University of Dundee School of Medicine Optimising prescribing in primary care in the face of multimorbidity and polypharmacy Bruce Guthrie Professor of Primary Care Medicine, University of Dundee NICE Multimorbidity Guideline Development Group Chair
The limits of current evidence Exclusion criteria driving this pattern Age, comorbidity, co-prescription Investigator discretion and many others on top Median exclusion for common conditions Atrial fibrillation 38%, CHD 75%, hypertension 83%, COPD 84%, rheumatoid arthritis 92%, type 2 diabetes 93%, asthma 96% Die of disease Precision 1 Die of stuff Precision 2 http://geriatricresearch.medicine.dal.ca/pdf/clinical%20faily%20scale.pdf
High-risk prescribing Prescribing is a high benefit, high risk, high cost activity 6.5% of hospital admissions are related to ADEs ADE directly leading to admission in 80%, half preventable Mostly due to appropriate drugs that guidelines tell us to prescribe more of Warfarin, aspirin, (non-steroidal anti-inflammatory drugs), ACEI/ARB and other renal toxic drugs, hypoglycaemic drugs, blood pressure lowering drugs High-risk or potentially inappropriate prescribing is not a never event, but needs regular review The correct level is NOT zero
Odds ratio of patient receiving a high risk prescription in each practice High risk prescribing variation between practices 3.5 3 2.5 Odds ratio for each practice Upper 95% CI Lower 95% CI 2 1.5 1 0.5 0 Practices ranked in ascending order of prevalence of high risk prescribing Guthrie B et al. BMJ 2011;342:d3514
High risk prescribing variation between patients No. of chronic drugs 0 drugs 1-2 drugs 3-4 drugs 5-6 drugs 7-8 drugs 9-10 drugs 11+ drugs % getting a high risk prescription 4.3 11.0 12.7 14.5 18.3 21.5 26.6 Adjusted OR Reference 2.7 3.2 3.8 5.0 6.1 7.9 Guthrie B et al. BMJ 2011;342:d3514
Percentage of patients receiving specified number of drugs No. of drug classes dispensed in last 84 days in 1995 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age group Guthrie B et al. BMC Medicine 2015 0 drugs 1 drug 2 drugs 3 drugs 4 drugs 5 drugs 6 drugs 7 drugs 8 drugs 9 drugs 10 drugs 11 drugs 12 drugs 13 drugs 14 drugs 15+ drugs
Percentage of patients receiving specified number of drugs No. of drug classes dispensed in last 84 days in 1995 2010 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age group Guthrie B et al. BMC Medicine 2015 0 drugs 1 drug 2 drugs 3 drugs 4 drugs 5 drugs 6 drugs 7 drugs 8 drugs 9 drugs 10 drugs 11 drugs 12 drugs 13 drugs 14 drugs 15+ drugs
Safer but more people at risk People on warfarin prescribed NSAIDs, antiplatelets, high-risk antibiotics, oral azole antifungals 16.0% in 1995 (258/1611) 10.7% in 2010 (538/5006) Safer but more people are at risk Even if increasing prescribing is more effective, it creates increasing risk that needs managing
Improving prescribing safety Focus on indicators of high-risk prescribing Many available indicators of varying specificity Focus on people at particular risk Most commonly people with polypharmacy Focus on prescribing systems Medicines reconciliation at transitions Repeat prescribing systems Do something Small things matter
Indicator interventions PINCER (two arm cluster RCT in 72 practices) Pharmacist-led, some feedback, education & coaching ~40% reduction in targeted prescribing but effect wanes somewhat after the pharmacist leaves EFIPPS (three arm cluster RCT in 262 practices) Feedback +/- behaviour change intervention Six high-risk prescribing indicators DQIP (stepped-wedge cluster RCT in 33 practices) Educational outreach, informatics and financial incentives Nine high-risk prescribing indicators PINCER main trial paper. Avery et al. The Lancet 2012; 379(9823): 1310-9. EFIPPS development. Barnett et al. Implementation Science 2014; 9(1):133. DQIP development. Grant et al. BMJ Open 2014;4(1):e004153.
Guthrie et al. BMJ 2017:354; i4079
DQIP intervention: Components Review and correct prevalent high-risk prescribing Avoid incident high-risk prescribing Financial incentive 350 up front 15/patient reviewed Education Outreach by pharmacist Written educational material Progress updates Informatics Patient identification Facilitate review Monitor progress
Dreischulte et al. NEJM 2016; 374: 1053-64.
DQIP trial findings Primary outcome 37% decrease Ongoing high-risk prescribing 40% decrease New high-risk prescribing 23% decrease Sustained 12 months after the intervention stopped Gastrointestinal bleeding admissions 34% decrease Heart failure admissions 27% decrease Acute kidney injury admissions 16% decrease (ns) Unrelated ACSA no change Dreischulte et al. NEJM 2016; 374: 1053-64.
Does it work in real life? YES IT DOES! NO IT DOESN T! Triple whammy Antipsychotics in dementia MacBride-Stewart et al. BJGP 2017:67;e352-e360.
