Pharmaceutical care in the elderly - the UK experience

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"Pharmaceutical care in the elderly - the UK
experience"

• Professor Ian Chi Kei Wong
• Department of Health Public Health Career
  Scientist
• The School of Pharmacy
• University of London

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United Kingdom

• Population
• England 49.1 million
• Wales 2.9 million
• Northern Ireland 1.7 million
• Scotland 5.1 million

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• National Health Service is a state-funded
  healthcare delivery model.
• Traditionally prescribing and dispensing are
  separate
• Medical practitioners are prescribers
• Pharmacists are medication providers

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Medical and Pharmaceutical Services

• Primary care medical service provided by General
  Practice
• Also employ other health professionals such
  practice nurses and practice pharmacists
• Primary care pharmaceutical services are provided
  by community (retail) pharmacies

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Community pharmacy

• Community pharmacies are not employees of NHS
• Contractors
• On average each pharmacy provide 100 hours per
  week service to the NHS
• 80 of income is from the NHS
• Provide a range of services

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Traditional Service

• Traditional responsibilities of the pharmacist
  are
• to prepare and dispense medication for patients

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Traditional Service

• Traditional responsibilities of the pharmacist
  are
• to prepare and dispense medication for patients
• to provide advice for patients

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Evolution

• Pharmacy has evolved
• The role of the pharmacist has adapted from
  product-oriented custodian to service-oriented
  technologist.

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New services

• New services are available such as
• Smoking cessation programme
• Supervised administration of methadone
• Minor ailments scheme
• Contraception including emergency hormonal
  contraceptive services
• Anticoagulant Monitoring
• Medicines Use Review

Pharmacist
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Pharmaceutical Care

• Pharmaceutical care has been defined as
• "The responsible provision of drug therapy for
  the purpose of achieving definite outcomes that
  improve a patient's quality of life." (Hepler
  Strand 1990 and adopted by UKCPA)

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Medicines Management

• Medicines management encompasses a range of
  activities intended to improve the way that
  medicines are used, both by patients and by the
  NHS.
• Medicines management services are processes based
  on patient need that are used to design,
  implement, deliver and monitor patient-focused
  care.

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Medicines Management

• For the benefit of this talk
• Pharmaceutical care model in the US Medicines
  management model in the UK

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Results of four major RCTs in Elderly

• Clinical medication review trial (Zermansky et al
  2001)
• Medication review trial (Krska et al 2001)
• HOMER medication review trial (Holland et al
  2005)
• RESPECT Pharmaceutical Care trial (Wong et al
  unpublished)

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Basic details of the studies
Zermansky et al 2001 (1131 pts) One practice pharmacist see patients mainly at practice Age 65 1 repeat
Krska et al 2001 (332 pts) Clinically-trained Pharmacist see patients at home Age 65 4 repeat 2 chronic illness
Holland et al 2005 (872 pts) Pharmacists with PG training see patients at home Age 80, discharge after emergency admission
Wong et al unpublished (760 pts) Pts usual community pharmacist see patients in community pharmacies Age 75 5 repeat
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Zermansky et al 2001

• Leeds in West Yorkshire England

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Zermansky et al 2001

• Leeds in West Yorkshire England
• 581 in intervention cases and 550 controls
• Practice pharmacist see patients at practice
• Age 65 and 1 repeat
• Duration of study 1 year

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Clinical medication review (CMR)

• Pharmacist reviewed the patient, the illness, and
  the drug treatment.
• Evaluated
• appropriateness and efficacy of treatments
• progress of the conditions
• compliance
• actual and potential adverse effects interactions
• The outcome of the review was a decision about
  the continuation (or otherwise) of the treatment.

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Results

• Pharmacist took 20 minutes each review
• Intervention group more likely to have changes (P
  0.02)
• Mean number of changes per patient
• Interventions 2.2
• Control 1.9

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of Patients with Changes
Type Intervention Control
New Drug 46 49
Drug Stopped 41 33
Switched drug 20 17
Dose changed 17 11
Changed to generic 11 7
Formulation changed 3 2
Frequency changed 1 0
Any of the above 75 72
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Changes in Treatment Between the Start and Finish
of Study
Intervention Control P value
Mean No. of repeat medicines 4.8 ? 5.0 Increased by 0.2 4.6 ? 5.0 Increased by 0.4 0.01
Mean cost over 28 day () 29.3 ? 31.1 Increased by 1.80 28.3 ? 34.9 Increased by 6.52 0.001
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No changes in

• Number of GP consultations
• Number of out-patient appointment
• Number of hospital admission

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Conclusions

• A clinical pharmacist can conduct effective
  consultations with elderly patients in general
  practice to review their drugs.
• Such review results in significant changes in
  patients' drugs and saves more than the cost of
  the intervention without affecting the workload
  of general practitioners.

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Krska et al 2001

• Grampian region of Scotland

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Grampian region
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Krska et al 2001

• Grampian region of Scotland
• 332 patients
• Clinically-trained pharmacist saw patients at
  home
• Age 65
• 4 repeat
• 2 chronic illness

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Methods

• Pharmacists reviewed 332 patients and identified
  the Pharmaceutical Care Issues
• Information obtained from the practice computer,
  medical records interviews.
• In 168 patients, a pharmaceutical care plan was
  then drawn up and implemented.
• The 164 control patients continued to receive
  normal care.
• All outcome measures were assessed at baseline
  and after 3 months.

