The benefits of medication review for patients and practice based commissioners

1
The benefits of medication review for patients
and practice based commissioners

• Dr Duncan Petty
• Lecturer Practitioner University of Leeds
• Practice Pharmacist

2
What is a clinical medication review?

• Aims
• Optimise the treatment
• Identify and solve problems
• Improve compliance and patient involvement
• Reduce waste
• Requirement of
• The nGMS contract
• Older peoples NSF

3
Aims of medication review

• Optimising the treatment regimen
• Is the medicine needed?
• Is it working?
• Is the dosage evidence based?
• Does the patient have any under-treated
  conditions?
• Does the patient have any untreated problems

4
Aims of medication review

• Identifying problems
• Are the medicines being ordered?
• Is the patient able to take it?
• Is the medicine interacting with other medicines?
• Is the medicine contraindicated?
• Are there any adverse drug reactions (ADRs),
  either reported by the patient or evident from
  tests?

5
Aims of medication review

• Patients views and preferences
• Does the patient want to take the medicine?
• Does the patient have any information needs about
  their condition and its treatment?
• Does the patient understand the purpose of the
  medicine?
• Are the prescription directions clear and
  practical?

6
Aims of medication review

• Waste reduction
• Branded to generic
• Unwanted medicines
• Unneeded medicines
• Over ordering

7
Benefits of medication review

• Improve the use of medicines
• Improve outcomes for nGMS measures
• Improve outcomes for NSFs
• Formulary implementation
• Reduce medicine risk
• Adverse events
• Litigation
• Effect on hospitalisation (?)

8
Benefits of medication review

• Reduce practice workload
• Appointments for review and re-authorisation of
  medicines.
• Review of discharge advice notes and letters
• Home visits to the vulnerable
• Improve patient satisfaction with medicines
• Questioning answering and education
• Shared decision making (or concordance)
• Reduce medicine waste

9
Who is at risk of repeat hospital admissions.

• Its hard to say!

10
Who is at risk of repeat hospital admissions

• Patients with multiple emergency admissions are
  often identified as a high risk group for
  subsequent admissions
• Patients aged gt65yr with 2 admissions were
  responsible for 38 of admissions in the index
  year but fewer than 10 in following year and
  just over 3 5 years later.
• Roland R. BMJ 2005330289-292

11
Research evidence Drug related admissions

• Potentially preventable drug-related morbidity is
  associated with 5-17 of admissions.
• Cunningham G. Age Ageing 1997
• Mannesse CK BMJ 1997
• Pirmohamed et al BMJ  200432915-19 
• Howard RL et al. Br J Clin Pharmacology
  2006June 26th
• About 20 of patients experience an adverse event
  after discharge.
• Forster A. Ann Intern Med 2003
• Forster A. CMAJ 2004
• Poor discharge can result in unplanned
• re-admission.
• Williams EI. BMJ 1998

12
Effect of medication review on hospital admissions

• All studies, Odds Ratio 0.64 (0.43-0.96)
• Only RCTs, Odds Ratio 0.91 (0.8-1.4)
• i.e. Medication review studies show only a weak
  effect on reducing hospitalisation
• Royal, S et al. Qual Saf Health Care
  20061523-31

13
Targeted reviews may be beneficial in reducing
poor outcomes

• Patients
• Poor adherence
• Polypharmacy
• Reduced drug handling
• Very elderly
• Living on own
• Living in a care home
• Multiple pathology
• Unplanned hospital admissions

14
Targeted reviews may be beneficial in reducing
poor outcomes

• Medicines
• Risky medicines
• Areas of dangerous or inappropriate prescribing
• Too few beneficial medicines
• Lack of monitoring
• Recent hospital admission

15
Hepler definitions for classification of drug
related admissions

• Score 1 inappropriate prescribing.
• Score 2 inappropriate delivery (unavailable
  when needed, inappropriate formulation, failure
  to administer, dispensing error).
• Score 3 inappropriate behaviour by the patient
  (non-compliance).
• Score 4 patient idiosyncrasy (response to
  drug, mistake, or accident).
• Score 5 inappropriate monitoring.
• Hepler CD, Strand LM. Opportunities and
  responsibilities in pharmaceutical care. Am J
  Hosp Pharm 19904753343.

16
Medication-related risk factors associated with
poor health outcomes

• Lack of routine for taking medicines
• Multiple storage locations
• Therapeutic duplication
• Hoarding of medicines
• Confusion with medicines names e.g. branded and
  generic
• Multiple prescribers
• Still using discontinued repeat medicines
• Poor adherence
• Older age
• Increasing number of medicines found in home
• Sorensen L et al. Medication management at home
  medication-related risk factors associated with
  poor health outcomes. Age and Ageing
  200534626-632.

