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Research Projects
Polypharmacy Assessment, Review, and Rationalization for Optimal Treatment
PARROT focuses on enhancing medication management for complex care and frail inpatients receiving care at ESNEFT.
By establishing a specialised pharmacy service, the project aims to assess medications using evidence-based tools, deprescribing when suitable, and optimising medication to enhance patient safety.
The project's objectives include evaluating incidents of polypharmacy (the use of multiple medicines), identifying inappropriately prescribed medications, documenting interventions made, and measuring the resulting reduction in medication.
Throughout the study, patients will be monitored to collect data, feedback, and ensure their well-being, contributing to a comprehensive service evaluation that aims to enhance patient care and safety.
Just over half of the population in England aged >85 live with moderate or severe frailty, a clinically recognised state of increased vulnerability associated with a decline the body’s physical and psychological reserves (British Geriatric Society, 2017; Walsh et al, 2023). 47% of hospital inpatients aged >65 are living with frailty, costing the NHS approximately £5.8b per year (BGS, 2023; Doody et al, 2022). As the population of older people is expected to double between 2016 and 2041 (Department of Health & Social Care, 2023; Age UK, 2023), there is an increasing demand on health and care services to support older people to age well in line with the NHS Long Term Plan (NHS, 2019a).
Frailty is associated with multimorbidity, with recent meta-analysis demonstrating 70% of adults living with frailty also had multimorbidity (Vetrano et al, 2019). As each co-morbid condition is treated according to national guidelines, the use of multiple medications, known as polypharmacy, can occur. Previously, definitions of polypharmacy focused on specific quantity of medicines however polypharmacy may be appropriate for a patient with multimorbidity if their medications are optimised and prescribed according to best evidence. Polypharmacy can be problematic where ‘multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realised’ (Department of Health & Social Care, 2021; Kings Fund, 2013; RPS, 2019). The World Health Organisation has described polypharmacy as a major global problem, estimating that more than half of all medicines are prescribed, dispensed or sold inappropriately, and half of all patients fail to take them correctly (WHO, 2019).
As frailty results in a decreased reserve in body systems, frail older people have increased susceptibility to adverse effects of medications (BGS, 2017) and the risk of adverse effects increases with every new medication commenced (Riberio et al, 2018). A person prescribed 10 or more medications is 3 times more likely to experience problematic polypharmacy and harm as a result of their medications (Cahir et al, 2023). An estimated 16.5% of unplanned hospital admissions are due to adverse drug reactions and problematic polypharmacy, with 70% of these potentially avoidable, resulting in decreased quality of life and increased health service costs (Cahir et al, 2023; Health Innovation Network, 2025; Osanlou et al, 2022; Tsang et al, 2024). Between 2008 and 2015, there was a 53% increase in the number of emergency hospital admissions caused by adverse drug reactions with the annual cost to the NHS in England estimated to be £2.21 billion (Health Innovation Network 2025). ). As it is estimated that almost 50% of the older UK population could be affected by polypharmacy by 2030 (Department of Health and Social Care, 2021), interventions to tackle problematic polypharmacy present an opportunity to reduce preventable cost to the healthcare system and increase the quality of patient care. The NHS England Medicines Optimisation Executive Group has identified addressing problematic polypharmacy as one of their national medicines optimisation objectives for 2024/25 (NHS England, 2024).
Medication review (MR) is a core component of comprehensive geriatric assessment (CGA) and NICE endorsed to address problematic polypharmacy (BGS, 2023; NHS England, 2024; NICE, 2015a). A structured medication review (SMR) is defined as ‘a critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines and minimising the number of medication-related problems’ (NICE, 2015a; NICE, 2016a). There are several NHS policy papers which support the need for SMR, including NICE QS120 which states healthcare providers should have systems to identify those who would benefit from SMR (NHS, 2019b; NHS England, 2023; NHS England, 2024; NICE, 2016; RPS, 2019). However, the current evidence base to support SMR as a single intervention is low-moderate quality and equivocal (Duffy & Paterson, 2021; Stewart et al, 2021). This is likely due to the relative infancy of SMR as a concept, and several large-scale trials and systematic reviews to measure efficacy are ongoing (Duffy & Paterson, 2021; Martin-Kerry et al, 2022; Stewart et al, 2021).
SMR is currently predominantly delivered by pharmacists in primary care as part of the Additional Roles Reimbursement Scheme (NHS England 2024). Patient groups highlighted as most likely to benefit from SMR include those residing in care homes, patients taking 10 or more medications, patients with severe frailty who have had recent hospital admissions and/or fall and those taking medications that are commonly associated with medication errors, dependence and/or risk of harm (NHS England, 2024). The importance of MR for problematic polypharmacy in secondary care is increasingly being recognised, as evidenced by the RCP acute care toolkit 17 (RCP, 2024) but there is scarce published evidence on the impact of SMR delivered in secondary care.
In September 2024, 8% of the English population aged 75+ and 8.9% of those aged 85+ were prescribed complex polypharmacy, defined as 10 or more unique medications. Within the Suffolk and North East Essex (SNEE) ICB, 16.9% of patients aged 75 years or older were prescribed complex polypharmacy in 2022/23, with this figure rising to 20.8% for those aged 85 years or older (NHS Model Health System, 2024a). Although this local data is older than national data therefore direct comparisons cannot be made, it would suggest that the prevalence of complex polypharmacy in the local area is higher than the national average. This may be reflective of a higher population of older people registered with a GP living within the SNEE ICB (22.9%) compared to the national average (19.3%) (NHS Model Health System, 2024b).A baseline audit indicated that 28% of frail older patients attending ED received SMR in primary care in the previous 12 months and only 4% received SMR as part of CGA in acute care (Arnott, 2024). This highlights a missed opportunity to optimise patient outcomes in this population, allowing the opportunity for targeted intervention.
The focus of this service development project is to evaluate the feasibility of the introduction of a pharmacist-led polypharmacy assessment, review and rationalisation service to deliver SMR in secondary care to inpatients living with severe frailty admitted to Ipswich Hospital, East Suffolk and North Essex Foundation Trust.
Aim: To evaluate the feasibility of the introduction of a pharmacist-led polypharmacy assessment, review and rationalisation service to deliver SMR in secondary care to inpatients living with severe frailty admitted to Ipswich Hospital, East Suffolk and North Essex Foundation Trust.
Objectives
- To determine the feasibility of the recruitment, financial cost and time resources required for an inpatient pharmacist-led SMR service.
- To determine the potential impact of pharmacist-led SMR on the following clinical outcomes immediately after and at 30 days post-discharge:
- Incidence of complex polypharmacy (defined as 10 or more unique medications) in patients with a Rockwood clinical frailty score of 7 or above
- Incidence of potentially inappropriate prescriptions as defined by the PrescQIPP Improving Medicines and Polypharmacy Appropriateness Clinical Tool (2024)
- Anticholinergic burden score
- ED attendances post current admission
- To determine if medication changes made as part of pharmacist-led SMR in secondary care are correctly communicated to primary care on discharge and medication changes are reflected on primary care records within 14 days of discharge
- To measure the impact of pharmacist-led structured medication review on prescription cost-savings related to deprescribing of potentially inappropriate prescriptions
To evaluate patient and specialist clinician feedback on the value of a pharmacist-led structured medication review service in appropriateness of intervention location, patient safety and communication between transfer of care settings.
Organisations involved in this group
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