How much does it cost to care Optimising the safety of medicines for older people in nursing homes

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How much does it cost to care? Optimising the
safety of medicines for older people in nursing
homes

• Susan Patterson, Chris Cardwell, Grainne
  Crealey and Carmel Hughes
• School of Pharmacy, Dept. of Epidemiology,
• Queens University Belfast. Clinical Research
  Support Centre
• 30th October 2008

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People gt65yrs with long-term conditions (England)
15 million, 2008
18 million, 2025
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Ageing and illness

• The over 80s are the fastest growing age group in
  the UK
• ¼ of UK population is over 60 years
• Compression of morbidity? Expected time lived in
  poor health
• 1981 6.5 yrs (men) 10.1 yrs (women)
• 2001 8.7 yrs (men) 11.6 yrs (women)
• Variety of drugs
• Multiple medical conditions

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Older people and medicines

• 81 men and 86 women over 75 take one or more
  medicines
• 36 of over-75s take four or more medicines
• Polypharmacy
• Appropriate
• Inappropriate
• Increased risk of drug interactions
• Increased risk of Adverse Drug Events related to
  number of drugs taken
• Number of drugs prescribed is a significant
  predictor of mortality (Dale et al., 2001)

Dale et al. Int J Geriatr Psychiatry. 20011670-6
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Age-related physical changes

• Changes in composition in the ageing body
• Water and fat balance altered
• Decline in physiological functions
• By age 75, 50 decline in renal function
• Hepatic blood flow reduced and cytochrome p450
  enzyme less active
• Gastric emptying slow and reduced blood flow to
  gut
• Decreased cardiac output

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Prescribing for older people

• Most frequent medical intervention experienced
• Complex due to multiple morbidities
• Limited evidence from studies usually carried
  out in the under 65s
• Prescribing cascade
• Add-on treatment for side effects
• Diagnosis important before prescribing
• Repeat prescriptions are common
• Convenient for patients but
• Less opportunity for prescriber to monitor
  therapy and intervene

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Inappropriate medication

• Unnecessary medicines or
• Lack of treatment
• Studies indicate a prevalence of inappropriate
  prescribing, a modifiable risk factor for adverse
  drug events in older people, in nursing homes of
  up to 55 (Rancourt et al. 2004)
• Inappropriate medication results in an increased
  number of falls, adverse drug events and costly
  hospital admissions

Rancourt C et al. BMC Geriatr 2004 4 9-19
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Prescribing of Hypnotics and Anxiolytics in
General Practice in N. Ireland
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Prescribing of Antimanic drugs and Antipsychotics
in General Practice in NI
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Making drug therapy safer

• Manage the risk of medication-related problems
  by
• Reducing the number of drugs (polypharmacy)
• Reducing inappropriate drugs
• Increasing appropriate drugs
• Monitoring
• Therapeutic effects
• Safety side effects, laboratory tests
• Regular review of medicines brown bag
  approach

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Pharmaceutical care
Ensuring that patients get the best drug
treatment responsible provision of drug
therapy for the purpose of achieving definite
outcomes that improve a patients quality of
life (Hepler Strand, 1990)

• the Fleetwood NI project

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Development of the Fleetwood US model of
pharmaceutical care

• Developed by the American Society of Consultant
  Pharmacists.
• Moving beyond US regulations
• Reduction in the use of inappropriate medication
• Tackles under treatment of medical conditions
• Seeks to reduce adverse drug events
• Promotion of evidence-based practice

Cameron K et al. Consultant Pharm 2002 17
181-194
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Components of the Fleetwood model

• Screening for high-risk patients
• Prospective medication review
• Resident assessment by the consultant pharmacist
  pharmaceutical care needs
• Pharmacist intervention and direct communication
  with the prescriber
• Formalised pharmaceutical care planning

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Fleetwood NI Project

• Adapt the US model for use in NI phase 1 study
• Test the adapted model in NI nursing homes
• Focus of analysis on psychoactive drugs
• Primary outcomes
• No. residents taking one or more inappropriate
  psychoactive drugs
• No. residents who fall
• Secondary outcomes
• Changes in healthcare resource use over time
• Professional satisfaction

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Fleetwood NI project design

• 22 nursing homes across NI participated
• 11 matched pairs randomly assigned as
  intervention or usual care
• 15 residents per home recruited, total334
• Pharmaceutical care plan designed to encourage
  standardised approach
• stepwise design based on elements of model
• 9 prescribing support pharmacists delivered
  intervention to 11 homes
• Training provided on intervention and medicines
  for older people

