A Drug-related Problem Risk Assessment Tool (DRP-RAT) for use by home care practical nurses Maarit Dimitrow, PhD (Pharm) University of Helsinki Finland www.helsinki.fi/yliopisto
Background The demand for long-term home health care services for the aged is growing Those needing home care (HC) are increasingly older and have more complex health problems In Finland, practical nurses (PNs) have 3-year vocational education that concentrates mainly on technical nursing rather than pharmacotherapy www.helsinki.fi/yliopisto
Background PNs working in HC are those who make regular home visits to the elderly => PNs are in a key position to monitor and notice changes in their clients health status including positive and negative outcomes of possible drug treatments Due to lacking physician resources in HC, the physician-conducted home visits are rare => PNsʼ role in medication risk management is pronounced www.helsinki.fi/yliopisto
DRP-RAT PNs need a practical tool for identifying problems related to drug treatments => Development and validation an easy-to-use Drugrelated Problem Risk Assessment Tool (DRP-RAT) for PNs caring for home-dwelling aged 65 years PNs need training to use the Tool PNs conduct the risk assessments during their normal home visits in collaboration with the HC client (if possible) PNs report their risk assessments to other healthcare providers www.helsinki.fi/yliopisto
Development of the draft DRP-RAT 1. Two systematic literature reviews 2. Expertice of the research group 3. Consultation of a geriatrician not involved in the research group Content validation of the draft DRP- RAT 3-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy Feasibility of the final DRP-RAT Conducted among practical nurses in home care of two towns in southern Finland Testing the validity of the final DRP- RAT in clinical practice An experienced geriatricianʼs reliability evaluation of PNsʼ risk assessments Geriatrician identifyed the clinically most significant DRPs Phase I Development Phase II Validation process 23.11.2017 5
Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 6
Is there anyone who determines whether the client takes his/her medicines? (added based on the feasibility study)
OTC High risk medicines Polypharmacy
Involving the client and his/her proxy to clientʼs care Fall tendency Symptoms suggestive of ADRs
Clientʼs health status Potential problems with transfer of clinical patient data
Involving the client/care giver in clientʼs care Adherence
Interventions for resolving the problems Increases the awareness among PNs and the aged of options to improve medication safety
Symptoms suggestive of ADRs When developing the DRP-RAT we had to take into account the PNʼs ability to answer the items of the tool It is not useful to ask the PNs if the clients uses anticholinergic medicines, sedatives or medicines that may cause hyponatremia etc. Thus, we decided to ask the PNs if their clients have symptoms suggestive of adverse drug reactions (ADRs) that these problematic medicines may cause The symptoms listed in the Tool include ADRs of a wide range of medicines (e.g., anticholinergics, sedatives, neuroleptics, diuretics, hypoglycemic, diuretics, blood pressure medications, etc.) www.helsinki.fi/yliopisto
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Main results of the feasibility study Participants: 36 PNs Time spent to complete the DRP-RAT 10-45 minutes; mean 20±8 minutes The PNs identified 88% of the risk medicines listed in the Tool Challeges the PNs met in completing the tool Generic names of medicines Time resctrictions Short client contacts Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 15
Geriatricianʼs reliability evaluation of PNsʼ risk assessments Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 16
Outline of the study Participants: A clinically experienced geriatrician 26 home care PNs 46 home care clients 1. First phase of the study: The PNs conducted risk assessment for their clients using the DRP-RAT during their normal home visits The PNsʼ risk assessments were forwarded to the research geriatrician ifaculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 17
2. Second phase of the study: DRP risk assessments and medication reviews by the geriatrician The geriatrician reviewed the same clientsʼ medications using three different review methods: Method 1: Review based on the PN-completed DRP-RAT information and the medication list printed from the health centerʼs medical records Method 2: Review based on the health center s medical records ( gold standard ) of the study) Medical records encompass the following patient data: a) visits in health center, b) clinical examinations (health status, anamnesis, conclusions), c) medication lists, d) laboratory test results, e) hospitalizations, f) HC workers open comments about their home visits Method 3: Review based on Methods 1 and 2 together = all client information available Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 18
Geriatricianʼs assessment of clinical importance of the items in identifying risks for clinically significant drug-related problems in study sample Based on each review the geriatrician was asked to classify the patients as an risk patient or not an at risk patient Risk patient: a patient is at risk for clinically significant DRPs needing more comprehensive medication review If the geriatrician classified the client as an at-risk patient based on Method 1 (PN-completed DRP- RAT information and medication list) she was asked to tick those PN-identified risk predicting notes in the Tool that she regarded as clinically significant risk factors Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 19
