Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP)

Polypharmacy (prescribing multiple medicines to one individual) is widespread and growing in the UK; ~6% of adults take 10+ regular medicines. Although often clinically appropriate, polypharmacy may be problematic leading to a range of adverse outcomes. Despite recent national guidance, there is a lack of evidence for medication optimisation interventions that improve outcomes. The aim of this project is to develop and evaluate an intervention to optimise medication use for patients with polypharmacy in a general practice setting. The IMPPP intervention will be based in general practice involving GPs and pharmacists working together, drawing on the specific skills of each professional sensitive to the context of each practice. The intervention will comprise two key elements: (1) a model for conducting polypharmacy medication reviews (including pharmacist-GP collaboration and case finding) and (2) components to enhance professional engagement (education, practice feedback, financial incentives). These two key elements will be supported by an informatics tool integrated into practice clinical systems. We will conduct a 48-month 3-phase study adhering to the principles of the MRC framework for complex interventions: • Phase 1 (Development): Mixed-methods study in 2 Scottish Health Boards that are implementing novel informatics tools to support NHS polypharmacy reviews. Interviews with healthcare professionals (HCPs) plus patient focus groups will be used to understand implementation and their experience of polypharmacy review, and the strengths/limitations of the various intervention components. Epidemiological analysis of practice data will be used to explore the prevalence, variation and amenability to change in potentially inappropriate prescribing (PIP). These findings will inform the initial intervention design, which will then be refined in consultation with HCP and patient groups. • Phase 2 (Optimisation): Pilot-feasibility study in 5 Bristol-area GP surgeries to optimise the intervention in the English context. A formative qualitative process evaluation will examine initial adoption and intervention implementation, including likely barriers/facilitators to implementation which will be addressed prior to the full trial. We will also pilot/evaluate trial processes including collecting quantitative data on patient recruitment/retention. • Phase 3 (Evaluation): Multicentre cluster-RCT comparing intervention vs usual care. The primary outcome is the mean number of PIP indicators triggered per patient. Secondary outcomes include quality of life, health service use and treatment burden. A cost-effectiveness analysis will be conducted. A parallel mixed-methods process evaluation will be undertaken examining implementation to help explain the success or otherwise of the intervention, and to inform subsequent implementation in practice. This study will establish whether and how the IMPPP intervention is effective and cost effective. It will provide valuable insights into how to best implement case-finding and prioritisation for review in patients with polypharmacy, how GPs and pharmacists can best collaborate to meet patients’ needs, and the role of informatics in supporting case-finding and focused review. If effective, our intervention has the potential to improve health related quality of life, improve prescribing and reduce adverse medication effects and treatment burden in a growing and highly vulnerable population.