By 2022 it is hope that the iSIMPATHY project, which started in February 2021, will have delivered 15,000 polypharmacy medicines reviews. In addition, 120 health care professionals will have been to carry out polypharmacy medicine reviews in a systematic way. These could include hospital doctors, GPs, other pharmacists and nurses.  It is important that the approach developed for the study is sustainable going forward, explains Dr Scullin. “We want to contribute towards the embedding of a single approach for polypharmacy management as well as firmly establishing the cross-border element of this field”, she adds.

It will also be critical to undertake a rigorous evaluation to demonstrate evidence of benefit to patients and to make recommendations for further work. The Eden intervention scale and the Medication Appropriateness Index (MAI) will be used to assess the impact of interventions. Patient-reported outcome measures (PROMs) will also be used to capture the patient experience.

The Eden intervention scale provides a way of grading pharmacists’ interventions.  “Some interventions can be significant but don’t make that big a difference in patient care but the majority of interventions we have shown are grade 4 or above which indicates that there is also an improvement to patient care”, says Dr Scullin.

The Medication Appropriateness Index (MAI) is a well-known validated tool.  As part of this project it has been adapted to include a person-centred element.  “Members of the iSIMPATHY team have worked alongside the original author, Professor Joe Hanlon, in the USA to do this”, explains Dr Scullin.

For the patient-reported outcome measures (PROMs) the researchers plan to use an app that has been developed by the Scottish Government called ‘Managing your Medicines’ both pre- and post –review.

As the project progresses there will also be ongoing peer review and opportunities for pharmacists to share experiences and present challenging cases.

The goal is to produce a systems approach across health and care that is going to ensure the optimal and sustainable use of medicines for those with multi-morbidity to enable them to live active and healthy lives. “What we really mean by that is we are adding ‘quality-added’ life years [and not extra years in poor health]”, explains Dr Scullin.  “It’s important for us because it forms part of the action plan for Northern Ireland as directed by the Department of Health and our Health Board. It will also make a major contribution to the WHO’s third global health challenge which is to reduce the harm caused by medicines by 2023”, she adds.

Patients frequently say that they don’t know what all their medicines are for and really appreciate the opportunity to discuss their treatment. “Ultimately the goal is better ownership of health and medicines and to improve outcomes”, says Dr Brown.

Read more in the iSIMPATHY project here.

Read and watch the full series on our website or on YouTube.

“Ultimately, what we are aiming to do is to deliver 15,000 reviews over the next two years, by 10.5 pharmacists who will be trained in the iSIMPATHY method”. Of these 6000 interviews will be carried out in Scotland and 4500 each in The Republic of Ireland and Northern Ireland. “We are unique in Northern Ireland because we are delivering our medicines reviews in the hospital setting, in secondary care, while Scotland and the Republic [of Ireland] are delivering the  reviews in primary care”, noted  Dr Scullin.

The Medicines Optimisation and Innovation Centre (MOIC) is involved because for the past 20 years it has been involved in investigating the role of the clinical pharmacist in improving patient outcomes. Evidence of this can be seen in the many publications from the MOIC over that period.  “We see [iSIMPATHY] as an extension of that current medicines’ optimisation service improvement area that we have been working on for a long time”, says Dr Scullin.  Current services tend to focus on medicines’ optimisation at the time of admission and discharge.  “Sometimes that bit in the middle can lose out a bit”, she adds. The iSIMPATHY project is expected to deliver real benefits at this stage as project pharmacists will be delivering intensive medicines’ reviews to hospital inpatients.

