A qualitative exploration of barriers to efficient and effective Structured Medication Reviews in Primary Care: Findings from the DynAIRx study

Abstract

Introduction: Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them. Methods: Qualitative focus groups and semi-structured interviews took place between 2022-2023. Nine focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n=21), and three patient focus groups with patients at high-risk of rapidly worsening health from multimorbidity (n=13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using a thematic approach. Results: Two key themes limiting the effectiveness of SMRs in clinical practice were identified: ‘medication reviews in practice’ and ‘medication-related challenges’. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication. Conclusion: SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Antipsychotic management in general practice: serial cross-sectional study (2011-2020)

“…For a patient prescribed long-term APM for personality disorders, anxiety, or autism, and thus who is not captured on any QOF psychiatric illness register, there is no funding or automatic recall for GP review, or for cardiometabolic monitoring. GPs are supposed to conduct annual medication reviews, but research shows that these are of often incomplete, often of variable effectiveness, and limited action occurs particularly when APM is involved and there is no ongoing psychiatric input due to GP reluctant to change these medications [18, 21, 36, 39].…”