Medicines Management in Chronic Disease

Transcription

1 Medicines Management in Chronic Disease Professor Ines Krass Faculty of Pharmacy

2 Talk overview Background Challenges Prescribing Efficacy and safety Patient perspectives Adherence Medicines management Effective QUM interventions How to move forward? 2

3 Chronic Disease Currently those aged 65 years and over represent 12% of the population In Australia, in 2004/5 just over 7 million people had one chronic condition Those aged over 45 years, 20% had three chronic conditions. The health care expenditure totaled 34 million in 2001 and accounted for 70% of all allocated health expenditure Medications are the most common intervention in the management of chronic conditions Chronic diseases [cited 2011 April 13]; Available from: National Health Priority Action Council (NHPAC). National Chronic Diseases Strategy April 13th 2011; Available from: AIHW Australia Health

4 Prescription medication use in the Australian community Cross-sectional survey ( ) of Australians aged 50 years N= % of participants took one or more medicines 43% took five or more in the previous 24 hours. 40% used both conventional and complementary medicines. Doctors recommended 79% of all medicines and 93% of conventional medicines Morgan TK et al MJA 2012;196 (1) 4

5 Australia's National Medicines Policy Better health through quality use of medicines

6 QUALITY USE OF MEDICINES Quality Use of Medicines is defined as: -selecting management options wisely; -choosing suitable medicines if a medicine is considered necessary; and -using medicines safely and effectively. Better health through quality use of medicines

7 Choosing appropriate medicines 7

8 Clinical Guidelines oaddress single disease states obased on evidence in very narrow populations typically exclude people with multiple comorbidities 8

9 Medicine s Action Drug Dose Concentration in plasma Concentration at effect site Pharmacological effect PHARMACOKINETICS PHARMACODYNAMICS Pharmacokinetics what the body does to the drug Pharmacodynamics what the drug does to the body

10 Adverse effects in older patients Reduction in organ function Altered pharmacokinetics Altered pharmacodynamic Reduced homeostatic function Adverse effects Multiple diseases Multiple prescribers Multiple medicines Poor adherence

11 Polypharmacy The more drugs a patient is exposed to, the more likely they are to be prescribed inappropriately. Potential issues Hard to obtain an accurate medication history Prescribing cascade - additional drugs are prescribed to treat the adverse effects of other drugs Prescription of more than one drug in the same class or prescription of a drug that interacts with or is contraindicated in combination with another of the patient's medicines. Lack of an indicated drug Hilmer S Aust Prescr 2008;31:2-3 11

12 Medication efficacy and safety in chronic disease 12

13 Drug related problems in HMRs (n=234) Stafford AC et al Pharm World Sci (2009) 31: Mean (± SD) [ range] Mean number medical conditions 8.2 (±4.2) [ 1-27] Mean number medications 10.9 (±4.1) [2-25] Mean number of DRPs per case reviewed Mean number of more significant DRPs identified per case 4.6 (±2.2) [2-25] 1.9 (±1.0) [1-6] 13

14 Distribution of DRPs in HMRs (n=1038) Stafford AC et al Pharm World Sci (2009) 31: % Drug selection Untreated indications Dose Compliance Monitoring Toxicity Other 14

15 Prevalence of medication problems detected in home visits for HMR (n=204) Sorensen L et al. J Clin Pharm Therap 2006;

16 Medication safety In a US general practice patient population 661 respondents 181 events 25% had experiences an ADE in the previous 6 months. 1 Ghandi TK et al. N Engl J Med 2003;348: Australian Council for Safety and Quality in Healthcare. Second national report on patient safety improving medication safety. Canberra,

17 Prevalence of medication related hospitalisations The overall proportion of potentially preventable medication-related hospitalizations was 20.3% (n = 43, 963). Of the veterans included in the study (25.7%) had at least one potentially preventable medication-related hospitalization (6.6%) veterans had two or more potentially preventable admissions. Kalisch et al. Int J Qual Health Care /intqhc/mzs015 17

18 Imdur makes me so sick, I can t get up, I have to lie down Categories of medication related problems all the time, it gives me a headache 98 interviews 58% female Mean age 67 42% lived alone He the GP don t tell me that this is for your heart and this is for your sugar and this is for something else. So I m taking tablets but I don t know what the hell Im taking them for 18

19 Medication taking in chronic disease in Australia the SCIPPS study Leeder S et al. Medication taking ocomplicated otime-consuming oinconvenient oconfusing. Concerns oinsufficient knowledge about drug-interactions and side effects. olimited knowledge and understanding of their medication ocomplex process of finding suitable medications to manage their conditions requiring good communication with HCPs. o Lack of communication between different HCPs looking after each comorbid condition 19

20 Patient Factors Medication adherence/ management 20

21 Medication Adherence in Chronic Disease Estimates of the extent to which patients adhere to pharmacotherapy vary between 36% and 70%.