Traffic lights of risks Risk predicting factor Has the client had any of the following symptoms in the last 4 weeks? drowsiness, fatigue, skin rash or itch, dizziness, urination problems, muscle pains, nausea, diarrhea, constipation, dizziness when getting up, recurrent falls, swellings, memory problems, confusion, visual problems, stiffness, troubles in walking, low blood pressure; systolic pressure under 110 mmhg (n=44) Does the client have more than one physician involved in his/her care? (e.g., general practitioners, specialists, private practitioners) (n=44) Has the client had more than one fall in the past 12 months? (n=44) Does the client use any of the following medicines (please check the ones used)? amiodarone, carbamazepine, digoxin, fluoxetine, lithium, methotrexate, theophylline, warfarin (n=44) Prevalence in the study sample 40 (yes) (91%) 22 (yes) (50%) 18 (yes) (41%) 16 (yes) (36%) Clinical Importance of the of the questions in identifying risks for clinically significant drug-related problems 26 20 18 14 Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 20
Risk predicting factor Traffic lights of risks Has the client had troubles in a) remembering to take the medicines? b) following the medicines regimen? c) knowing what his or her medicines are used for? d) affording the medicines (i.e., economic problems)? e) opening the drug bottles or packages or managing with medicines related therapeutic devices? (n=44) Does the client use medicines that a) relieve pain by reducing inflammation (does not apply to paracetamol)? b) elevate the rate of urination (diuretics)? c) are intended to lower the cholesterol level (statins)? ) d) the physician does not know about? (n=44) Have the client's relatives/proxies expressed their concern about the client's medicine use? (n=43) Has the client started a new medicine in the last 4 weeks? (excluding different brands of the same active incredient) (n=44) Prevalence in the study sample 30 (yes) (68%) 35 (yes) (80%) 7 (yes) (16%) 7 (yes) (16%) Clinical Importance of the of the questions in identifying risks for clinically significant drug-related problems 11 8 7 6 Farmasian tiedekunta / Henkilön nimi / Esityksen nimi 23.11.2017 21
Implications for practice DRP-RAT: Can assist in identifying clients needing medication review Provides additional information for pharmacists who conduct medication reviews Educational implications www.helsinki.fi/yliopisto
An example of an operational model (case Lohja, Toivo et. al. 2017) Practical Nurses Update of the medication lists Risk assessment with DRP-RAT (Clinical tests) Coordinating pharmacist Preliminary assessent of the medication using Medication lists Risk assessments Available databases (pharmacokinec and -dynamic interactions) Coordinating pharmacist and physician Shared decisionmaking for further actions Physician, nurse, pharmacist Case-spesific actions, e.g., prescription review, MR, CMR (physician) Carrying out the decided actions (pharmacist) Follow up after 3 months (nurse)
First assignment Think ideas how to implement the DRP-RAT in your health care system? Other ideas to benefit the DRP- RAT? Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 24
Second assignment The case of Mrs. K Mrs. K is an 86 years old lady, living alone in her own house. Home care practical nurse Miss. A visits her 3 times a week. Mrs. K suffers from cardiac failure, hypertension, diabetes mellitus, osteoarthritis, depression, troubles with sleeping and constipation. Earlier, she also has had several urinary tract infections. Most of her medicines are dispensed by automated dose dispensing (i.e., regularly used medicines are machine packed into unit dose bags for each time of administration), home care practical nurse administers the rest (i.e., buprenorphine plaster, local estrogen). Mrs. K takes her daily tablets (except the plasters and local estrogen) on her own. During the last weeks Miss. A has noticed that Mrs. K has been tired and forgetful, from time to time she has not taken all her dispensed medicines. Miss. A wondered if the used medicines could cause these symptoms. As Miss. A had been trained on the content and use of the DRP-RAT by her home care organization, she conducted the medication risk assessment during her next home visit to Mrs. K. She also printed Mrs. K medication list from health centre s medical records and compared the medicines Mrs. K. really uses with the medication list. Farmasian tiedekunta / Henkilön nimi / Esityksen nimi www.helsinki.fi/yliopisto 23.11.2017 25
The case of Mrs. K Which do you think are the most essential PN-reported risk predicting factors in the completed DRP-RAT? Justify your opinion Which medicines and/or what combination of medicines that Mrs. K uses may cause her symptoms? Use databases, Beers criteria etc. Do you agree with the PNʼs recommendations for action? If not, what would you prefer Mrs. K for further actions? Justify your opinion Farmasian tiedekunta / Henkilön nimi / Esityksen nimi www.helsinki.fi/yliopisto 23.11.2017 26
Thank You! Farmasian tiedekunta / Henkilön nimi / Esityksen nimi www.helsinki.fi/yliopisto 23.11.2017 27