17
Targeted interventions that can reduce poor
outcomes

• Around 4.3 of admissions due to medicines
• Most common cause of medicine related admissions
• Diuretics 16
• Antiplatelets 16
• NSAIDs 11
• Anticoagulants 8
• Howard RL et al. Br J Clin Pharmacology 2006June
  26th

18
Adverse drug reactions as cause of admission to
hospital

• Drugs causing adverse drug reactions
• Drug group No () of cases Adverse reactions
• NSAIDs 363 (29.6) Aspirin (218) GI bleeds
• Others (145) Haemorrhagic CVA
  Renal impairment
• Diuretics 334 (27.3) Renal impairment,
• Hypotension, Electrolyte
  disturbances
• Warfarin 129 (10.5) GI bleeding
• Haematuria
• Haematoma
• Pirmohamed et al BMJ  200432915-19 

19
Medicines associated with drug related risk

• Warfarin
• NSAIDs
• Diuretics (in older people)
• Hypotensives (in older people)
• Hypnotics (in older people)
• Antipsychotics (in older people)
• Digoxin
• Amiodarone
• Tricyclic antidepressants (in older people)
• Hypoglycaemics (especially long-acting
  sulphonylureas)
• Medicines with a narrow therapeutic index e.g.
  antiepileptics, lithium, theophylline

20
Reasons for medicine admissions

• Prescribing (35) e.g.
• NSAIDs with 2 or more risk factors for GI bleed
• Antiplatelets with 2 more risk factors for GI
  bleed
• Monitoring (26) e.g.
• Diuretics not monitoring fluid balance, renal
  function.
• Sulphonyrueas failure to monitor blood glucose
• Digoxin failure to monitor dig levels/renal
  function
• Adherence (30) e.g.
• Loop diuretics CCF exacerbation
• Antiepileptics fitting
• Inhaled steroids asthma exacerbation

21
Targeting medication reviews at medicine risk

• Target at patients prescribed
• Diuretics - risk/monitoring/adherence
• Antiplatelets - risk
• NSAIDs - risk
• Antiepileptics - adherence
• Digoxin - monitoring
• Benzodiazepines - falls risk

22
Targeting medication reviews at patients at risk

• Decreased renal function
• because medicines accumulate and some medicines
  can further worsen renal function e.g. NSAID,
  ACE-I.
• Risk of falls
• hypnotics and antihypertensives can be a cause
  of falls
• Older people
• handle medicines less well and need smaller
  doses.
• Care home residents
• Polypharmacy, drug handling, lack of review,
  autonomy.

23
Clinical medication review by a pharmacist of
elderly people living in care homes- randomised
controlled trial Zermansky AG, ALLDRED DP, Petty
DR et al. Age and Ageing 2006 35 586-591

• Outcomes during six months follow-up period
• Intervention Control Difference
• (RR 95CI P value)
• GP consultations 2.9 (1 to 4) 2.8 (1 to 4) 1.03
• Number (IQR) (0.93 to 1.15) 0.50
• Falls Mean 0.8 (0 to 1) 1.3 (0 to1) 0.59
  (0.49 to 0.70) (IQR) lt0.0001

24
Clinical medication review by a pharmacist of
elderly people living in care homes. Cont..

• Patients hospitalised
• Number () Intervention Control OR
  P value
• 47 (14.2) 52 (15.8) 0.89 (0.56 to 1.41)
  0.62
• Medication review by doctor
• Number () 58 (17) 62 (19) 0.88 (0.56 to 1.37)
  0.55

25
Medication review as part of falls assessment

• Review need for medicines
• Review, in particular sedatives and hypotensives.
• e.g. withdraw of psychotropic medicines in care
  home residents reduced relative risk of falls by
  0.34 (95 CI 0.16-0.74).
• Campbell et al. J Am Geriatr Soc 199947850-3

26
Targeting medication reviews at cost

• PPIs high dose to low dose
• Clopidogrel (440/patient/year)
• Atorvastatin switch to simvastatin
  (190/patient/year)
• Therapeutic switching e.g. PPIs
• Branded generic switching e.g. Becloforte
• Reducing unnecessary medicine use
• (Our RCT showed saving of 61/patient/annum. BMJ
  20013231340)

27
Effectiveness of telephone counselling by a
pharmacist in reducing mortality in patients
receiving polypharmacy

• Periodic telephone counselling by a pharmacist
  improved compliance and reduced mortality
• After two years
• 31 (52) of the defaulters had died
• 38 (17) of the control group had died
• 25 (11) of the intervention group had died
• After adjustment for confounders, telephone
  counselling was associated with a 41 reduction
  in the risk of death (relative risk 0.59, 95
  confidence interval 0.35 to 0.97).
• Wu JYF et al etal BMJ  2006333522,

