Clinical Audit template The clinical audit process has been tested and refined over time. Its purpose is to encourage

teams to reflect and act on the best information available to improve clinical practice. The

method can be applied to any aspect of practitioner or practice activity to assist with

identifying ‘where you are now’, ‘where you could do better’ and ‘how to get there’.

TOPIC Polypharmacy in older people Why is this topic of interest?

Polypharmacy can refer to the prescribing of many medicines (five or more

medicines is often quoted) or to the addition of inappropriate medicines to an

existing regime.[1]

Polypharmacy is associated with negative health outcomes including adverse drug

reactions, poor adherence and clusters of health problems described as “geriatric

syndromes”, for example, urinary incontinence, cognitive impairment and impaired

balance leading to falls.[2]

Older people (defined here as those aged 65 years and over), especially those with

frailty or multiple comorbid conditions, are more susceptible to medicine-related

morbidity and mortality.

What is this audit about?

This audit consists of a review of 15 people aged 65 years and over who are

receiving:

- 5 or more medications

- 8 or more medications

- 11 or more medications

References

1. Aronson J. 2004. In defence of polypharmacy. British Journal of Clinical

Pharmacology. 57(2): 119–20.

2. Haijar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J

Geriatr Pharmacother. 2007;5:345–51.

Recommended reading

Ministry of Health. Medicines Care Guides for Residential Aged Care.

Wellington: Ministry of Health, 2011.

PLAN Indicators The doctor / practice reviews prescription practices and appropriateness for older

patients.

Local DHB prescribing practice is compared with other DHBs across a range

of indicators. Indicators where local DHB is significantly lower or higher

than the national mean are identified (from the Atlas: http://tinyurl.com/PolypharmAtlas

Patients who meet the criteria are identified and reviewed (from practice’s

PMS)

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Criteria (how will the indicator be measured)

The aim of this audit is to identify people who may benefit from medication review:

1. People aged 65 years and over who are receiving 5 or more medicines or 8

or more medicines.

Depending on how many patients meet this criteria, further subanalyses

could be considered:

By number of medications: 5 or more medicines or 8 or more

medicines

By age band: 65-74 years, 75-84 and 85+.

Standards (the standards to be achieved)

Prescribing patterns have been examined

80% of own patients in identified categories have had prescribing reviewed

Note that the focus is on improving standards of clinical practice, with 80%

achievement identified by the RNZCGP as an appropriate target and 100% as an

ideal. Individual GPs and practices may choose to set a differing target for a first or

subsequent audit/s, with a view to increasing standards over time.

DO

Discover what you are doing now (collect data)

1. Look at your DHB’s results in the Atlas of Healthcare Variation: Polypharmacy in

Older People. This is a good activity to do as part of a peer review group or as

a practice.

The Atlas presents data by DHB and provides analyses by ethnicity and age

group. http://tinyurl.com/PolypharmAtlas

a. Identify the gap between your DHBs results and the national mean across

different indicators. How do your DHB results compare with similar

DHBs?

b. Are your DHB’s rates lower or higher than average when you look at

different age groups, ethnicities or gender?

c. Based on these results, are there particular indicators, age groups,

ethnicities or gender in your patient population that may warrant

particular attention?

2. Free patient management system (PMS) queries to identify a list of your

patients meeting the search criteria are available to MedTech and MyPractice

users. For detail on how to run these queries and which queries are available,

choose the ‘find my patients’ button on the polypharmacy atlas page. (Note:

these queries can take 5 or 10 minutes to run, it is recommended to run these

outside of office hours.)

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In your PMS, select and run polypharmacy queries. This is recommended

outside of office hours. Instructions to find the queries are available here:

http://www.healthstathqsc.co.nz/?atlas=polypharmacy1) or for MedTech at the

end of this document. This will generate a list of your patients.

