Addressing the Polypharmacy challenge in Older people with Multimorbitidies research project is being carried out by Deborah Swinglehurst, Nina Fudge, Celia Roberts, Alison Thomson and Sarah Collins between March 2016 and February 2021, funded by the National Institute for Health Research. Our project acronym APOLLO-MM draws inspiration from the Greek deity Apollo, who has been associated with medicine and healing. Drawing parallels with polypharmacy today, Apollo was seen as a god who could prevent disease as well as cause it.
It is common for people living with multiple, long-term conditions (such as diabetes, high blood pressure, asthma) to be prescribed numerous medicines. This is known as polypharmacy – the co-prescription of four or more medications. In the past decade in England, the average number of items prescribed for each person per year in England has increased by 54% : in 2001 people were prescribed on average 12 different items per year, but this rose to 18 in 2011. A large Scottish study found similar increases in prescribing: in 1995 12% of patients were dispensed 5 or more drugs, but this increased to 22% in 2010.
Whilst the benefits of preventing and treating ill health are hard to question, being prescribed numerous medicines can be a burden for patients and their families and can sometimes be harmful. Polypharmacy can expose patients to risks such as falls and hospital admissions related to side-effects or drug-drug interactions. A recent international meta-analysis (a study which combines the results from a number of studies) found that about one in ten hospital admissions of older patients are due to patients having an adverse reaction to their medicines. Prescribing errors are also more common in the context of polypharmacy.
Why polypharmacy research now?
A number of factors are coming together making polypharmacy an urgent research priority:
- an ageing population living with multiple, complex, long-term conditions - most people over 65 have multimorbidity and this rises to 80% of people over 80
- a health system and best practice guidelines which are organized around a ‘single disease’ model and a focus on reduction of risk, which may inadvertently drive polypharmacy
- concern that prescribing numerous medicines is costly and wasteful to an already cash strapped NHS - approximately half of medicines prescribed for long-term conditions are not used.
Although the problems of polypharmacy are increasingly recognised, our capacity to reconfigure care to adapt to the complex realities of patients’ lives is limited by our poor understanding of what matters to patients and healthcare professionals. Patients may experience a ‘burden of treatment’ but we lack evidence to support patients and healthcare professionals in complex decision-making around stopping treatments or not prescribing medicines.
Careful attention to real world priorities and practices of patients around medicines-taking, alongside study of professional practices and institutional contexts that sustain and challenge polypharmacy may hold clues for how best to optimise prescribing.
Our research questions
- What is the patient experience of polypharmacy in multimorbidity?
- How are patients’ lives shaped by practices of medicine-taking?
- How is ‘managing medicines’ shaped by living with multimorbidity?
- How do the practices of patients and their carers, healthcare professionals and care systems support ‘appropriate’ polypharmacy (or challenge ‘inappropriate’ polypharmacy) …and with what consequences for quality and safety of care?
- How can insights from longitudinal patient case studies inform medicines optimisation?
Our research will:
- Identify where there are opportunities to avoid and address:
- unnecessary or unwanted treatments
- vulnerabilities to error and waste
- Produce evidence-based e-learning materials
- Work directly with patients to co-design patient engagement resources and raise public awareness of polypharmacy issues
How will we do this?
In this project we are going to use a variety of qualitative methods as part of an in-depth ethnographic case study located in two general practices:
- Longitudinal observation of 30 patients, aged 65+ and prescribed 10+ medications (‘high risk’ polypharmacy) over 2 years. We will follow these patients’ medicines trajectory, their interactions with health services, and medicines practices. We will undertake narrative interviews with these people and make ethnographic observations in the home and healthcare settings.
- Observation of healthcare professional practices and key organisational routines (in general practice and pharmacy settings). This will include shadowing, interviewing and video-recording of ‘medicines review’ consultations.
- Identifying professional concerns through video-elicited feedback with clinicians, individually and in action learning sets (video-reflexive ethnography)
Our key aim is to improve the care of patients by producing ‘practice-based evidence’ to inform medicines optimisation, ensuring that patients’ priorities for their care and professionals’ concerns for good practice are upheld.