Tackling inappropriate polypharmacy in NHS Scotland Francesca Aaen Lead Care Homes Pharmacist - NHS Lanarkshire Heather Harrison - Senior Prescribing Advisor/ Chronic Pain Primary Care Service Development Project Manager - NHS GGC
NHS Lanarkshire Care Homes Project NHS Lothian Polypharmacy review NHS GGC Polypharmacy LES
SPARRA=Scottish Patients At Risk of Readmission and Admission SPARRA is a risk prediction tool developed by Information Services Division (ISD), NHS Scotland predicts an individual's risk of being admitted to hospital as an emergency inpatient within the next year What is a SPARRA Score? SPARRA scores can range from 1 to 99% for patients in the 4.2m cohort Patients with a score of e.g. 50% are generally said to have a 1 in 2 chance of being admitted to hospital in the next 12 months What is the purpose of SPARRA? SPARRA data can help health care professionals to prioritise patients with complex care needs who are likely to benefit most from anticipatory health care. SPARRA data can also be used in a service planning capacity by locating groups of patients who would benefit from specific interventions or services.
Taking long term responsibility for prescribing in a care home NHS Lanarkshire GP enhanced service for care homes Care Homes Pharmacist Medication Reviews Community pharmacist independent prescribers
Pilot supporting care homes without GP enhanced service in one locality 2 care homes caseload of 168 residents 6 GP practices Reviews prioritised by high risk meds or by referral
Outcomes Case studies Positive feedback from Patients and families Carers GPs Practice staff Care Home staff Community pharmacy
35 30 25 20 15 10 5 0 10 2014 11 2014 1 12 2014 2 3 CARE HOME A 4 5 6 7 8 9 Hypnotics and anxiolytics Antipsychotics 35 CARE HOME B 30 25 20 15 10 Hypnotics and Anxiolytics Antipsychotics 5 0 10 2014 11 2014 1 12 2014 2 3 4 5 6 7 8 9
Average cost per patient (PIS data)
Next steps Expand the service 2 care homes in a second locality 102 patients 9 GP practices Develop a referral system Pharmacist as first point of contact for review Teach and Treat
Teach and Treat NHS Education for Scotland funded initiative Develop clinical capacity for IPs Each board delivering differently NHS Lanarkshire Polypharmacy and respiratory Pharmacists from any setting Intensive training programme Ongoing commitment to deliver clinics
NHS Lothian Polypharmacy review
NHS Lothian Polypharmacy Review Jan 2012 onwards: Aims and Outcomes Pilot project NHS Lothian Alpana Mair 2011 level 3 medication reviews for residents of two care homes with GP and care of the elderly consultant input involving optimising medications to minimise iatrogenic risk to elderly patients ADRs and drug-related hospital admissions and maximise benefit All 126 GP practices in NHS Lothian invited to participate in Service Level Agreements (SLA) Aims & Desired Outcomes To target priority patient groups - those most at risk of ADRs: care home residents, frail housebound, those on high-risk medications (either alone or in combination). To carry out systematic medication reviews to optimise medicines minimise medicines which may be harmful (particularly in those experiencing ADRs) or no longer appropriate, maximise benefit in line with NHS Lothian Polypharmacy Guidance for prescribing in frail adults (based on NHS Highland guidance, later Scottish guidance 1 st ed Oct 2012) To undertake joint review discussions GP/patient/pharmacist and implement changes
NHS Lothian Polypharmacy Review Jan 2012 onwards: Developments Ward rounds in care homes with Medicine of the Elderly Consultant/GP/pharmacist SurveyMonkey GP feedback questionnaire Peer review sessions for integrated care pharmacists Central database of patients who have had medication review
SUMMARY 2012/13 2013/14 2014/15 to date patient cohort care home residents plus 24 patients per practice aged >75yrs on >10 repeat meds at least one of which high risk 24 patients per practice aged >75yrs with SPARRA score 40-60% having received meds from >10 BNF sections one of which high risk care home residents plus 24 patients per practice aged >75yrs with SPARRA score 40-60% having received meds from >10 BNF sections one of which high risk no. practices signed up to SLA/126 practices NHS Lothian 55 85 91 no. patient medication reviews 2616 2764 1664/4858 no. medicines stopped 3322 3067 2100 of which high risk medicines 680 660 507 no. medicines with dose reduced 604 696 421 no. medicines with dose increased 88 101 65 no. medicines started 596 299 125 no. medicines switched 532 719 356 estimated medicines cost/patient/year saved ( ) 112 (1 st 368pts) 65 (1 st 602 patients 114 (random sample 20 patients per month
NHS Lothian Polypharmacy Review Jan 2012 onwards: Limitations Snapshot in time Face-to-face patient/pharmacist contact limited Prioritisation/scheduling of interventions GP time to implement interventions Documentation of outcomes so that shareable intra/inter profession Standardisation of review paperwork
Medicine is a science of uncertainty and an art of probability. William Osler
NHS GGC Polypharmacy LES enhanced polypharmacy review in a planned face to face consultation with a GP for patients considered priority for medication review. (1.5% weighted practice list) One GP from each practice to attend an external small group learning session and one internal practice learning session
Who is considered as prioirity?
