Understanding cognitive barriers to safer prescribing for frail patients

Deciding to stop medicines that have been prescribed in line with clinical guidelines could be seen as counter-cultural. It goes against the grain for clinicians, and often patients, too. This Safer Prescribing for Frailty project used an understanding of the cognitive barriers to stopping medicines to enable general practice teams to design, test and embed ways to better meet the medication needs of their frail populations. We took a comprehensive approach to this assessment using the Theoretical Domains Framework^[1]
and using resources from the Improvement Academy Behaviour Change toolkit.

Holistic medication review, which targets problematic polypharmacy, normalises shared decision-making and improves the quality of healthcare interactions. In doing so, there is a reduced medication burden for people with frailty, and this reduces adverse events and hospitalisations.

This project was carried out by the Harrogate and Rural District Clinical Commissioning Group (CCG) medicines management team, in partnership with Yorkshire and Humber Academic Health Science Network (AHSN) Improvement Academy (funded by the Health Foundation), and aimed to:

• Improve medication review and reduce potential inappropriate prescribing for frail older people;
• Improve knowledge and skills of the primary care team in deprescribing;
• Develop an intervention specific to the setting for undertaking and improving medication reviews using evidence-based tools and national guidelines;
• Train primary care teams in transferable quality improvement skills;
• Evaluate how psychological theory could be used to assess the barriers to deprescribing medications for older people at risk of severe frailty in primary care, and identify the factors contributing to deprescribing practice among primary care health care professionals.

A total of 12 general practices were recruited from 5 CCGs across North and West Yorkshire to participate in the training and action programme. A ‘training and action for behaviour change’ approach^[3]
to improvement was used, which included:

• Training in clinician behaviour change theory and tools;
• Training in change management and quality improvement techniques;
• Increasing awareness of evidence-based tools available to support medication reviews, such as the STOPP/START tool and the Scottish polypharmacy guideline;
• Opportunities to learn and share good practice with fellow primary care practitioners;
• A package of ongoing support from the Improvement Academy team, including on-site visits.

A broad range of cognitive barriers to safer prescribing were reported by prescribers from the 12 general practice teams. Lack of knowledge scored the highest, and the environment (time available and process) followed in close second. Social influences and a fear of consequences were also cited as barriers.

The programme was led by quality improvement and behavioural change experts from the Improvement Academy over a 24-week period. Following the training, the teams were supported to develop interventions to apply evidenced-based tools to support deprescribing that utilises the electronic frailty index to identify patients^[2]
. The main measure used was the total number of repeat prescription items within each practice’s defined cohort. There was fortnightly monitoring of the impact of change over the project period.

In addition to the interventions described above, practices were supported in mapping their individual barriers to behaviour change techniques^[4]
, which formed the basis for acceptable, practicable, (predicted to be) effective, affordable and safe (APEASE criteria^[5]
) interventions to support safe prescribing. As reported above, the interventions (change ideas) tested were general practice-specific, and were tailored to the specific barriers identified within that practice. However, there were some commonalities across the practices, including:

• The use of a template for recording the medication reviews;
• Better use of the skills available to the practice, particularly the optimal use of practice pharmacists for those teams that had access to one;
• Protected time for polypharmacy medication review consultations;
• Consideration of home visits for the medication review consultations;
• Sharing learning with the wider team within the GP practice.

The Safer Prescribing for Frailty project achieved a 6% reduction in the average number of prescription items prescribed to people with frailty. This equated to 795 prescription items across the cohort of patients in the project.

A more in-depth review carried out in one practice (74 patient reviews) demonstrated an average saving of £69.27 per review; 30% of medicines stopped were deemed to be high risk in frail older patients according to the NHS Scotland polypharmacy guidelines; and 17% of medicines stopped resulted in a reduction in anticholinergic burden.

Overall, this project has been successful at achieving more appropriate prescribing; it has had a significant impact on the culture of prescribing in the practices involved, and has improved the care for patients living with frailty.

Christopher Ranson, senior pharmacist; Harrogate and Rural District CCG;

Tony Jamieson, director of transformation, Yorkshire and Humber ASHN;

Megan Humphreys, implementation manager, Yorkshire and Humber AHSN Improvement Academy;

Sarah De Biase, improvement programme manager, Yorkshire and Humber AHSN Improvement Academy;

Judith Dyson, senior lecturer, implementation Science; School of Health and Social Work; University of Hull;

Maureen McGeorge, programme manager; Yorkshire and Humber AHSN Improvement Academy;

John Bibby, quality improvement consultant, Yorkshire and Humber AHSN Improvement Academy;

Beverley Slater, director, Yorkshire and Humber AHSN Improvement Academy