Polypharmacy Reviews in the real world

Transcription

1 S P S Community Health Services Specialist Pharmacy Service Medicines Use and Safety Polypharmacy Reviews in the real world Lelly Oboh Consultant Pharmacist, Care of Older People Guys & St Thomas NHS Founda@on Trust (Community Health Services) NHS Specialist Pharmacy Services Specialist Pharmacy Service Winner: Dressings, PrescQIPP Innovation awards 2013; Winner: RPS Pharmaceutical Care award 2013; Finalist: HSJ Improving Patient Safety in Primary Care 2015; Winner: UKCPA/Guild Conference Best Poster award 2013

2 Session Overview» Polypharmacy basics» The their medicines needs and outcomes» The Challenges» The Strategies & Tools Our approach»

3 Polypharmacy defini8ons» Use of more than 4/5 drugs at the Use of more drugs than is clinically indicated» More common with, but not limited to older people» Not always bad! Newer concepts» vs Appropriate polypharmacy (Kings Fund 2013)» Oligopharmacy (<5drugs) (O Mahoney 2013)» Hyperpolypharmacy ( 10drugs) vs polypharmacy ( 5drugs) (Gnjidic 2013)» Deprescribing (DTB 2014) 3

4 Polypharmacy, ADE and Non- adherence Supporting selfmedication Administering medicines Adverse drug events (ADEs) Monitoring medicine effects Patient outcomes Non Adherence Polypharmacy Prescribing & Medication reviews (health only) 4

5 Polypharmacy and older people Medicines Optimisation can have a high impact on patient experience, health outcomes and costs Naylor S et al. Kings Fund Transforming our health care system: Ten priorities for commissioners

6 Medicines Op8misa8on Outcome focused approach to safe and effec8ve use of medicines that takes into account the pa8ent s values, percep8on and experience of taking their medicines Important Outcomes for adults Improved quality of life Making a posi@ve contribu@on Improved health and emo@onal wellbeing Personal Dignity Control and choice Economic wellbeing Freedom from discrimina@on Independence Well- being and Choice 2005, Our health, our care, our say 2006, Strong and Prosperous Communi@es

7 Focus: Frail Older People 10% of over 65s and 25-50% over 85s 1 Many have more than 4 LTCs Take more medicines (mostly repeats) Higher risks of adverse drug events (ADEs) Frequent hospital admissions and longer stays High users of health & social care resources More dependent on others to take medicines 1. Clegg A, Young J, Iliffe S, Rikkert M, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):

8 Frailty Age- associated decline in physiologic reserve and func8on across organ systems leading to increased vulnerability for adverse health outcomes (Fried et al 2001) A dis@nct health state where a minor event can trigger major changes in health from which the pa@ent may fail to return to their previous level of health (Bri@sh Geriatric Society) Progressive condi@on, with episodic deteriora@ons Co-morbidities Acute illness Adverse outcomes Social vulnerability Ageing

9 Poor resilience to stressors

10 Survival curves of frailty (phenotype model) Fried JP et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology 2001: Vol 56A, No. 3, M146 M156

11 Impact of frailty on medicines use Challenge 1 Managing complexities The Older person s medicines related needs 1 1. Access to medicines 2. Adherence & prac8cal support 3. Clinical/therapeu8c Standard therapeutic approaches may not work Positive outcomes emerge from the interactions of the whole vs. discrete parts 1. Rosenbloom, E. K., and F. R. Goldstein. "The development of trigger questions to support the case finding of people with unmet medicines-management needs." IJPP 15 (2007): 21.

12 Challenge 2 Integra8ng best research evidence with clinical exper8se and pa8ent values (SackeU et al. 2000) Pa8ent's Best available goals, research values & evidence wishes Pa8ent's Clinical exper8se circumstances of the prac88oner Best available research evidence Pa@ent's circumstances Pa@ent's goals, values & wishes Clinical exper8se of the prac88oner

13 Challenge 3 Managing Polypharmacy Many drugs are oben con@nued beyond the point at which they are beneficial and may actually cause harm (DTB 52:2014) Deprescribing (DTB 52:2014) The complex process required for the safe and effec@ve cessa@on (withdrawal) of inappropriate medica@on. Takes into account the pa@ent s physical func@oning, co- morbidi@es, preferences and lifestyle A significant element of the medicines op@misa@on process must include deprescribing. 12

