Title: The benefits of medication review for patients and practice based commissioners
1The benefits of medication review for patients
and practice based commissioners
- Dr Duncan Petty
- Lecturer Practitioner University of Leeds
- Practice Pharmacist
2What 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
3Aims 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
4Aims 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?
5Aims 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?
6Aims of medication review
- Waste reduction
- Branded to generic
- Unwanted medicines
- Unneeded medicines
- Over ordering
7Benefits 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 (?)
8Benefits 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
9Who is at risk of repeat hospital admissions.
10Who 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
11Research 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
12Effect 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
13Targeted 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
14Targeted 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
15Hepler 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.
16Medication-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.
17Targeted 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
18Adverse 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
19Medicines 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
20Reasons 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
21Targeting medication reviews at medicine risk
- Target at patients prescribed
- Diuretics - risk/monitoring/adherence
- Antiplatelets - risk
- NSAIDs - risk
- Antiepileptics - adherence
- Digoxin - monitoring
- Benzodiazepines - falls risk
22Targeting 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.
23Clinical 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
24Clinical 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
25Medication 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
26Targeting 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)
27Effectiveness 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,
28Cost 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
29Targeting 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
30Interventions 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.
31Odds ratios for major gastrointestinal
complications with NSAIDs by age and sex
32Interventions 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
33Unplanned 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.
34Increasing 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
35COPD 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
36Benefits 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.
37Review 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.
38Interventions 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.
39Conclusion
- 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.