Polypharmacy reviews to improve patient outcomes and healthcare sustainability

Populations are ageing and many people over the age of 50 years live with multiple  long-term conditions and as a result take multiple medications (known as  polypharmacy). Polypharmacy can be appropriate, but the increased risk of harm from interactions between medicines or between medicines and diseases may outweigh benefits.  

Currently, around 50 million EU citizens are estimated to have multiple diseases (known as multimorbidity). However, 29% of people with multiple morbidities are under the age of 65 years, and disproportionally come from the most deprived communities­¹.This presents a growing safety, clinical, environmental and economic challenge underlining the need for appropriate polypharmacy management.  

Medication is the single most common healthcare intervention generating the third highest cost of health expenditure, together with significant amounts of medicines waste, incurring environmental impacts from production to disposal.  

Preventable medication-related harm remains a serious problem, causing severe or potentially life-threatening outcomes in over a quarter of all preventable harm cases². This leads to greater use of health services, hospitalisation, reduced quality of life and substantial financial cost to healthcare systems. Up to 17% of unplanned UK hospital admissions (around 8.6 million admissions in Europe) are attributable to medication-related harm, with 50% of these potentially avoidable^3,4. There is also a significant environmental cost. In Scotland alone, there are 46,000 preventable admissions each year with a carbon footprint of 44,000 tonnes of CO2e. This is around 1.5% of NHS Scotland’s total carbon footprint, which could be avoided through the implementation of comprehensive, person-centred polypharmacy medicines reviews.

In addition to the potential harms from medicines, inappropriate polypharmacy can result in medicines waste, for example where items are prescribed that are no longer needed or medicines are not taken as prescribed. 

In Scotland, every 10 days a 10-tonne truck of medicines waste (returned to community and hospital pharmacies) is transported for incineration. This is 365 tonnes a year incinerated, with a CO2e equivalence of 28 car journeys around the world. As well as the unused medicines that are returned to pharmacies, others are disposed of incorrectly, such as in general waste, poured down the sink or flushed down the toilet, which increases the risk of environmental harm. 

Reduction of medicines waste can be achieved by ensuring appropriate prescribing and initiation of medicines, regular person-centred medication reviews and deprescribing where appropriate. Reducing waste from medicines has a double carbon benefit by: 

• reducing upstream emissions e.g. in production and distribution 
• reducing downstream emissions, e.g. with fewer medicines to be disposed of. 

Addressing the challenge  

The World Health Organisation has recognised polypharmacy as a priority area of the third global patient safety challenge, Medication Without Harm^5,6. A person-centred approach, to address patient needs, enable self-management and involving patients in decisions is needed to address potential harm and ensure improved patient outcomes and sustainability in medicines use and healthcare systems.  

Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years (iSIMPATHY) was a three-year, €3.5m European Union (EU) project funded by the Special EU Programme Body (SEUPB) led by Scottish Government and involving Scotland, Northern Ireland and the Republic of Ireland to March 2023. 

iSIMPATHY aimed to ensure optimal and sustainable use of medicines for patients experiencing polypharmacy by delivering person-centred medicines reviews with shared decision-making, and using Patient Reported Outcome Measures (PROMs). The project embedded a multidisciplinary collaborative approach to deliver pharmacist-led, person-centred medicines reviews using the 7-Steps methodology. Key learnings and strategies which supported the successful implementation of the project are outlined below.

Key learning: Adopting a holistic approach to address all dimentions of quality health care 

• Adopting the 7-Steps methodology when reviewing medicines with people with multimorbidity, improving understanding and facilitating shared decision making with empowered patients.. Applying the 7-Steps as part of a holistic medication review has the potential to address all six dimensions of quality in health care: efficacy, safety, efficiency, timeliness, equity, and acceptability.  
• Over 120 healthcare professionals were trained and supported to deliver 7-Steps medicine reviews to 6,481 people and evaluated the impact through assessing the levels of polypharmacy, medicines appropriateness, PROMs and pharmacist interventions.

Key learning: Engaging a coordinated multidisciplinary approach is essential for delivery 

Implementation strategies included:

• Having adequate dedicated pharmacist capacity to deliver comprehensive person-centred medicines reviews with those with complex polypharmacy.  
• Providing training, guidance and peer and professional support to ensure capability of those delivering medicines review. 
• Developing processes, documentation and support structure ahead of delivery of reviews.  
• Identifying factors which would help prioritise those who would benefit most from a review.  
• Embedding innovation and new technology. This could include intelligent clinical decision support tools to identify those who would benefit most from a review and the use of pharmacogenomics to inform prescribing decisions. 
• Working with policy makers, patients, clinical leaders and finance colleagues to ensure the scale and spread of this methodology into routine practice.

Key learning: Empowering patients to be active participants in the review is crucial

• Support patient awareness and empowerment to be active participants in the review, informed by patient involvement in the design of the delivery of the service. Resources such as PROMs can support this: where required, adequate support should be provided such that patients can use digital technology e.g. PROMs.