescribing tool to identify and prioritise high-risk medications for deprescribing; 3) Preparing patients and carers using a leaflet sent prior to SMR explaining the purpose of SMR and reasons for potentially stopping or changing medications; 4) Conducting a person-centred SMR face-to-face or by phone, tailored to patient/carer needs, involving other MDT members based on their expertise; 5) Tailored follow-up plans allowing continuity of care and highlighting signs and symptoms for patients and carers to monitor, and arranging follow-up through text, phone or face-to-face appointment. A complex MDT SMR and deprescribing intervention for older people living with frailty was developed to address multiple challenges to deprescribing. The use of rigorous methods and behaviour and implementation theories potentially maximises the intervention's feasibility, acceptability and successful implementation.

Introduction Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting. Method Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22-28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made. Results Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioid medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six-month review. Conclusion(s) Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

BackgroundNHS England has introduced a new structured medication review (SMR) service within primary care networks (PCNs) forming during the COVID-19 pandemic. Policy drivers are addressing problematic polypharmacy, reducing avoidable hospitalisations, and delivering better value from medicines spending. This study explores early implementation of the SMR from the perspective of the primary care clinical pharmacist workforce.AimTo identify factors affecting the early implementation of the SMR service.Design and settingQualitative interview study in general practice between September 2020 and June 2021.MethodTwo semi-structured interviews were carried out with each of 10 newly appointed pharmacists (20 in total) in 10 PCNs in Northern England; and one interview was carried out with 10 pharmacists already established in GP practices in 10 other PCNs across England. Audiorecordings were transcribed verbatim and a modified framework method supported a constructionist thematic analysis.ResultsSMRs were not yet a PCN priority and SMR implementation was largely delegated to individual pharmacists; those already in general practice appearing to be more ready for implementation. New pharmacists were on the primary care education pathway and drew on pre-existing practice frames, habits, and heuristics. Those lacking patient-facing expertise sought template-driven, institution-centred practice. Consequently, SMR practices reverted to prior medication review practices, compromising the distinct purposes of the new service.ConclusionEarly SMR implementation did not match the vision for patients presented in policy of an invited, holistic, shared decision-making opportunity offered by well-trained pharmacists. There is an important opportunity cost of SMR implementation without prior adequate skills development, testing, and refining.

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

AimsThe COVID-19 pandemic caused significant disruption to routine activity in primary care. Medication reviews are an important primary care activity ensuring safety and appropriateness of prescribing. A disruption could have significant negative implications for patient care. Using routinely collected data, our aim was first to describe codes used to record medication review activity and then to report the impact of COVID-19 on the rates of medication reviews.MethodsWith the approval of NHS England, we conducted a cohort study of 20 million adult patient records in general practice, in-situ using the OpenSAFELY platform. For each month, between April 2019-March 2022, we report the percentage of patients with a medication review coded monthly and in the previous 12 months with breakdowns by regional, clinical and demographic subgroups and those prescribed high-risk medications.ResultsIn April 2019, 32.3% of patients had a medication review coded in the previous 12 months. During the first COVID-19 lockdown, monthly activity decreased (-21.1% April 2020), but the 12-month rate was not substantially impacted (-10.5% March 2021). The rate of structured medication review in the last 12 months reached 2.9% by March 2022, with higher percentages in high-risk groups (care home residents 34.1%, 90+ years 13.1%, high-risk medications 10.2%). The most used medication review code was Medication review done 314530002 (59.5%).ConclusionsThere was a substantial reduction in the monthly rate of medication reviews during the pandemic but rates recovered by the end of the study period. Structured medication reviews were prioritised for high-risk patients.

ObjectivesTo investigate the feasibility of delivering structured psychotropic medication review in community services for adults with intellectual disability (ID).DesignSingle-arm feasibility study conducted over a 6-month period.SettingSpecialist community ID teams in...

Executing structured medication reviews (SMRs) in primary care to optimize drug treatment is considered standard care of community pharmacists in the Netherlands. Patients with Parkinson's disease (PD) often face complex drug regimens for their symptomatic treatment and might, therefore, benefit from an SMR. However, previously, no effect of an SMR on quality of life in PD was found. In trying to improve the case management of PD, it is interesting to understand if and to what extent SMRs in PD patients are of added value in the pharmacist's opinion and what are assumed facilitating and hindering factors. To analyse the process of executing SMRs in PD patients from a community pharmacist's point of view. A cross-sectional, qualitative study was performed, consisting of face-to-face semi-structured in-depth interviews. The interviews were conducted with community pharmacists who executed at least one SMR in PD, till data saturation was reached. Interviews were transcribed verbatim, coded and analysed thematically using an iterative approach. Thirteen pharmacists were interviewed. SMRs in PD were considered of added value, especially regarding patient contact and bonding, individualized care and its possible effect in the future, although PD treatment is found already well monitored in secondary care. Major constraints were time, logistics and collaboration with medical specialists. Although community pharmacist-led SMRs are time-consuming and sometimes logistically challenging, they are of added value in primary care in general, and also in PD, of which treatment occurs mainly in secondary care. It emphasizes the pharmacist's role in PD treatment and might tackle future drug-related issues. Improvements concern multidisciplinary collaboration for optimized SMR execution and results.