Optimising a whole-person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy: the Tailor Medication Synthesis

Conference:

SAPC ASM 2020 - cancelled due to pandemic

Talk Code:

U.24

Presenter:

Amadea Turk

Twitter:

@AmadeaTurk

Co-authors:

Amadea Turk, Richard Byng, Tom Fahey, Ruaraidh Hill, Janet Krska, Daniel Lasserson, Michelle Madden, Dee Mangin Kamal Mahtani, Elizabeth Mitchell, Edward Ranson,Nia Roberts, Emma Wallace, Tom Walley, Geoff Wong, Joanne Reeve

Author institutions:

University of Oxford, University of Liverpool, University of Hull, University of Exeter, University of Birmingham, McMaster University,

Problem

Problematic polypharmacy, the concurrent use of multiple medicines in a single person, on a long term basis when the intended benefit is not achieved, is a significant problem in Primary Care. Polypharmacy can be appropriate, extending life expectancy and improving quality of life. However ~40% of people taking 5 or more medicines a day report feeling significantly burdened by their medication. Discontinuing long-term-medicines can cause anxiety and concern for clinicians and patients. Despite guidelines on stopping inappropriate medicines, clinicians report a broader problem of knowing how and when to stop medication that may be clinically ‘appropriate’ but not right for individual patients. Balancing clinical and patient and theory carers needs and priorities is increasingly recognised as a research and policy imperative.. To help clinicians and patients make these often challenging decisions on optimising medications, we are conducting a realist review. It will unpack and understand optimisation of medicines to answer the broad question “what works, for whom, in what circumstances, to what extent, how and why?”

Approach

The Tailor Medication synthesis is a 21 month NIHR funded project comprising of a parallel scoping review and realist review. Here we report the realist review component. The realist reviews are a theory-driven approach to synthesising qualitative, quantitative and mixed-methods literature. Our review followed established steps and the RAMESES quality standards for realist reviews (www.ramesesproject.org). Briefly, after initial programme theory development we systematically search electronic databases, articles were screened, data extracted and analysed to explore issues surrounding the patient-centred management of polypharmacy. Relevant sections of text were analysed both inductively, retroductively and deductively and used to critically challenge, examine and refine the programme theory.

Findings

Early findings highlight complex social, professional and system-level dynamics underlying patient-centred medication management. Prescribing is influenced by a range of social norms. For example the symbolic value of medicines for both prescribers and patients and their families shape the ways in which medicines are prescribed, deprescribed and managed in general. Furthermore the presence of multiple prescribers and transitions between primary and secondary care make it difficult to keep track of medication-related decision making. This is compounded by the absence of unified electronic systems. Clinicians also report they lack the skills necessary to manage polypharmacy and multimorbidity making them reluctant to challenge the decisions made by clinicians in other specialties.

Consequences

Optimising medication is a complex process and whilst primary care clinicians can be skilled up to do so, any training must consider the important influences of societal and professional norms and practices on this process and create an enabling environment.

Submitted by:

Amadea Turk

Funding acknowledgement:

NIHR HTA 17/69/02