Developing a measure of polypharmacyappropriateness in primary care: systematicreview and expert consensus study
Jenni Burt, Natasha Elmore, Stephen M. Campbell, Sarah Rodgers, Anthony J. Avery and Rupert A. Payne
Background:Polypharmacy is an increasing challenge for primary care. Although sometimes clinically justified,polypharmacy can be inappropriate, leading to undesirable outcomes. Optimising care for polypharmacy necessitateseffective targeting and monitoring of interventions. This requires a valid, reliable measure of polypharmacy, relevantfor all patients, that considers clinical appropriateness and generic prescribing issues applicable across all medications.Whilst there are several existing measures of potentially inappropriate prescribing, these are not specifically designedwith polypharmacy in mind, can require extensive clinical input to complete, and often cover a limited number ofdrugs. The aim of this study was to identify what experts consider to be the key elements of a measure of prescribingappropriateness in the context of polypharmacy.Methods:Firstly, we conducted a systematic review to identifygeneric (not drug specific) prescribing indicatorsrelevant to polypharmacy appropriateness. Indicators weresubject to content analysisto enable categorisation.Secondly, we convened a panel of 10 clinical experts to review the identified indicators and assess their relativeclinical importance. For each indicator category, a brief evidence summary was developed, based on relevantclinical and indicator literature, clinical guidance, and opinions obtained from a separate patient discussion panel.A two-stage RAND/UCLA Appropriateness Method was used to reach consensus amongst the panel on a core setof indicators of polypharmacy appropriateness.Results:We identified 20,879 papers for title/abstract screening, obtaining 273 full papers. We extracted 189 genericindicators, and presented 160 to the panel grouped into 18 classifications (e.g. adherence, dosage, clinical efficacy).After two stages, during which the panel introduced 18 additional indicators, there was consensus that 134 indicatorswere of clinical importance. Following the application of decision rules and further panel consultation, 12 indicatorswere placed into the final selection. Panel members particularly valued indicators concerned with adverse drugreactions, contraindications, drug-drug interactions, and the conduct of medication reviews.Conclusions:We have identified a set of 12 indicators of clinical importance considered relevant to polypharmacyappropriateness. Use of these indicators in clinical practice and informatics systems is dependent on theiroperationalisation and their utility (e.g. risk stratification, targeting and monitoring polypharmacy interventions)requires subsequent evaluation.