14 Reducing polypharmacy: Literature 1-8 No long term outcome data.. reduces drug usage/costs & unlikely to cause harm Evidence to stop certain drugs safely What works On- going (not one- off), periodic review Pa8ent centredð & involvement Holis8c Done in context of overall goals Focused med. review consulta8ons ð sufficient 8me to address (use clinical pharmacists) By lead clinician who also co- ordinates care Mul8disciplinary approach Improved co- ordina8on/communica8on during care Done slowly adequate monitoring & f/up Structured approach needed 1. BGS Quest for quality in care homes CHUM Study 2009, 3. Kings Fund. Polypharmacy Kings Fund. Quality of GP prescribing NICE Managing medicines in care homes Garfinkel D, Mangin D. Feasibility study of a systema@c approach for discon@nua@on of mul@ple medica@ons in older adults: addressing polypharmacy. Arch. Intern Med 2012;170: O Mahony, O Connor. Pharmacotherapy at the end- of- life. Age and ageing 2011;40; Hilmer SN, Gnjidic D and Le Couteur D.Thinking through the medica@on list. Australian Family Physician 2012 Vol 41 no 12, p924 13

15 The pa8ent Ms JA, 72 year old lady Referred by Community Matron: Uncontrolled diabetes, severely impaired mobility re poor pain control & SOB Social history» Lives alone in 4 th floor flat in housing estate»?housebound»?self managing medicines» Forgerul, unsteady Medical history» Type 2 diabetes» Asthma (?) / COPD» Diver@cular disease» L3- L4 stenosis» Depression» GORD» Pulmonary Fibrosis» Obstruc@ve sleep apnoea» Obesity» Type 2 diabetes mellitus» Polyarthralgia Rx 1. Movelat Gel 125G 2-6 inches QDS 2. Oxycodone 5mg/5ml 2.5mls QDS PRN 3. Buprenorphine 10mcg/hr 1 weekly 4. Pregabalin 300mg caps 1 BD 5. Quinine sulphate 200mg 1 ON 6. Carbomer % Gel QDS 7. Salbutamol 5mg/2.5ml nebs 1 QDS 8. Salbutamol 100mcg cfc-free inhaler 2 puffs QDS PRN 9. Tiotropium 18mcg caps inhalation 1 ON 10. Prednisolone 5mg Tabs 8 tabs OD 5/7 11. Azithromycin 250mg Caps 1 3xweek 12. Lorazepam 1mg ½ tablet BD 13. Adcal D3 750mg/200iu caplets 2 BD 14. Esomeprazole 40mg 1 OD 15. Diazepam 5mg 1 ON 16. Hydroxocobalamin 1mg/1ml injection every 3 months 17. Ferrous Sulfate 200mg tablet 1 TDS 18. Aspirin 75mg tablets 1 OD 19. Hyoschine butylbromide 10mg 1 BD 20. Novomix 30 flexpen 34units OM and 24 units ON 21. Metformin 1G MR tablets 1 BD 22. Lactulose Solution 15mls BD 23. Ispaghula Husk 3.5g/Sachet PRN

16 Solu8ons Strategies and Tools to support reduc8on of polypharmacy in UK

17 Recent

18 Tool to iden8fy Poten8ally inappropriate medicines (PIMs) in older people STOPP/START criteria» assessment» Lisle or no clinical assessment needed» Quick to use Others» Burden Risk Scales» Beers Criteria

19 STOPP/START tool vs » Screening Tool of Older Persons inappropriate (80 criteria)» Screening Tool to Alert doctors to Right (i.e. indicated, appropriate) Treatment (34 Criteria)» From literature reviews, expert opinions, consensus techniques» Evidence Up to 40% PIMs prescribed in care homes Improves medicines appropriateness index Reduces ADR Saves money» To support not replace expert knowledge» Needs regular 19

20 Applying STOPP/START in prac8ce Mr WW 82 year old care home resident problems» OA knee» Glaucoma bilateral» Recent hospital admission Pneumonia» Recent fall, no #» Moderate Very tearful PMH» #NoF 2002» Ex smoker» Weight loss 11lb over 1 yr 2005» 1st degree heart block» Alcohol dependence syndrome 2008» Stopped drinking may 2012» Mild auditory hallucina@ons» Aggressive behaviour- threatens other residents» Agitated by noise, 2008» Depression 2011 Repeat Rx x Meloxicam 15mg tabs 1od cc x Olanzapine 10mg tablets on x Hyoscine tablets 300mcg 1prn» Vitamin B co strong tabs 2 bd» Ketovite tablets 1od» Thiamine 100mg 1od» Co- codamol 30/500mg tabs 1-2 bd prn ü Ini@ate SSRI ü Ini@ate AChEI

21 Community Health Services Our Solu8on: New Services and Innova8ons in Healthcare A Pragma@c approach Aim: Pharmacists take lead to iden8fy, resolve and co- ordinate medicines related care Reduce inappropriate polypharmacy and adverse effects. Improve adherence and understanding of medicines Reduce u8lisa8on of emergency services through beser therapeu@c control of mul@ple morbidi@es Facilitate partnership working across agencies and improve medicines use during transi8ons of care Increase medicines related knowledge and skills among general prac@ce/community teams Inves@gate and develop methods of collabora8on with community pharmacy