28
Cost savings identified in RCTs

• Zermansky et al (2001) 61/patient/year
• Rodgers et al. (1999) 63/patient/year
• Mackie et al (1999) for every 1 spent on
  pharmacists
• 2 per year was saved on medicine costs.
• 1.Zermansky AG, Petty DR, Raynor DK et al.
  Randomised controlled trial of clinical
• medication review by a pharmacist of elderly
  patients
• receiving repeat prescriptions in general
  practice. British Medical Journal.
• 2001323 1340-1343.
• 2. Rodgers et al Controlled trial of pharmacist
  intervention in general practice the
• effect on prescribing costs. Brit J Gen Pract
  1999 49 717-720
• 3. Mackie CA et al. A randomized controlled trial
  of medication reviews in patients

29
Targeting medication reviews at supporting nGMS
measures

• Why?
• QoF markers are for long-term conditions
• Long-term conditions are mostly managed with
  medicines
• If medicines are not prescribed optimally or
  patients are not taking them then outcomes will
  not be achieved.
• Helps GPs

30
Interventions to reduce risk from highest risk
drugs

• NSAIDs
• Stop treatment
• Change to safer NSAIDs
• Counsel patient to use less
• Provide PPI cover
• Antiplatelets
• Ensure use is needed
• Provide PPI cover if at risk
• Reduce combined use of clopidogrel with aspirin.

31
Odds ratios for major gastrointestinal
complications with NSAIDs by age and sex
32
Interventions to reduce risk from highest risk
drugs

• Loop diuretics
• Stop use for gravitational oedema
• Ensure patient know how to take it
• Monitoring UEs frequently
• Ensure lowest necessary dose is used
• Thiazide diuretics
• Ensure patient know how to take it
• Monitoring UEs frequently
• Ensure lowest necessary dose is used

33
Unplanned hospital admissions

• Emergency admissions by ACS condition 2003/04
• ACS condition No. of spells
• COPD 106,517
• Angina (uncomplicated) 79,228
• ENT infections 72,831
• Convulsions and epilepsy 64,664
• Congestive heart failure 62,582
• Asthma 61,264
• Delivering quality and value. Institute for
  Innovation and Improvement. www.institute.nhs.uk
  accessed October 1st 2006.

34
Increasing prescribing to reduce health care use

• COPD
• Long acting beta agonists, long acting
  anticholinergics, inhaled steroids.
• Heart Failure
• ACE-I, beta blockers, spironolactone
• Atrial fibrillation
• Warfarin
• Falls and fractures
• Vitamin D (calcium), bisphosphonates

35
COPD treatments - Numbers need to treat to
prevent one exacerbation per year

• Carbocysteine 1 probably not effective
• Inhaled steroids 2 5
• Tiotroprium 3-5 2 to 5
• Salmeterol 6 4 to 5
• NNT to prevent a hospitalisation
• Pulmonary rehabilitation7 80
• 1. Decramer M. Lancet 2005361518-20
• 2. Inhaled steroids for COPS. Bandolier
  www.jr2.ox.ac.uk/bandolier
• 3. Casaburi R. Eur Respir J 200219217224
• 4. Vincken W,. Eur Respir J 200219209216. 
• 5. Brusasco V,. Thorax 200358399404
• 6. Sin DD. JAMA 20032902301-12
• 7. Unpublished data

36
Benefits of beta blockers in heart failure

• Mild to moderate heart failure (already on an
  ACE-I and loop diuretics).
• For every 100 patients treated for 1 year, 3
  deaths and 4 hospital admissions will be
  prevented.
• Beta blockers for heart failure. Clinical
  Evidence. Available online at http//www.clinicale
  vidence.com/ceweb/conditions/cvd/0204/0204_I6.jsp
  Accessed on 27th April 2005.

37
Review medicines at discharge

• Highly risky time
• Unintentional changes occur.
• Ensures that
• correct medicines are on medication record
• patient knows about the changes
• a care plan for monitoring, dose titration and
  stopping are put in place.
• non-formulary medicines are not continued.

38
Interventions to improve adherence

• Simplified dosing
• Reminders (tailoring regimen to daily habits)
• Reminder pill packing
• Appointment and repeat prescribing fill reminders
• Telephone follow up/automated telephone
• More instructions and medicine and condition
  being treated.
• Involving patients more in their care
• Family intervention
• Health lay mentoring
• Comprehensive pharmaceutical care services.
• Haynes et al. Cochrane Database of Systematic
  Reviews 20054.

39
Conclusion

• Medication reviews underpins the management of
  long-term conditions. They may have some effect
  on hospitalisation. A lack of review will result
  in increased risk of medication errors poor
  outcomes and increased medicines costs.
• Face to face reviews are vital for involving
  patients in the management of their own condition
  and they may have some effect positive effect on
  compliance.
• Pharmacist medication reviews are cost neutral
  and may save more money then they cost.