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Adapted from Oborne et al., 2002
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Baseline resident characteristics
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Baseline resident diagnoses
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Fleetwood NI Baseline data

• Total number of medicines per resident 10.8
• 7.6 regular3.0 prn0.2 acute
• 155 GPs cared for 334 residents
• 0.38 medication reviews per resident
  (intervention homes) during pre-study year

Number of residents receiving one or more CNS
(BNF Chapter 4) medicines at baseline
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Types of pharmacists interventions
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Fleetwood NI Project Results

• 2.83.3 clinical interventions per resident at
  first visit
• 72.4 interventions accepted by prescribers
• Increase in medication reviews to 1.50 per
  resident during study year in intervention homes
• Reduction in the numbers of inappropriate
  psychoactive and all CNS drugs over time

Numbers of residents receiving one or more CNS
medicines after 12 months
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Number of CNS prescriptions in intervention homes
over time
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Significant reduction in residents prescribed
inappropriate psychoactives
After one year the odds of a resident receiving
an inappropriate psychoactive drug in an
intervention home 0.26 (95 CI 0.14, 0.49)
compared to a resident in the control group of
homes
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Fleetwood NI Project Falls

• No change in the numbers of nursing home
  residents having one or more falls in the control
  and intervention groups during the pre-study year
  and the study years
• No change in falls risk score after one year

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Professional Satisfaction
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Conclusions

• An adapted US model of holistic pharmaceutical
  care was successfully implemented in a cluster
  RCT in nursing homes in Northern Ireland
• A need for regular review of nursing home
  residents medication was demonstrated
• There was a significant decrease in the rate of
  inappropriate psychoactive prescribing in the
  intervention group of nursing homes
• No changes were detected in the number of home
  residents who fell

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Health economics

• Clinical benefit of pharmaceutical care is proven
• But

• How much does it cost to care?

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What is economic evaluation?

• The comparative analysis of alternative courses
  of action in terms of both their costs and
  consequences
• Costs on one side of the equation
• Outcomes on other side of equation

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Outcome side of the equation

• Outcome in terms of patient benefit (e.g.
  change in prevalence of inappropriate
  psychoactive drugs)
• Another potential outcome
• Changes in resource usage generated as a result
  of the new intervention (as compared to current
  resource usage)
• Hence we need to quantify such changes (for
  example, increased patient mobility could
  increase or decrease usage of nursing resources)

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Data collection
Quantity x unit costs (PSSRU data)
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Economic evaluationmethods results

• Unit costs NHS services (PSSRU)
• Frequency of each cost element calculated for
  pre-study year and study year
• Intervention and control groups compared
• Increase in total costs in both groups of homes
  after one year
• No difference between intervention and control
  homes

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Costs per resident of primary and secondary care
resources
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Economic modelling

• Pharmaceutical care service costs unknown
• Service analysed and measured during study year
  using
• Multidimensional work sampling (MDWS)
• Pharmacists payment claims
• Economic modelling undertaken
• Scenarios compared
• Reference case
• Optimistic case
• Pessimistic case

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MDWS Pharmaceutical care activities
Proportion of professional, semi-professional and
non-professional time spent by pharmacists
providing a pharmaceutical care service to
nursing home residents
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MDWS pharmacists time, location contact with
others
Time spent on different types of activities
Location of pharmacist
Contact with others
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Building an economic model

• Service profile
• Three scenarios
• Targeting those at highest risk through screening
• Staffing
• Skill mix
• Grading salary
• Overheads
• Premises
• Travelling

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Reference case scenario
Cycles of pharmaceutical care as they occurred in
the Fleetwood NI study
Risk screening by community pharmacist to
identify residents at highest risk of adverse
drug events
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Outcomes of economic model
Output of the economic model Cost estimates in
the reference scenario
Comparison of three modelled scenarios
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Sensitivity analysis
Sensitivity analysis Variations in cost
parameters in the reference case
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Why is this important?

• Already interesting findings from the study
• breakdown between professional and
  non-professional activities
• Analysis of data enables profiling of
  activities and identification of efficiencies
• Allows a service delivery costing feasibility
  model to be developed
• Can provide accurate financial projections
  address planning issues relating to the service
• Aids decision-making (reduces uncertainty)

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Conclusions

• Benefits of pharmacist input were demonstrated in
  nursing homes reduction in inappropriate
  psychoactive prescribing
• Can calculate how much it costs to care through
  the use of economic modelling techniques
• This approach can assist decision-makers by
  providing evidence-based cost estimates of
  proposed new services

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Thank you for listening

• Any questions?

Contact spatterson20_at_qub.ac.uk