Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice

Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients' health and wellbeing is instead becoming part of the problem. The way we practice medicine has become a driver for the problem. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of compromise into the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and, in our understanding of the process of research, how we generate the knowledge that informs practice. This review considers the current state of play in all 3 areas and identifies some of the work we still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health

Trends and practices in the use of non-prescription drugs among university students in the United Arab Emirates

Background: A wide variety of medication, from vitamins to analgesics and anti-inflammatory drugs, can be purchased by users without a medical prescription. These are referred to as Oral Non-Prescription Drugs (ONPD). While this may empower patients to treat themselves, when used irrationally these medications can have a negative health impact. Previous research on higher education students, particularly healthcare students, has demonstrated that they might be a high-risk population for irrationally use of ONPD. In 2004, the World Health Organisation issued specific guidelines to address research in this area. However, recent investigations still indicate that irrational use of medication occurs among this population. Therefore, the current thesis will be guided by the WHO framework in an attempt to develop a strategy to address this problem. Aim: The aim of this thesis is to determine the prevalence of irrational use of medication sold without a prescription in UAE to university students and to identify the reasons for this behaviour. A secondary aim of this investigation is to develop, implement and evaluate the effectiveness of an educational intervention to improve knowledge and awareness of, as well as attitudes and practice towards, rational use of ONPD medication by university students in UAE. To reach the aims of the study, a health behavioural model was used together with qualitative and quantitative methods. Methodology Study One: The aim of this study was to determine the prevalence and risk factors of four types of irrational use (incautious use, inappropriate use, use of antibiotics without prescription and polypharmacy) of ONPD among undergraduate students in UAE. This study used a cross-sectional design employing a randomised sampling technique (n=2875). Statistical analysis was used to analyse this data. Results obtained from this study indicated that 85.9% of students used ONPD, with 38.6% using antibiotics without a prescription. Based on WHO risk assessment criteria, this behaviour was found to the most severe form of irrational use. Additional findings indicated that female participants were 34% less likely to be incautious users (OR =0.344, 95% CI: 0. 244-0.486, p≤0.001), which set males at a higher risk of engaging in this behaviour. Not verifying the expiration date also increased the likelihood of being an incautious user by as much as 51%. Seeking drug information from health care professionals was found to be a protective factor against incautious ONPD use (OR =0. 798, 95% CI: 0.540-0.967, p967, p≤0.05). At the same time, not seeking information on cautious use of ONPD either from medical books or the internet was associated with a higher risk of incautious use (OR = 1.914, 95% CI: 1.353-2.708, p≤0.001). Being a healthcare student significantly increased the odds of being an incautious user of ONPD (OR = 1.561, 95% CI: 1.103-2.208, p≤0.05). Using antibiotics without a prescription was reported among 35.9% of the sample, with no statistically significant difference being observed between healthcare and non-healthcare students. Study Two: Based on the WHO Severity Rating Matrix, the use of antibiotics without prescription was found to be the most significant risk for personal and population health. Therefore, the aim of this study was to further explore the reasons for use of antibiotics without prescription among healthcare university students. This study used a qualitative design employing an interview method and a purposive sample selection technique (n=15) which included only the population of students who used antibiotics without a prescription. Thematic analysis was used to analyse the data. Five main themes emerged from this study: knowledge, awareness, attitude, views, and perceptions, as well as possible strategies to decrease their misuse of antibiotics. Study Three: The aim of this study was to develop and test an intervention for reducing the use of antibiotics without prescription based on the findings of study 1 and 2. The intervention was carried out for 14 weeks. Each session was delivered on a weekly basis and comprised of a 15 minutes PowerPoint presentation followed by 10 minutes of discussion. A quasi-experimental design with purposive sampling was used in which participants (n=140) were assessed at baseline for knowledge, awareness, attitude, and practice of using antibiotics without prescription. Results obtained through comparing baseline measures with post-intervention measures demonstrated a statistically significant (p<0.05) improvement in reducing the use of antibiotic without prescription among the sample. Moderate improvements were also noted in knowledge, attitude, and awareness of antibiotic use. Conclusion: This thesis has demonstrated that the prevalence of ONPD is high among university students in the UAE. This is particularly significant as this increased prevalence occurs concomitantly with irrational use. The most significant risk was related to using antibiotics without prescription. Although the intervention to change this behaviour was successful, other issues such as access to health care and lack of time to see medical practitioners may still promote the use of antibiotics without prescription. Recommendations underlined in this investigation include educating pharmacists to provide information to ONPD buyers

How can deprescribing be safely and routinely implemented within primary care?

