TAILOR: Tailoring prescribing with advanced generalist medicine

TAILOR : optimising a whole-person-centred approach to tailoring the use of medicines

There are 56 million people in England. 27million of them regularly take one of more medicine a day. 8.4million take 5 or more; and 3.8million take 8 or more. A growing proportion of our population experience polypharmacy

Of those taking 5 or more medicines a day, 40% report feeling burdened by taking medicines. Research shows this burden is not just due to side effects of medicines, but the whole lived experience of using medication. People describe the work involved in having to organise ordering, collecting and taking their medicines; planning their day around medicines; worrying about their medicines as just some examples.

A report from the Chief Pharmaceutical Officer for England in 2020 described that we need to tackle this problem of overprescribing He called for a change in both the culture and system design that shape the ways we use medicine.

Since then we’ve seen growing interest in reducing the number of medicines people are using – or deprescribing. But this has raised a whole new set of problems. Clinicians and patients alike don’t feel confident in knowing how to safely reduce the use of medicines? Safe deprescribing is a worry for patients, clinicians and policy makers alike

This is the focus for our research.

NIHR lay summary

Drawing on our expertise in tailored, advanced generalist medical practice, we set out to understand if/how we can apply generalist principles to understanding a new approach to prescribing.

We used 2 review methods to answer two questions. Firstly, what do we know about the safety, effectiveness and acceptability of describing (stopping medicines). Secondly, what is needed to support and deliver tailored deprescribing.

To answer the first question, we did a scoping review. Effectively a map of the existing research in this area. For the second question we used a realist review – a method that allows us to systematically examine and describe how things work in context.

Professor Joanne Reeve is Primary Investigator. The Co-Investigators are:

• Michelle Maden, Ruaraidh Hill (Liverpool)
• Amanda Turk, Geoff Wong, Kamal Mahtani (Oxford)
• Dan Lasserson (Warwick)
• Janet Krska (Kent)
• Dee Mangin (McMaster)
  Richard Byng (Plymouth)
• Emma Wallace (RCSI)
• Ed Ranson (PPI)

The project is funded by NIHR HTA 17/69/02.

We finished out reviews in 2022 and the final report is published in the NIHR library.

Our findings from TAILOR provide an evidence base that deprescribing/tailored prescribing is potentially safe and acceptable if done using a structured approach.

4 key practice elements are needed to do it well:

1. Access to appropriate range of data;
2. Clinician confidence in creating a tailored explanation of role/value of medicines for this individual in their context (advanced generalist skills);
3. Trust – maintained between patient and clinician and across teams; and
4. Supportive infrastructure to enable this complex work

The findings have been translated into an NIHR Evidence Alert – a lay reported version of the research available here.

We have been sharing the outcomes from our work with a range of clinical audiences. Our work is relevant both to those involved in prescribing, and in advanced generalist medicine.

As a result we have been invited to present our work at a range of educational and professional development meetings (see our outputs below) including GP Vocational Training, PresQuipp (a community interest company supporting optimised prescribing) and within our CATALYST programme.

We have also developed free-to -access on-line educational resources for clinical colleagues which can be accessed on the WiseGP website and the NIHR website.

Next plans for our work focus on supporting the practice level changes our research described as needed. Work here includes research within the TIMES project.

How to reduce medications for people with multiple long term conditions. BMJ 2023;382:p1708 doi: https://doi.org/10.1136/bmj.p1708

Turk, A., Wong, G., Mahtani, K.R. et al. Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 20, 297 (2022). https://doi.org/10.1186/s12916-022-02475-1

Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, et al. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022;26(32) https://doi.org/10.3310/AAFO2475

Reeve J. Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice. Br J Clin Pharmacol. 2021; 87: 76–83. https://doi.org/10.1111/bcp.14531

Smith DM, Friend C, Reeve J. Polypharmacy and rationalisation of medications. InnovAiT. 2020;13(2):87-93. doi:10.1177/1755738019890003

Workshops and seminars including:

• British Pharmacological Society, Royal College of Physicians. November 2021
• PRESQUIPP March 2023