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A tool for doctors to review the medications of complex cases

Published: 19 Oct 2020
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By Christopher Threapleton

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This blog is written by Chris Threapleton, an Early Career Researcher, who published ‘Development of a structured clinical pharmacology review for specialist support for management of complex polypharmacy in primary care’ in the British Journal of Clinical Pharmacology in 2019. This blog is adapted from this article. 
 
Polypharmacy, or taking lots of medicines, is increasingly common. For example, did you know that one in 20 UK adults over 19 years of age takes 10 or more medicines over a three-month period?
 
Although polypharmacy might be appropriate in some cases, taking multiple medicines increases the risk of harmful side effects, which can result in a hospital admission. Taking multiple medicines also increases the risk of prescription mistakes, and people are less likely to take their medicines correctly when faced with so many.
 
People taking multiple medications should be reviewed by a health professional regularly, to see whether any medicines need to be changed. However, reviews of the most complex patients are challenging because of pressures on primary care and a lack of clear guidance. Our research team, made up of clinical pharmacologists (doctors with expertise in the use of medicines), GPs and experts in epidemiology, set about developing a structured framework for reviewing complex patients to guide health professionals in primary care.
 
We used information from 100 patients in the UK, taken from a large, anonymised GP database. This information included age, sex, diagnoses, prescriptions, measurements (such as weight and blood pressure), and the results of blood tests and scans. We looked through patients’ records to decide what recommendations we would make for their medicines. Through this process, we have developed the Clinical Pharmacology Structured Review (CPSR), an approach that healthcare professionals can use to help them to review patients with complex polypharmacy.
 
On average, patients were taking 10 medicines regularly. We identified at least one potential change in medication for every patient and, on average, made 5.5 recommendations per patient. The most common recommendation was to stop a medicine (on average 1.7 medicines per patient) and the most common reason was to reduce harm. Despite the majority of patients having had their medicines reviewed within the last year by their GP or pharmacist, we were still able to make these changes. This suggests that a specialist assessment could add value for patients with complex polypharmacy.
 
We worked out which measurements were the most important in making decisions. It would be useful to organise these before reviewing a patient’s medicines. We also developed the Stopping by Indication Tool (SBIT) to help healthcare professionals discuss the risks of stopping medicines with patients and decide on a plan. We hope that this could help empower patients and healthcare professionals to discuss their medicines and make the right choices.
 
We are keen to build on the results of this work by using the CPSR and SBIT in face-to-face medication reviews with patients. A patient-centred approach is important in medication reviews. Issues may have come to light in our study if we had been able to speak to patients, and this could have affected the medication decisions we made. Face-to-face consultations also have the benefit of improving patients’ knowledge, satisfaction, and adherence to treatment.
 
Since this research project, we have set up a polypharmacy network to guide healthcare professionals through the decision-making process when performing medication reviews. We have used the CPSR and SBIT, and initial feedback has been very positive. We aim to see the most complex patients ourselves, in our new specialist polypharmacy clinic. This service is open to referrals from hospital and community healthcare professionals in South West London. This will be a great opportunity to formally test the CPSR and SBIT in real life situations and allow us to see whether our approach could be recommended more widely.

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About the author

Chris Threapleton

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Dr Chris Threapleton is a specialty registrar in clinical pharmacology and therapeutics and general internal medicine at St George's Hospital in London. His research and clinical interests include the interaction between polypharmacy and multimorbidity, and how best to optimise medicines for this complex patient group. He is an honorary lecturer at St George's, University of London and teaches on the UK's first Clinical Pharmacology BSc.  He is the chair of the Registrar Sub-Committee of the British Pharmacological Society, which is responsible for ensuring quality training for UK clinical pharmacology registrars and for encouraging recruitment into this exciting specialty.