How do pharmacists navigate clinical uncertainty when reviewing polypharmacy? A critical literature review

Background:
Clinical pharmacists are the principal profession reviewing polypharmacy in English general practice. Pharmacists reviewing polypharmacy can encounter clinical uncertainty, thus affecting decision-making and the utility of medication reviews. Understanding factors and interventions that mitigate clinical uncertainty could improve polypharmacy medication reviews. This review’s objective was to explore how primary care clinical pharmacist decision-making can be improved when reviewing polypharmacy in the context of clinical uncertainty.

Methods:
A critical literature review was undertaken in key databases. Included articles explored polypharmacy, clinical uncertainty and medication review by primary care clinical pharmacists. Exclusion criteria included community pharmacy and monotherapy management. Quality assurance was conducted using Lincoln and Guba’s evaluative criteria. Contents of included papers were thematically analysed and conceptual models produced.

Results:
647 titles/abstracts were screened and 11 full-text articles included, encompassing focus group, interview, ethnography and intervention-development studies. Pharmacists expressed feelings of self-competence occurring alongside apprehension when reviewing polypharmacy. Relationships with patients, including shared decision-making, continuity of care and engagement can support medication reviews. Decision-making is impacted by environmental factors, with poor working relationships within organisations, working across several sites and time pressures hindering deprescribing. The absence of clinical and deprescribing guidelines for multimorbid patients contributes to clinical uncertainty. Multidisciplinary working mitigates clinical uncertainty and training interventions can support pharmacists to proactively deprescribe.

Conclusion:
Pharmacist, patient and environmental factors can influence pharmacists’ decision-making when experiencing clinical uncertainty during polypharmacy review. Clinical education, peer support and multidisciplinary working have roles in reducing clinical uncertainty and therefore optimising pharmacists’ reviews of polypharmacy.