22 The five dimensions of adherence Sabate, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva, Switzerland: World Health Organization

23 Unintentional and intentional aspects of non adherence Identify barriers to adherence Intentional Non-adherence Motivation Unintentional Non adherence Ability Belief Skills Self regulation of regimen Health Beliefs necessity and concerns Knowledge deficits Lack of faith in the treatment Adverse effects Cost Regimen complexity Health literacy Difficulty in remembering Knowledge deficits Physical difficulties e.g., coordination, eyesight Lack of self-efficacy

24

25 Strategies to improve medication safety 25

26 1. HMR 1 Interventions to improve prescribing 2. Prescribing decision support 2 3. Audit and feedback 3 4. Academic detailing 3 1. Bright TJ et al Ann Intern Med 2012 : 157(1): Ostini M et al Ann Pharmacother March 2009;43: cateschemist.com.au 26

27 Home Medicines Review A HMR logo.gif A structured and collaborative health care service provided to patients living at home HMR involves the consumer, their GP, an accredited pharmacist and regular community pharmacy or other relevant members of the healthcare team The accredited pharmacist visits the consumer at their home, reviews their medicine regimen and routine Provides their GP with a report. The GP and consumer then agree on a medicine management plan. Home Medicines Review strokefoundation.com.au

28 Evidence inconclusive? Some potential impacts of HMR oreduced the number and cost of medications Krass I & Smith C Intl J Pharm Prac 2000; 8: oimprove medication appropriateness Castelino R et al, Ann Pharmacother. 2010;44: oimprove drug knowledge and adherence Holland R et al.. Br J Clin Pharmacol 2008 Mar;65(3): o Reduced time to next hospitalisation for warfarin induced bleeding in veterans Roughead EE et al. J Clin Pharm Ther Feb;36(1): o Reduced time to next hospitalisation for heart failure veterans Roughead EE et al. Circ Heart Fail 2009; 2: o Reduced the number of falls in nursing home patients Zermansky AG Age and Aging 2006 Nov;35(6):

29 Interventions to improve medication safety oundertaking medication reconciliation at interfaces of care o obtaining a complete and accurate list of each patient s current home medications including name, dosage, frequency and route of administration and comparing the physician s admission, transfer, and/or discharge orders to that list oproviding better information on medicines labels to address to following issues o Active ingredients prominence o Look alike branding o Look alike and sound alike medicine names o Look alike packaging obetter systems of data collection for pharmacovigilance 29

30 Strategies to address non adherence /improve medicines management 30

31 WHO White Paper on Adherence The World Health Organization has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skill requirements. Sabate, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva, Switzerland: World Health Organization

32 How to address non adherence? 32

33 Interventions to enhance medication adherence in chronic conditions Informational interventions educate and motivate by instructional means Behavioural interventions designed to influence behaviour through shaping, reminding or rewarding desired behaviour Family or social interventions provided by family or another group Combined involve 2 or 3 of the preceding categories Kripalani et al, Arch Intern Med 2007;167:

34 Interventions to enhance medication adherence in chronic conditions identifying patient-specific adherence barriers, identifying other adherence issues, tailoring interventions to eliminate or reduce barriers, and providing ongoing social support for patients. Touchette DR et al J Manag Care Pharm. 2008;14(6)(suppl S-d):S2-S10 34

35 Community Pharmacy supporting medicines management in chronic disease ccbcd5-grande.jpg 35

36 ocmi oadherence Support Pharmacy Prescribed Medicines Programs odose Administration Aids omedication management services ohome Medicines Review oresidential Medication Management Review omedscheck/diabetes MedsCheck

37 Chronic Disease Management in Community Pharmacy 1. Diabetes 2. Asthma

38 Successful interventions Interventions involving multiple elements delivered over time - Monitoring and feedback - Self management plans - Reinforcement - Occasionally rewards We have focussed on complex interventions - patient education - empowerment - goal setting - monitoring Kripalani et al, Arch Intern Med 2007;167:

39 Cycle of monitoring, review and feedback Needs assessment Possible interventions Behaviour change Patient Goal Setting Monitoring and feedback

40 Diabetes care in community pharmacy The Diabetes Medication Assistance Service oproviding support of self blood glucose monitoring (SMBG), omonitoring and promoting adherence with medication and other components of selfmanagement oidentifying and resolving drug related problems oproviding targeted information omotivating patients to take control oreminding patients of the importance of regular examinations for diabetic complications 40

41 41

42 The Asthma DSM Service Six step plan followed Sprirometry at each visit Medication issues/ses/asthma control Inhaler technique Adherence assessment and Health Beliefs Identify triggers Action plan ownership and understanding Goal setting

43 43

44 Key issues osafe and effective prescribing olabelling of medicines opatient education about medicines oadherence support oinformation systems oregular monitoring and review eg HMR, ocommunication between HCPs looking after patients with chronic disease omedication reconciliation at transitions of care 44

45 Looking to future- improving medication management Personally Controlled Electronic Health Records? Collaborative and integrated teams of practitioners (Medicare locals) Implementation of Chronic care models Education Chronic-Disease-Management-Image.jpg ohatoday.com 45