Background: As a result of ageing and advances in technology, people are living longer with multiple co-morbidities, and are likely to take multiple medicines concurrently. This can lead to problematic polypharmacy and the use of inappropriate medicines, compromised patient safety, and higher costs. Deprescribing has been identified as a way of addressing problematic polypharmacy. However, there is limited knowledge, derived from implementation science, concerning the safe and routine implementation of deprescribing in primary care. Aim: To identify the barriers and facilitators, and effective strategies, to safe and routine implementation of deprescribing in primary care. Methods: A multi-method, pragmatic approach used Normalisation Process Theory to guide research methods and contextualise findings. This comprised a systematic review to identify barriers and facilitators to deprescribing implementation and interviews with patients and healthcare professionals to explore their views on deprescribing in primary care. This informed a co-design process with patients and healthcare professionals to produce deprescribing resources to aid implementation in primary care. Results: A lack of reporting of implementation factors and research on deprescribing appraisal was identified. Patients highlighted the significance of deprescribing rationales; clear communication; interpersonal skills; education; support; and provided views on healthcare professionals’ involvement. Healthcare professionals expressed that current healthcare is focused on prescribing with minimal deprescribing consideration, how stakeholder buy-in can drive implementation, how safety can be maintained through follow-ups and safety nets, and the potential role of community pharmacists. The co-design process identified patients as potential catalysts for routine deprescribing, and the role of community pharmacists as a safety net. This led to the development of medicine necessity questions for patients and a logic model of a community pharmacy deprescribing safety net. Conclusion: Deprescribing resources have been developed that may aid the implementation of routine, safe deprescribing in primary care. Future work should assess their feasibility and effectiveness

An action research evaluation to understand and inform the role of the Integrated Care Pharmacist across health and social care

Introduction A research study was commissioned to understand and inform the new role of an Integrated Care (IC) Pharmacist, founded to work as part of the health and social multidisciplinary team (MDT) within the IC program for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG). Aim The aim of the study was to understand and inform this new role of the IC Pharmacist for ELRCCG and how to develop and sustain such a role. Methods A participatory mixed methods research strategy, which aligns with pragmatism as a philosophy was used. The qualitative arm of the mixed methods was predominantly underpinned by phenomenology and included interviews with two IC patients and seven professionals who were a core part of the integrated MDT and one focus group. For the quantitative arm, key performance indicators(KPIs) documented in line with the sponsor evaluation policy were analysed. Findings The six themes derived from the qualitative methods were: teamwork; accessibility and visibility; resources and enablers; reflection on the role functions; Impact of the role and evaluating performance of the role. For the quantitative results, all the KPIs were achieved, including a return of investment of 311%, a reduction of polypharmacy by the de-prescribing of 54 drugs, the completion of clinical medication reviews in 100% of patients and repeat prescription reviews in 37% of patients and the provision of four medication training sessions for the IC coordinators. Discussion The findings support existing literature by qualitatively and quantitatively showing how the role functions and positive outcomes achieved by pharmacists in integrated primary care roles can be extended to social and health integrated care teams. Role functions highlighted include provision of pharmaceutical care to patients and training and education to staff. Positive outcomes delivered by the IC pharmacists include participant empowerment and bridge building between health and social care professionals.Furthermore, this study contributes to existing knowledge by identifying enablers and showing how they can optimise these outcomes. A key enabler was to fully embed the IC pharmacist role within a health and social MDT and co-locating the MDT at a GP surgery, instead of remote offices . Ensuring effective teamwork which is facilitated by a shared agenda, role understanding, respect, accessibility and visibility is another important enabler. A third enabler identified as crucial to sustain the role, is funding to transform the model to a fully embedded GP hub pharmacist and technician team, to ensure holistic staff capacity. Finally, the study highlighted that the role could be evaluated through stakeholder feedback as well as the utilization of admissions avoidance figures after adjusting for assumptions. Conclusion In line with action research, both action and additional knowledge were achieved. Action was achieved by ultimately transforming and expanding two roles to twelve teams of pharmacists and pharmacy technicians. Additional knowledge contributed include the views of key stakeholders across health and social carer, including patients, regarding what exactly the IC pharmacist role is, how it is delivered and could be adapted to increase sustainability, what outcomes it delivers and how they can be evaluated. Further research is required to inform which of the models would be best suited for the local population

Social and cognitive influences on prescribing decisions among non-medical prescribers.