22 Project Evalua8on with School of Pharmacy, UCL) Evalua8on 1 Data collected systema@cally from in- depth medicines assessments from 143 pa@ents) Characterising the problems Poten@al contributory factors leading to problems Pharmacist s interven@ons to resolve Evalua8on 2 Interviews and focus groups Longer term pharmacist led strategies and collabora@ve working Experience, workability and impact of service

23 A pharmacist- led approach to op8mising medicines use for frail older in the community Centred, Co- ordinated, and Frail older person during vulnerable periods & deteriora8ng health e.g. post discharge Receives GSTT Consultant/Advanced level clinical pharmacists input in the community Stable frail older person Receives generalist pharmacists ongoing input STEP 5 Community Pharmacy team implement specific long term goals within care plan. **Case management, Community MDTs, GPs, Enhanced Rapid response, Teams Liaise with GP (??Prac@ce based pharmacists) & mul@disciplinary teams Featured in the RPS Now or Never Report 2013: hsp:// of- care/models- of- care- in- ac@on.asp Winner : PresQIPP awards 2014 Shared decision making category Runner Up: Clinical Pharmacy Congress 2014: Best innova@on category 17

24 Step 1: Iden8fy the pa8ent and Frail older people vs. set criteria Recognise atypical of medicines related needs Requests for MCA Referrer s percep@on of pa@ents inability to cope

25 Steps 2, 3 and 4

26 The pa8ent centred approach to polypharmacy» Each step provides support for clinicians to embed pa/ent centredness, safety, evidence base into rou8ne reviews» Provides prompts for points to consider, to take and to ask» Allows the to Priori8se the issues important to the risks, benefits and current evidence Focus on one or a small number of key concerns as needed» Emphasises need for effec@ve communica@on incl. pa@ent, family/carers and other prac@@oners Ensure any changes made are ac@oned and followed up.

27 Assess needs and review therapy Assessment is about pubng together informa8on on a person s needs and circumstances, making sense of the informa8on in order to iden8fy needs and agreeing what advice support or treatment to provide DoH. Common Assessment Framework for Adults Gathering informa@on Med reconcilia@on- Pa8ent list The pa@ent s narra@ve of their experience Reviewing the research evidence Applying clinical judgement and personalising therapy

28 and care co- Summarise agreed plan requested wrisen summary and f/up GP Community pharmacist Geriatrician Record and document

29 Are we on the right track? Other consultant pharmacist- led older people projects In line with current best available guidance Our Beser understanding of cohort, their needs and appropriate role for advanced/general level pharmacists as medicines leads wherever access care close to home of other to med. Improved proxy markers BP, HBA1c, feedback and individual case scenarios - 95% felt they were involved in decisions about their medicines GPs, geriatricians, nurses, staff, value service and want more!

30 Consultant Pharmacists led ini8a8ves» Intermediate care pharmacist project Darcy C 2013 Drug cost savings 164K p.a. Significant reduc@on of MAI on admission and discharge» Care homes outreach clinics (16 homes) Mckee H % reduc@on in A&E presenta@ons Drug cost savings 107k pa» IMPACT Post discharge medicines project. Smith H 2013 Iden@fy high- risk, care planning, referral to primary care 86% clinical, 36% medicines support needs iden@fied 30 days readmission- 16% IMPACT vs 22%» Managing Preventable Medicines Related Readmission (PMRR) BarneU N et al 2007 Medicines rec. & review, discharge planning and post discharge follow up PMRR 0.3% vs 4.4% (P=0.002). Saving: 3 for every 1 spent on an IMM pharmacist

31 What we learnt Need Long term commissioning strategy with pharmacy workforce leading MO across care se{ngs Enabling/skilling wider workforce incl. carers and social care Need outcomes/gains measured across the local economy Training and clinical supervision for clinical pharmacist in community (domiciliary care/care homes) Need ways to gather research evidence research

32 Summary Increasing numbers of frail older people More complex needs being looked a er closer to home Polypharmacy and taking medicines are main issues Pa@ent experience and perspec@ve is a MUST! Many medicines related problems start at home Current clinical pharmacy exper@se and resources in community don t match need ð need a shi, closer to home Op@mising medicines use is everybody business Pharmacist leading medicines op@misa@on can reduce risks and improve pa@ent outcomes

33 Further reading and resources Polypharmacy, oligopharmacy & deprescribing: Resources to support local delivery SPS- E- and- SE- England/Meds- use- and- safety/service- deliv- and- devel/older- people- care- homes/polypharmacy- oligopharmacy- - deprescribing- resources- to- support- local- delivery/ Polypharmacy: Guidance for Prescribing in Frail Adults. NHS Wales 2014 The Kings Fund. Polypharmacy and medicines op@misa@on; Making it safe and sound. Nov 2013 NHS Scotland. Polypharmacy Guidance Fried JP et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology 2001: Vol 56A, No. 3, M146 M156