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Pharmaceutical Care Issues Resolutions
Issues Intervention Resolved Control Resolved P value
Potential/suspected ADR 84.3 57.8 lt0.0001
Monitoring issues 94.6 78.4 lt0.0001
Potential ineffective therapy 57.1 24.3 lt0.0001
Education required 80.7 18.4 lt0.0001
Inappropriate dosage regime 78.3 17.9 lt0.0001

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Pharmaceutical Care Issues Resolutions (cont/d.)
Issues Intervention Resolved Control Resolved P value
Potential / actual compliance 68.9 30.4 lt0.0001
Untreated indication 66.7 27.5 lt0.0001
Drug with no indication 54.2 18.8 lt0.0001
Repeat prescription no longer required 96.4 5.9 lt0.0001
Inappropriate duration of therapy 72.1 29.1 lt0.0001

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Pharmaceutical Care Issues Resolutions (cont/d.)
Issues Intervention Resolved Control Resolved P value
Discrepancy between doses prescribed and used 96.4 3 lt0.0001
Potential drug-disease interaction 7.2 47.1 0.1302
Others 82.3 59.2 lt0.05
TOTAL 78.8 39.3

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Other outcomes

• No change in medicines cost
• No change in healthrelated quality of life
• No change in hospital clinic attendance
• Slightly fewer hospital admissions but number was
  too small to be tested statistically.

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Conclusion

• Pharmacist-led medication review has the capacity
  to identify and resolve pharmaceutical care
  issues and may have some impact on the use of
  other health services.

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Holland et al 2005

• Norfolk and Suffolk in England

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Norfolk and Suffolk
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Holland et al 2005

• Norfolk and Suffolk in England
• Home based medication review
• 872 patients
• Pharmacists with post-graduate qualification and
  training
• Saw patients at home
• Age 80, discharged after emergency admission

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Methods

• Patient's discharge letter was sent to review
  pharmacists
• Pharmacists arranged home visits
• Assessed ability to self medicate adherence
• Educated the patient and carer
• Removed out-of-date drugs
• Reported possible ADRs or interactions to the
  General Practitioner and the need for a
  compliance aid to the local pharmacist.

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Methods

• One follow up visit occurred at six to eight
  weeks after recruitment to reinforce the original
  advice.

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Results

• 178 emergency readmissions occurred in the
  control group
• 234 in the intervention group
• The Poisson model indicated a 30 greater rate of
  readmission in the intervention group
• Rate ratio 1.30,
• (95 CI 1.07 to 1.58, P 0.009).

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Number of Emergency Hospital Re-admissions
No Intervention Control
0 235 281
1 113 99
2 34 26
3 or more 15 8
TOTAL 234 178
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Survival Analysis over 6 months
P 0.14
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Quality of Life

• Utility scores EQ-5D decreased in both groups,
  but the changes were not significantly different
  between the groups
• Scores on the visual analogue health scale also
  fell the difference of 4.1 (95 CI 0.15 to
  8.09) units in favour of the control group (P
  0.042).

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Other outcomes

• No change in GP clinic attendance
• No change in number of prescription items

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Conclusion

• Home based medication review for older people
  recently discharged from hospital increased
  hospital admissions and worsened patients'
  quality of life.
• Patients may have adhered better to their drugs,
  with a resultant increase in adverse effects.
• Alternatively, intervention may have provoked
  better understanding and help seeking behaviour.

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Wong et al

• East Yorkshire

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East Yorkshire
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Wong et al

• East Yorkshire
• 760 patients
• Patients' usual community pharmacist see patients
  in community pharmacies
• Age 75
• 5 repeat

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Designs

• Randomised multiple interrupted time series
  design in which five Primary Care Trusts
  implemented Pharmaceutical Care at quarterly
  intervals and in random order.
• We followed patients, who also acted as their own
  controls, for 36 months between recruitment and
  final visit, including their 12 months in
  Pharmaceutical Care.

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Randomised multiple interrupted time series design
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Pharmaceutical Care

• Both pharmacists and GPs attended training before
  starting the intervention.
• Pharmacists interviewed patients at the community
  pharmacy and developed a Pharmaceutical Care Plan
  (PCP).
• Shared the PCP with the patients GP.
• Undertook monthly medication reviews for one
  year.

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UK Medication Appropriateness Index (UK-MAI).

• Primary outcome was UK-MAI.
• Anglicised this from the US version.
• The resulting score depends on the number of
  drugs being prescribed and the appropriateness of
  each.
• As a drug can score between 0 (completely
  appropriate) and 20 (completely inappropriate),
  the lower the score the better.

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Other outcomes

• Pharmaceutical Care has no significant effects
  on
• Number hospital admission
• Number GP clinic consultation
• Mortality rate
• QoL SF-36

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RESPECT Conclusion

• We judge that this lack of evidence stems from
  our experience that Pharmaceutical Care is
  difficult to implement in full in a community
  setting.

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Summary of all 4 studies

• Pharmacists are able to identify pharmaceutical
  care issues and initiate changes
• However, traditional research instruments are
  unable to detect positive changes in clinical
  outcomes

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To debate

• Lack of transferability?
• Lack of effects?
• Lack of sensitivity?
• Are we measuring the right things?
• Anything else?????