Digital technologies

The topic experts highlighted increasing interest in using new digital technologies to support medicines adherence and optimisation. Therefore, we undertook a literature search to identify evidence in these areas as described above.

Polypharmacy and deprescribing

Topic experts noted polypharmacy and deprescribing as areas in which additional guidance would be welcome. The guideline on medicines optimisation already has several recommendations recognising that people on multiple medicines may benefit from interventions such as medicines review or additional support on discharge from hospital.

A few studies reported on deprescribing, such as reducing proton pump inhibitor (PPI) use. However, the evidence was applicable to a few specific populations and was insufficient to indicate a need to update the overarching guidelines on medicines adherence or medicines optimisation.

However, guidance on deprescribing of specific drugs is covered in disease-specific guidelines. For example, NICE’s guideline on gastro-oesophageal reflux disease and dyspepsia in adults recommends reducing the dose or frequency of PPIs in long term use.

NICE has also published a guideline on multimorbidity: clinical assessment and management which addresses polypharmacy, but no new evidence indicated a need to update this guideline.

Multi-compartment medicines systems

We also received feedback on concerns about multi-compartment medicines systems, which are used to aid adherence; however, no studies eligible for consideration in surveillance were identified. Observational studies of this issue are limited by the inability to determine whether multi-compartment medicines systems are themselves problematic, or if they are a marker of polypharmacy and possible inappropriate prescribing. The guideline suggests these systems as one of several options to overcome practical problems associated with nonadherence if a specific need is identified.

Shared decision making

Feedback also suggested that there has been progress in aspects of care covered by the guidelines, including shared decision making. NICE is part of a shared decision making collaborative that aims to make shared decision making part of everyday care. NICE is also developing a guideline on shared decision making.

Merging the guidelines

Topic experts indicated that the guidelines would be better presented as a single guideline. The surveillance review confirms that the guideline recommendations are still current. However, if any new evidence becomes available, the guideline will be reviewed before its next scheduled surveillance review. If the guidelines need updating we will consider merging them at that point.

We will also consider merging the guidelines when NICE’s guideline on shared decision making publishes (expected in April 2021). This guideline may make recommendations that supersede recommendations on patient involvement in decisions about medicines in the guideline on medicines adherence.

Medicines adherence

Overall, 18 stakeholders commented.

Eight stakeholders agreed with the decision and included 3 professional societies, 2 NHS trusts, 1 patient group, and 1 pharmaceutical company.

Ten stakeholders disagreed with the decision to not update the guideline:

• 7 patient groups sent coordinated and similar responses highlighting evidence that prescription charges inhibit adherence to medicines in long-term conditions. Because decisions about prescription charges are made by the Department of Health and Social Care, we have not covered this issue in the summary of evidence and it is outside the remit of the guidelines.
• 1 stakeholder suggested that recommendations should be more specific on the use of community pharmacy services and on capabilities of pharmacy systems. The guidelines provide general guidance for implementation in the most appropriate way and because these issues are dependent on local availability and circumstances, no update is necessary. NICE also has a guideline on community pharmacies: promoting health and wellbeing, which aims to encourage more people to use community pharmacies by integrating them within existing health and care pathways and ensuring they offer standard services and a consistent approach.
• 1 stakeholder provided evidence on multi-compartment medicines systems, which had contradictory findings on whether these systems improved adherence and resulted in adverse events and therefore the evidence was insufficient to support an update in this area. This stakeholder also highlighted a tool to identify people at risk of nonadherence to their medicines. However, the evidence highlighted was a validation study that included a sample with high adherence so not the typical population. Additionally, the results of the study resulted in changes to the tool that have not been tested. Thus, the findings are insufficient to support an update to the guideline.
• 2 stakeholders did not explain why they disagreed with the surveillance decision.

Additionally, 2 stakeholders highlighted issues with the scope of the guideline:

• 1 stakeholder noted the exclusion of children from the scope. However, the scope noted that
• ‘the guideline recommendations may be considered for a child or young person who is deemed competent to express a view on their prescription’ so the issue is addressed where appropriate.
• 1 stakeholder suggested including stronger guidance on deprescribing. However, we consider that deprescribing may be the result of a medicines review, rather than the focus of a review. Additionally, we have not identified evidence indicating that deprescribing would be suitable for specific drugs, drugs classes or indications (see polypharmacy and deprescribing above). Therefore, no update in this area is necessary.

One stakeholder suggested that ‘polypills’ should be covered in response to the question on equalities. We consider the recommendation on simplifying the dosing regimen to apply to this subject, if the prescriber considers an available product to be appropriate for the patient. Additionally, the issue of polypills does not meet the criteria for an equalities issue because it does not affect a group with a protected characteristic.

Medicines optimisation

Overall, 6 stakeholders commented.

Four stakeholders agreed with the decision. These were the Department of Health and Social Care, 2 professional bodies and 1 NHS trust.

Two stakeholders disagreed with the decision:

• 1 stakeholder commented on deprescribing and multi-compartment medicines systems. These comments were generally the same as those submitted on the guideline on medicines adherence addressed in the previous section.
• 1 stakeholder suggested adding a recommendation advising that specialist teams should be contacted when a patient is admitted. The guideline has a section addressing medicines-related communication systems when patients move from 1 care setting to another, and this covers admission to hospital and sharing information about medicines. Communication about non-medicines aspects of care is outside the remit of the guideline but services following the advice on communication have the opportunity to share other information pertinent to the patient’s care.

See appendix B1 for full details of stakeholders’ comments and our responses for medicines adherence) and appendix B2 for full details of stakeholders’ comments and our responses for medicines optimisation).

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Medicines adherence (NICE guideline CG76)

The reference to the Disability Discrimination Act (2005) in the preamble to the recommendations should be updated to refer to the Equalities Act (2010).

In recommendation 1.1.31, the reference to NHS Choices should be updated to the NHS website.

In recommendation 1.1.16, a cross reference should be added to the NICE guideline on decision-making and mental capacity.

Medicines optimisation (NICE guideline NG5)

In the footnote to recommendation 1.2.1, the hyperlink to the Health and Social Care Information Centre’s A guide to confidentiality in health and social care (2013) should be updated to reflect its current home on the NHS Digital website. The Health and Social Care Information Centre website has been archived.

A cross reference to the NICE guideline on decision-making and mental capacity should be added in the sections dealing with self-management and patient decision aids.