Monitoring polypharmacy and reducing problematic prescribing
In this Audit 
Audit Focus
Patients taking ten or more medicines are at an increased risk of adverse events. The objective of this audit is to encourage documented medicine reviews for patients who
are taking ten or more medicines simultaneously. For the purposes of this audit, the term “medicine review” refers to a systematic process where all of the medicines a patient
is taking (including those prescribed by other providers and medicines and supplements purchased over-the-counter [OTC]) are listed, reviewed with the patient and the need for
treatment continuation or withdrawal documented for each medicine.
Background
Polypharmacy in New Zealand is growing as the age of the population and the number of people with multimorbidity increases. Polypharmacy is appropriate when the
potential benefits of multiple treatments outweigh the potential harms. However, polypharmacy also increases the risk of adverse health outcomes. These can occur when
medicines adversely interact with each other, or when the patient does not receive the intended benefit of treatment or when patients continue to take medicines for
longer than is beneficial. Among older patients polypharmacy is associated with falls and fractures, dehydration and acute kidney injury, delirium, hypoglycaemia,
malnutrition, hospitalisation and death.
Medicine reviews can help practitioners reduce the risk of problematic prescribing because they:
- Identify prescription medicines that may have been initiated by another prescriber, e.g. following discharge from hospital
- Identify previously unknown OTC medicines or supplements that the patient might be regularly taking, e.g. non-steroidal anti-inflammatory drugs (NSAIDs), St John’s Wort
- Provide an opportunity to discuss the goals of care, e.g. whether the continued use of a statin is appropriate in an older patient with progressive chronic
obstructive pulmonary disease (COPD)
- Encourage prescribers to use best practice guidance to reduce problematic prescribing; guidance may have changed since the medicines were initiated
Documenting medicine reviews is an important part of the medicine reconciliation process and information should be recorded so it is easily accessible. Documentation provides
other members of the primary care team with information about the patient’s treatment regimen, e.g. the use of OTC products, as well as the reasons why each medicine is being
taken and why any medicines have been withdrawn, e.g. intolerance. A formal medicine review is therefore more comprehensive than the routine three-monthly review that occurs
when patients are provided with repeat prescriptions. Formal medicine reviews are systematic, and in patients who are taking ten or more medicines, they are likely to
require a dedicated consultation.
Pharmacists are able to assist general practices in performing medicine reviews and there are several levels of involvement. Community pharmacists are able
to perform medicine reconciliations and are well placed to detect patients who are not collecting all of their prescriptions or who are taking OTC products. Clinical
pharmacists can provide more specialised assistance by being able to examine the patient’s medical record, and their role in medicine reviews in primary care is increasing.
Some DHBs have programmes in place where specifically trained pharmacists are able to assist general practices in performing medicine reviews.
For further information on polypharmacy in primary care, see:
www.bpac.org.nz/BPJ/2014/October/polypharmacy.aspx
Recommendation
Patients taking ten or more medicines are at an increased risk of harm and are likely to benefit from regular medicine reviews. It is recommended
that a formal medicine review should be undertaken at least every 12 months for patients who are taking ten or more medicines. The following steps are suggested
when performing a medicine review:
- Ask the patient to bring all their medicines, including OTC and alternative products, to the consultation and list each
medicine and the regimen. Family members, partners or caregivers may also be invited to participate, where appropriate.
- Record all of the patient’s medicine intolerances and previous treatment withdrawals
- Discuss each medicine with the patient and the need for ongoing treatment, weighing risks and benefits, via shared-decision making and document the results of this discussion
Encourage the patient to see the medicine review as an opportunity to optimise care so that they do not feel concerned about the potential withdrawal of treatment.
It may be helpful to explain to the patient that due to the physiology of ageing, e.g. declining renal function, the benefits and risks of treatment change with age.
For example, patients aged over 80 years are unlikely to have an extended life expectancy due to statin treatment and are at an increased risk of statin-associated myalgia.
Audit plan
The recommended steps for completing the audit are:
- Select 20 patients who are currently prescribed ten or more medicines
- Review each patient’s notes to establish if there is documented evidence of a medicine review by yourself, another prescriber or a pharmacist in the last 12 months
- Patients who are taking ten or more medicines, who have not had a medicine review in the last 12 months, should be flagged for a review. This could involve sending out letters.
Standards
Ideally all patients who are prescribed ten or more medicines will have documented evidence of a medicine review in the last 12 months.
However, for the purposes of this audit a target of 90% of patients with documented medicine reviews is suggested.
Data
Identifying patients
Search for patients who are currently prescribed ten or more medicines concurrently.
Sample size
Take the first 20 results returned from a search.
Review patient notes
Review each patient’s notes to establish if there is documented evidence of a medicine review in the last 12 months.
Criteria for a positive result
In order to score a positive result in this audit, patients prescribed ten or more medicines should have documentation of a formal medicine review within the last 12 months.
Identifying opportunities for Audit of Medical Practice
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual
performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
Taking action
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s).
- Change it to an aim.
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change.
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
Effective interventions
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to
bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behavior
Review
Monitoring change and progress
It is important to review the action plan at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
Audit
of Medical Practice summary sheet (Appendix
1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data
collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder
of the Audit of Medical Practice summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.