Non-medical prescribers make an increasing contribution to healthcare across the UK yet little is known about influences on their prescribing decision-making. The aim of this programme of research was to explore and describe prescribing decision-making by non-medical prescribers. A two stage programme of research was carried out. Stage 1 was a systematic review of the social and cognitive influences on prescribing decision-making by non-medical prescribers. Despite a paucity of research, various influences on prescribing decision-making were reported including evidence based guidelines, peer support and patient (or parental) relationships and expectations. While confidence and clinical experience as a practitioner were cited as influences, the lack of prescribing experience and aspects of pharmacological knowledge also impacted on prescribing decision-making, resulting in a cautious approach. Stage 2 of the research employed a phenomenological methodology underpinned by the Theoretical Domains Framework of behavioural determinants (TDF). It comprised three phases. In Phase 1, semi-structured interviews with five nurse prescribers and eight pharmacist prescribers in NHS Grampian explored their experiences and perceptions of influences on their prescribing decision-making, and the impact of these influences. Multiple and sometimes contradictory influences were uncovered. Twelve of the fourteen domains of the TDF were found to be influential along with multi-disciplinary working and experience; optimism and reinforcement did not feature. In Phase 2, these participants recorded reflections on prescribing decisions which they considered noteworthy in relation to their practice, and in Phase 3 participants were interviewed about their reflections. Complexity was a feature of many, in the patients clinical or social circumstances or in relation to wider concerns. The same 12 domains were found to be influential as were multi-disciplinary working, experience and complexity. This programme of research has produced original findings which it is hoped will impact on the education, training and practice of these increasingly important prescribers

Deprescribing in primary care in Australia: Perspectives of general practitioners and older adults

Background Deprescribing is an intervention used to help reduce the risks associated with inappropriate polypharmacy, especially for older adults. However, rates of polypharmacy use have continued to increase worldwide, including in Australia. Limited research is available that considers deprescribing and the management of polypharmacy from the perspective of both older adults and GPs. This is despite the key role both play in decision making. This study investigated deprescribing as an aspect of medication management. The role of older adult health literacy was explored to determine if this was an important facilitator of shared decision making about deprescribing. Aim The aim of this research was to explore the factors which influence the process of deprescribing in primary care in Australia. Objectives 1. How does the structure of the healthcare environment in primary care in Australia facilitate or impede discussions about polypharmacy and deprescribing between older adults and their GPs? 2. What is the relationship between perceptions of ageing and the likelihood of discussions about polypharmacy and deprescribing? 3. What is the role of health literacy in managing polypharmacy and making decisions about deprescribing? 4. What, if any, is the relationship between attitudes to medication use, age cohort, socio-economic status and the likelihood of discussions about polypharmacy and deprescribing? Methods A sequential, explanatory mixed methods approach was employed adopting a pragmatic theoretical stance. The views of GPs and autonomous, community living, older adults using five or more medications, were included. An initial quantitative phase was conducted using two observational cross-sectional surveys with GPs (n=85) and the second with older adults (n=187). A new survey tool was developed to assess GP practices and attitudes toward deprescribing, as no tool existed at the time. The older adult survey included two previously validated tools: the Patients’ Attitudes Towards Deprescribing tool (PATD) and the All Aspect of Health Literacy Scale (AAHLS). A second qualitative phase using individual interviews was also conducted with GPs (n=16) and older adults (n=25). The data for both quantitative studies were analysed using descriptive statistics and bivariate analysis of correlations and relationships between groups employing SPSS version 24. Qualitative data was explored using thematic analysis assisted by organising and coding the data in NVivo 12. Finally, the results from each study were considered together in order to identify points at which findings complemented, converged or diverged from each other. Results Structural and attitudinal factors were found to influence the process of deprescribing in Australia. GPs were often prevented from playing to the strengths of their generalist role when co-ordinating medication management. This was the result of structural factors such as short consultation times, poor communication between multiple healthcare providers and unclear lines of responsibility for medication management decisions. Continuity of care, provided by GPs, resulted in trust. The presence of trust was important to ameliorate the effects of uncertainty associated with medication management and deprescribing, in the context of multimorbidity. However, trust also resulted in some older adults deferring medication decisions to their GP and giving precedence to the decisions of specialists. Participants explicitly noted the role of structural factors however the influence of attitude was implied. Both older adults and GPs held negative attitudes toward age and ageing. This disrupted shared decision making and normalised medication use in the context of old age. A pragmatic attitude toward the use of medications meant GPs and older adults were more concerned about finding a level of appropriate polypharmacy and maintaining this over time, as opposed to deprescribing. Research driven numerical goals for polypharmacy use carried little weight although there was a general desire to use as few medications as possible, especially in those using 10 or more. High health literacy scores were associated with a willingness to consider deprescribing. Older adult participants described specific health literacy practices related to the daily management of their often complex and burdensome medications regimens. However, health literacy capabilities played a limited role in deprescribing decision making as older adult capabilities were generally not acknowledged or applied in consultations. Conclusion Implications for practice highlight opportunities to improve shared decision making. The consistent use of comprehensive medication reviews is recommended to allow older adults to share their daily experiences, goals and preferences regarding polypharmacy use. The acknowledgement and use of older adult health literacy capabilities would enable a collaborative approach to shared decision making. Recognition of capabilities would also reduce the disempowerment experienced by many because of the influence of negative stereotypes towards older people. The influence of frailty appears to be important although numbers of frail individuals in this study were small. Further research is needed to explore the impact of increasing health literacy demands and reduced access to primary care at a time when medication management needs are increasing. The pragmatic approach, using a mixed methods design, allowed the production of practical knowledge. It added a greater level of insight particularly the exploration of health literacy level and practices and the barriers to health literacy use in consultations

