Safer Prescribing for Frailty

yorkshire icon Connected Yorkshire
Question Answer
Researchers involved: Dr Andy Clegg, Dr Sujo Anathhanam, Megan Humphreys, Sarah DeBiase, Christopher Ranson, Tony Jamieson
Main disease areas impacted: Frailty, polypharmacy
Key partners: Health Foundation, Improvement Academy, Y&H AHSN, Harrogate & Rural District CCG, University of Hull
Start and end dates: April 2017 – ongoing

Project Overview

People get a great deal of benefit from medicines. Medicines extend healthy lives and can maximise the opportunities for improved wellbeing. The use of medicines in the NHS is driven by one of the most robust regulatory systems in the world and the evidence base upon which decisions are made is beyond comparison.

However, the evidence that is available to inform decisions is not equitably robust. People living with frailty, a condition of accumulated physical and mental deficits leading to a state of vulnerability1, are not well represented in the trials that are used to populate the evidence. At the same time, having multiple deficits (co-morbidity) leads to people using multiple medicines, which has become known as polypharmacy. People with frailty are more susceptible to the side effects of medicines. Indeed, a person with frailty is six times more likely to be on 10 or more medicines2 and can be 300% more likely to be admitted to hospital as a result3. The challenge our project is trying to address is to help people with frailty get the best out of medicines, meeting their needs and reducing the problematic polypharmacy that might cause harm.


What data are you using? Are the data anonymised?

Routinely available General Practice data extracted from the clinical systems will be used to support project development and findings to support:

  • Quality improvement measures displaying the impact of the team interventions. Anonymised Primary Care record data around the number of items on a repeat prescription across a group of patients identified using the eFI.
  • Health economic evaluation covering emergency hospital admissions, A&E attendances, medications on repeat prescription, general practice primary care utilisation and Out of Hours encounters. This will be analysed alongside practice level project implementation costs and the potential harms avoided.

Additional qualitative feedback from the project delivery team and clinicians delivering the intervention will be collated throughout the project providing stories and insight to the impact, challenges, learning and successes of their work.


What methods are you using to conduct this work? (How are you using the data?)

The design of the project has 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 Institute for Healthcare Improvement (IHI) model.
  • Measurement of improvement using run-charts.
  • Application of psychological theories to tailor improvement activity to overcome cognitive barriers to stopping medicines.

The programme is led by quality improvement and behavioural change experts from the Improvement Academy alongside clinical Pharmacist input. Teams will be supported to develop interventions which apply evidenced based tools to support deprescribing utilising the electronic frailty index to identify patients.


Who will/could benefit? (What will we know that we don’t already?)

Holistic medication review, targeting problematic polypharmacy, normalises shared decision making and improves the quality of healthcare interactions. With this knowledge we are helping people with frailty and those supporting them to get the best out of medicines, meeting their needs and reducing the inappropriate prescribing that might cause harm.

Using an understanding of the cognitive barriers to stopping medicines we are enabling GP practice teams to design, test and embed ways to better meet the medication needs of their frail populations.

Empowering patients, family members, carers and health care professionals to explore and improve the safety of prescribing, building confidence in approaching and having these conversations the project holds the potential a wide range of benefits for individuals and service provision.


What will be the intended outcome of your research project?

Our project aims to work with GP practices to reduce inappropriate polypharmacy for people with frailty. Further to effective implementation, outcomes and economic evaluation we will aim to spread and scale up the work to be refined as a toolkit which can be shared wider to facilitate further improvements in appropriate prescribing and frailty care.


Are there any early findings or indications you can report? Are there any publications?

Two tools could be readily incorporated into clinical practice:

  • STOPP tool template embedded into GP clinical systems.
  • The NHS Scotland Polypharmacy toolkit

The use of these tools needed to be underpinned by an element of formal ‘education’ or knowledge transfer from experts. Implementing effective and sustainable change was made possible by the quality improvement methodologies used.

A person centred approach is essential around:

a) Discussion and co-decision making with patients about reducing their medication and

b) Appropriate use of language around frailty and healthy ageing.

Results

  • Culture of prescribing changed leading to sustainable behaviour change.
  • Cognitive barriers to deprescribing covered a broad range. Lack of knowledge scored the highest with the environment (being time and process) following.
  • 6% reduction in the average number of prescription items per person with frailty.
  • Reduction in prescribing costs by £69 – £299 per patient year noted in practices.
  • Improved staff and patient rapport.

You may wish to check out the recently completed SPF videos which are now available online:

  1. Safer Prescribing for Frailty – Reducing inappropriate prescribing
  2. Safer Prescribing For Frailty – Achieving Behaviour Change
  3. Safer Prescribing for Frailty – A Quality Improvement Story

The project has been shortlisted as a HSJ finalist:


References & additional resources

  1. Clegg et al . (2013). Frailty in elderly people. The Lancet. 381 (9868), 752-762.
  2. Herr M et al (2015) Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf.  24  (6), 637-46.
  3. Payne RA et al.(2014) Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. British Journal of Clinical Pharmacology. 77 (6) 1073-1082

Safer Prescribing for Frailty Toolkit is currently under development.

Any further queries please contact:

Sarah DeBiase  Project Manager (Sarah.De-Biase@yhahsn.nhs.uk)

Megan Humphreys Implementation Manager (megan.humphreys@bthft.nhs.uk)

This project has been delivered as part of the Healthy Ageing Collaborative in conjunction with:

  • Harrogate & Rural District CCG
  • Improvement Academy
  • Connected Health Cities
  • Academic Unit for Elderly Care & Rehab
  • Yorkshire & Humber AHSN
  • University of Hull
  • Bradford Teaching Hospitals

Watch this video to find out more about the eFI tool and its development to date.