Note: calculating rates / dealing with small numbers:

The Atlas presents rates. These are calculated using a defined denominator

population, such as people aged 65 years and over residing in a DHB. For this

purpose, calculation of rates is not recommended as the number of patients

meeting the criteria is expected to be low. As a rule of thumb there should be

30 or more events per clinician or practice before statistical analysis is

attempted. Where events are less than 100, close attention should be paid to

the statistics of small numbers.

STUDY

Analyse what the results tell you

1. Analyse your results using the data sheet on the next pages. Consider the

following: a. Does your data appear complete?

Note that there are differences between Atlas data which shows

medications dispensed compared with your data which shows medications

prescribed. Your PMS may not include medicines prescribed by specialists.

b. Data coding. Is coding consistently applied? Is the query identifying your

patients as it should? For example, depending on how you categorise

medicines, it is possible that one or more PRNs are listed as the long term

medicines. These should be excluded from the count in your review.

2. Examine the individual patients on your list. For methods of medication review

in older people, see BPAC:

http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx

The link below takes you to some patient decision aids that have developed by

the NHS. These patient decision aids (PDAs) might be helpful to support

decisions in which patients need to consider benefits versus risks.

http://www.npc.nhs.uk/patient_decision_aids/pda.php#BNF

ACT

Make changes – what changes can be made to

improve patient care?

Based on your DHBs results in the Atlas, what variation have you identified?

Is any change in your prescribing pattern needed? What changes will you make?

Plan and implement a patient recall and review strategy.

Plan a review date to follow up on changes

The practice quality improvement plan can be used to record actions identified for ongoing

discussion, to monitor progress, and to provide information for team learning and reflection.

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RNZCGP Summary Sheet

Continuous Quality Improvement (CQI) Activity

Topic: Polypharmacy in older people

Doctor's name: ______________________________________________________________ Date of collection:________________

First cycle Sample size: If the query identifies more than 30 patients, it is suggested that those in highest risk groups be targeted. This could be:

a. those receiving 8 or more medicines,

b. those receiving 11 or more medicines,

c. those aged 85 and over.

For methods of medication review in older people, see BPAC: http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx

Patients receiving 5 or more long term medications

Patient How many long term medicines is this patient receiving? (number)

If they are receiving more than 5 medicines, has their medication been reviewed in the last 6 months? (Yes/No)

Medication review. If no, set alert or recall? (Alert, recall, no action)

1 2 3 4 5 6 7 8 9

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10 11 12 13 14 15

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Check: Describe any areas targeted for improvement as a result of analysing the data collected.

Action: Describe how these improvements will be implemented.

Monitor: Describe how well the process is working.

Comments:

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Second cycle

For methods of medication review in older people, see BPAC: http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx

Patients receiving 5 or more long term medications

Patient How many long term medicines is this patient receiving? (number)

If they are receiving more than 5 medicines, has their medication been reviewed in the last 6 months? (Yes/No)

Medication review. If no, set alert or recall? (Alert, recall, no action)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

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Data: Date of data collection:

Check: Describe any areas targeted for improvement as a result of analysing the data collected.

Action: Describe how these improvements will be implemented.

Monitor: Describe how well the process is working.

Comments:

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Running Find My Patients queries in MedTech32.

Instructions on how to run the HQSC Atlas of Healthcare Variation Queries in Medtech32 and

identify which patients contribute to the measures.

These queries can take 5 or 10 minutes to run. They can slow your system and it is

recommended to run them outside business hours.

1. Go to ‘ManageMyHealth’ from

the toolbar and select ‘Patient

Tools’

2. Click on ‘HQSC Queries’

3. Select the query from the list

‘Choose Patient List’ and click

‘Run/ Download’

4. A list of patients will be

displayed. Click on “Patientid”

to see basic demographics,

date last seen and contact

phone numbers.

HQSC Queries

5. You can apply alerts or recalls to these patients.

Choose an alert /recall and apply to entire list or apply

to individuals by ticking the boxes. Click ‘Update

PMS’ to write all alerts or recalls back to the PMS

automatically.