OntoPharma: ontology based clinical decision support system to reduce medication prescribing errors

Background: Clinical decision support systems (CDSS) have been shown to reduce medication errors. However, they are underused because of different challenges. One approach to improve CDSS is to use ontologies instead of relational databases. The primary aim was to design and develop OntoPharma, an ontology based CDSS to reduce medication prescribing errors. Secondary aim was to implement OntoPharma in a hospital setting. Methods: A four-step process was proposed. (1) Defining the ontology domain. The ontology scope was the medication domain. An advisory board selected four use cases: maximum dosage alert, drug-drug interaction checker, renal failure adjustment, and drug allergy checker. (2) Implementing the ontology in a formal representation. The implementation was conducted by Medical Informatics specialists and Clinical Pharmacists using Protégé-OWL. (3) Developing an ontology-driven alert module. Computerised Physician Order Entry (CPOE) integration was performed through a REST API. SPARQL was used to query ontologies. (4) Implementing OntoPharma in a hospital setting. Alerts generated between July 2020/ November 2021 were analysed. Results: The three ontologies developed included 34,938 classes, 16,672 individuals and 82 properties. The domains addressed by ontologies were identification data of medicinal products, appropriateness drug data, and local concepts from CPOE. When a medication prescribing error is identified an alert is shown. OntoPharma generated 823 alerts in 1046 patients. 401 (48.7%) of them were accepted. Conclusions: OntoPharma is an ontology based CDSS implemented in clinical practice which generates alerts when a prescribing medication error is identified. To gain user acceptance OntoPharma has been designed and developed by a multidisciplinary team. Compared to CDSS based on relational databases, OntoPharma represents medication knowledge in a more intuitive, extensible and maintainable manner

Strategies enhancing the public health role of community pharmacists in the UK

Introduction A number of UK studies have investigated the role of pharmacists in public health (Blenkinsopp, et al. 2002; Anderson and Blenkinsopp 2003; Agomo 2012a). However, many of these studies have also identified barriers in this public health role (Agomo 2012a; Agomo and Ogunleye 2014). My project aimed to identify strategies, which could enhance the public health role of community pharmacists in the UK. Method My project used a mixed methods approach, involving a content analysis of the UK undergraduate pharmacy curriculum, a descriptive survey of UK community pharmacists and interviews with healthcare practitioners to investigate strategies enhancing the public health role of community pharmacists in the UK. Results The majority of my survey respondents indicated that there was a need for pharmacists to work closely with other healthcare practitioners [93.1%, C.I. ±5.32]; pharmacy students to train with other healthcare students [81.4%, C.I. ±8.21]; students and pharmacists to be provided with advanced experience in public health [86.2%, C.I. ±7.24 and 89.8%, C.I. ±6.32 respectively]; as well as increasing the public health content of the undergraduate pharmacy curriculum [64.8%, C.I. ±9.97]. Respondents from Cardiff were more likely to participate in local authority-run schemes than other respondents (p < .001; η2 = .296). Male respondents were more likely to agree that 'insufficient funding from the government’ was a barrier to the public health role of community pharmacists [p = .011; ρ = -.269]. The findings of my interviews confirmed several aspects of my survey findings, particularly as regards accessibility, encouraging collaboration between pharmacists and other healthcare professionals, and tackling a number of barriers, such as the lack of awareness of the public health skills of pharmacists. There were some indications from my content analysis that the teaching of macro-level public health activities (such as epidemiology, assessment, pharmacovigilance, policy development and assurance at the population-based level) in most UK pharmacy schools was either minimal or lacking. Conclusion There is a need to enhance the public health role of community pharmacists in the UK. This will help make public health services more accessible to the public, reduce healthcare costs and pressures on other healthcare professionals, as well as helping to elevate the image of community pharmacists