Does it work in real life? No magic bullets The prescribing context matters Attribution and responsibility Fear of adverse consequences of stopping Professional culture rather than technical problem The organisational context matters Pharmacist-led concerns about sustainability GP-led may alter future prescribing more
Polypharmacy interventions Cochrane review (12 studies) Some evidence for improved prescribing outcomes, little evidence for change in clinical outcomes National guidance http://www.polypharmacy.scot.nhs.uk/ http://www.sehd.scot.nhs.uk/publications/dc20150415polypharmacy.pdf Part of GP contract In the process of major change Increasing use of primary care pharmacists Various roles including polypharmacy review Aim to use informatics to support review http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd008165.pub3/full
NHS Scotland polypharmacy NHS Scotland 7 step review process 1. Identify the goals of therapy what are we trying to achieve? 2. Identify essential drug therapy 3. Does the patient take unnecessary drug therapy? 4. Are therapeutic objectives being achieved? 5. Does the patient have, or is at risk of, adverse drug reactions? 6. Is there a significantly cheaper alternative? 7. Is the patient willing & able to take drug therapy as intended? http://www.polypharmacy.scot.nhs.uk/
Past medical history Hypothyroidism Urinary urgency Hypertension Diabetes Intermittent knee pain Possible TIA (funny turn/fall > treat as TIA ) Hip fracture after a fall Independent and manages well, long-term memory excellent
What s the right drug treatment? Hypothyroidism (TFTs fine) Urinary frequency Hypertension (BP 136/72) Diabetes (HBA1c 50, cholesterol 3.3, no microvascular complications) Intermittent knee pain Possible TIA Hip fracture after a fall Thyroxine 75mcg od Solifenacin 10mg od Perindopril 4mg od Indapamide 2.5mg od Bisoprolol 5mg od Atorvastatin 40mg nocte Metformin 500mg tds Gliclazide 80mg bd Clopidogrel 75mg od Naproxen 500mg as needed Calcium and vit D3 1 tab bd Alendronate 70mg weekly
Functional status Independent and manages well Walks the dog several miles a day, does the shopping for all the neighbours Lives alone but twice daily carers and family visit daily, uses a dispensing aid, walking frame fantastic Long term memory excellent Cognitive impairment or dementia
What s the right drug treatment? 1. Identify the goals of drug therapy what are we trying to achieve? 2. Identify essential drug therapy 3. Does the patient take unnecessary drug therapy? 4. Are therapeutic objectives being achieved? 5. Does the patient have adverse drug reactions, or is at risk of ADRs? 6. Is there a significantly cheaper alternative? 7. Is the patient willing and able to take drug therapy as intended? Thyroxine 75mcg od Solifenacin 10mg od Perindopril 4mg od Indapamide 2.5mg od Bisoprolol 5mg od Atorvastatin 40mg nocte Metformin 500mg tds Gliclazide 80mg bd Clopidogrel 75mg od Naproxen 500mg as needed Calcium and vit D3 1 tab bd Alendronate 70mg weekly
What are we trying to achieve? Patient/carer Clinician Patient context Life expectancy Frailty Quality of life and/or longer term prevention
120 indicators High risk prescribing Potential over-treatment Omitted monitoring Potential under-treatment
Polypharmacy interventions Needs much more than an informatics tool Evidence for treatment effectiveness in this population Professional practices don t always align Patient/carer expectations don t always align Time and resources What kind of professional or team? Culture Which life saving drug will I stop today? Difficult conversations about life, death and futility
Conclusion Prescribing safety can be improved by focusing on key indicators Optimising prescribing in polypharmacy is a hard nut to crack (but crack it we must) What are we trying to achieve here? Who is responsible? Should it be me? We really don t understand our safety critical prescribing systems very well
Want to do something? High-risk drugs and indicators Insulin, warfarin, NSAIDs STOPP and START criteria Risk of AKI when dehydrated Old, frail, CKD, heart failure On ACEI, ARB, diuretics, NSAIDs, metformin Can I stop a drug today? Perfect risk factor control in the frail Drugs for symptoms which are no longer present
Want to do something? Why do patients get high INRs? In my practice: Because they have chaotic control D&V/gastrointestinal upset Because we give them the wrong antibiotic Are some people unsafe on warfarin? Small number of people have chaotic INRs (6 patients in my practice had >200 INRs in a year) Direct oral anticoagulants Doesn t fix non-adherence and dose is often wrong
Want to do something? Let your imagination run riot but go and do something now
Thank you This presentation draws on work done in collaboration with many people Tobias Dreischulte, Aileen Grant, Adrian Hapca, Karen Barnett, Chris Roberston, Marion Bennie, Kim Kavanagh, Lyall Cameron, Graham Longair, Sean Macbride-Stewart, Davy He, Dan Morales NHS Scotland polypharmacy guidance http://www.polypharmacy.scot.nhs.uk/ http://www.sehd.scot.nhs.uk/publications/dc20150415polypharmacy.pdf NICE multimorbidity and medicines optimisation guidance Multimorbidity https://www.nice.org.uk/guidance/ng56 Medicines Optimisation https://www.nice.org.uk/guidance/ng5