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 medicinerelated 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).
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.)
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.
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
1
2
3
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)
4
5
6
7
8
9
10
11
12
13
14
15
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:
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
1
2
3
4
5
6
7
8
9
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)
10
11
12
13
14
15
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:
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.