Dr Brown explains what this will mean in practice for the project pharmacists. “We are all prescribers so we are able to action all of our recommendations ourselves –  but obviously in close conjunction with our medical and other pharmacy staff”, she says. The Scottish polypharmacy guidance – 7 Steps to appropriate polypharmacy is used as a framework for the medication reviews. The first step involves establishing what matters to the patient. The interview continues by determining which treatments are essential and which are unnecessary. Next, treatment is assessed to see if adjustments are needed to achieve therapeutic goals.  For example, this could be asking if a painkiller is working or checking to see if antidiabetic treatment is reducing haemoglobin A1C (HbA1C), explains Dr Brown.  The interview continues with consideration of actual or potential adverse drug reactions or side effects and then cost-effectiveness.  “Lastly we are looking at the patient’s willingness and ability to take their medicines as prescribed. There’s no point in prescribing a wonderful medicine if the patient does not believe it will work and will not take it. It’s no coincidence that the patient is the first step and the last step – they are the centre of the decision-making about their medicines and their health”, she says.

Information on non-pharmacological support for patients is also provided, including  self-care advice, referral to other services and ‘signposting’ to help patients take better care of themselves and take ownership of their health.

Pharmacists normally undertake medication reviews as part of their routine work, for example, medicines’ reconciliation is always carried out at the time of admission. However, these in-depth reviews take a lot of time. “These interviews take longer because we look at the patient holistically and take into account the patient’s own health goals and other factors that may not have been documented previously”, says Dr Brown.

The  three-year iSIMPATHY project is taking place in Norther Ireland, Ireland and Scotland led by the Scottish Government and is funded by the EU INTERREG VA program.

Read more in the iSIMPATHY project here.

Read and watch the full series on our website or on YouTube.

Dr Scullin is a senior research an innovation programme manager in the Medicines Optimisation and Innovation Centre (MOIC) in Northern Ireland and is the local project manager for the iSIMPATHY project. This is a collaborative project involving pharmacists in Northern Ireland, The Republic of Ireland and the lead partner, Scotland.

The MOIC is the only dedicated medicines optimisation centre in Europe. It receives finding from the Department of Health in Northern Ireland. The Centre is uniquely positioned to work alongside both public and private health care sectors to deliver better patient outcomes in relation to medicines optimisation.

Dr Brown is one of the three clinical pharmacists working on the iSIMPATHY (Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence THrough the Years) project. The project pharmacists will be responsible for conducting medication reviews and training other staff.

This study follows on from the successful SIMPATHY project – a Europe-wide initiative designed to stimulate and support innovation in the management of the growing problem of inappropriate polypharmacy. “We worked with a number of European countries where we tried to determine what level of polypharmacy guidance there is ….. What we ultimately discovered is that there actually wasn’t a lot”, says Dr Scullin.

‘Polypharmacy’ describes the concomitant use of multiple medicines. “It may not always be inappropriate”, says Dr Brown. Some patients with a number of comorbidities might have a large number of appropriate medicines. However, inappropriate polypharmacy can arise when medicines are no longer suitable, for example, because of deteriorating renal function or when patients have effectively collected prescriptions from multiple prescribers.  Adherence can also be a problem. When only one medicine is taken, adherence is about 80%, but when more than four medicines are prescribed, adherence drops to 50%. “The more medicines you take, the more likely you are to have an admission to hospital. If you are on more than 10 medicines, you are 300% more likely to be admitted to hospital with an adverse drug reaction”, explains Dr Brown. Part of the purpose of the study is to decrease inappropriate polypharmacy and to increase adherence to prescribed medicines.

The iSIMPATHY project builds on the six recommendations of the SIMPATHY project which were:

• Use a systems approach that has multidisciplinary clinical and policy leadership

• Nurture a culture that encourages and prioritises the safety and quality of prescribing

• Ensure that patients are integral to the decisions made about their medicines and are empowered and supported to do so

• Use data to drive change and measure outcomes

• Adopt an evidence based approach with a bias towards action

• Utilise, develop and share tools to support implementation·

“Our iSIMPATHY programme will train pharmacists and other health care professionals to undertake structured medicine reviews in line with the guidance developed during the SIMPATHY programme”, says Dr Scullin.

Read more in the iSIMPATHY project here.

Read and watch the full series on our website or on YouTube.