Organising polypharmacy: unpacking medicines, unpacking meanings

Problem

Approximately 64 million multi-compartment compliance aids (MCAs or ‘dosette boxes’) are issued by community pharmacies in England every year. Professional guidance directed at pharmacists strongly discourages their use in all but extreme circumstances, citing concerns such as: lack of evidence to support them; increased risk of dispensing errors; reduced medicine stability once medicines are removed from original packaging. Despite efforts from professional bodies to discourage use of MCAs, demand for MCAs is increasing. We investigate how professionals and patients organise polypharmacy and consider the remarkable persistence of the MCA as one way of organising polypharmacy in the context of high risk polypharmacy. We unpack the meanings attributed to different ways of organising medicines across a range of contexts: patients’ homes, GP surgeries and community pharmacy.

Approach

In-depth ethnographic case study employing mixed qualitative methods including longitudinal ethnographic follow-up of 24 patients aged 65 or older and prescribed 10+ items of medication (‘high risk’ polypharmacy). The dataset includes: 200 hours of ethnographic observation across patients homes, community pharmacy and GP practices; 20 ethnographic interviews with patients about their medicines practices; 10 interviews with pharmacy staff. We adopt a ‘practice theory’ lens to make sense of our data, with a particular focus on social practices (including people, technologies, artefacts and their interconnections) driven by a curiosity for what is being accomplished, and why and by whom.

Findings

This is work-in-progress. Our interim analysis identifies the MCA as a highly contested object, imbued with an array of different meanings and interpretations as it circulates within and between contexts, sustained by (and itself sustaining) a vast amount of ‘hidden work’ for professionals and patients. Four of our 24 patient participants receive pharmacy-prepared MCAs, but all have developed ways of organising their medicines, many using ‘do-it-yourself’ dosette boxes which are fraught with many of the same safety concerns as pharmacy-prepared MCAs. Regardless of who is doing the work, organising polypharmacy is necessary, labour-intensive and risky.

Consequences

The widespread use of MCAs is primarily a side-effect of polypharmacy, and may contribute additional risk to an already high risk situation. MCAs may have little evidence to support their use, but polypharmacy is itself rarely, if ever, evidence-based. Recent calls to more heavily regulate pharmacists, improve standards of MCA practice and thereby reduce the number of MCAs issued are welcome. But our research shows that polypharmacy necessitates ‘organising’. Unless the underpinning polypharmacy is itself tackled, the burden of organising this work will always fall somewhere and will always carry risk.