Patients on 5 or more repeat medicines including an oral NSAID + ACE Inhibitor or Angiotensin 2 Receptor Antagonist + Diuretic + Warfarin + antiplatelet + age 65 years without PPI Patients on 5 or more repeat medicines including warfarin + Other antiplatelet(s) Patients aged 65 over on 5 or more repeat medicines including any combination of medicines that increases the risk of falls. (High and moderate falls list drugs include Antidepressants, Antimuscaririncs, Antipsychotics, Benzodiazepines, Z drugs, Dopamine agonists,,opiates, Anti-epileptics,, Alpha Blockers, Diuretics, ACEIs and Betablockers) Patients age 65 and over on 5 or more repeat medicines that equates to an Anticholinergic Risk Score of 3 or higher
Patients age 65 and over on 5 or more repeat medicines including a long acting sulphonylurea agent Patients on 5 or more repeat medicines including 2 or more antiplatelets for greater than 12 months Patients aged 65 years and over on 5 or more repeat medicines including an oral antipsychotic prescription (as a proxy of oral antipsychotic prescribing to older people with dementia) Patients on 5 or more repeat medicines including any current combination of Step 2 opioids (codeine, dihydrocodeine, dextropropoxyphene, tramadol or buprenorphine) Patients on 10 or more repeat or regular acute medicines (excluding dressings, emollients etc) The Polypharmacy EMIS/VISION Microsoft Access application tool has been modified so the practice can identify patients on 5 or more repeat medicines and other named drugs considered as a particular priority for review within the individual practice.
Evaluation Activity measures Percentage of practices opting in=99% (240/242) Numbers of patients reviewed= 32,316 Percentage of patients viewed compared with target= 114% No outcomes measures such as reduced hospitalisations or ADRs
221 GPs attended the sessions Average Pre Post Knowledge & Awareness of National Polypharmacy Guidance / 7 steps of polypharmacy review 2.6 4.4 Knowledge & skills in applying a polypharmacy review How confident do you feel in delivering polypharmacy reviews 3.2 4.13 3.65 4.3
National Polypharmacy Guidance Supporting provision of Safe, Effective and Person-centred care (Prescription for Excellence) Describes a 7-step process: 1. Identify objectives of drug therapy 2. Identify essential drug therapy 3. Does the patient take unnecessary drug therapy? 4. Are therapeutic objectives being achieved? 5. Does the patient have ADR or is the patient at risk of ADR? 6. Is drug therapy cost-effective? 7. Is the patient willing and able to take the drug therapy as intended? http://www.sign.ac.uk/pdf/polypharmacy_guidance.pdf
Each section then detailed E.g.: Safety Drugs poorly tolerated in frail adults See Gold National Framework on frailty o Antipsychotics (incl. phenothiazines) o NSAIDs (46) o Digoxin (doses? 250 mcg) (9) o Benzodiazipines (24) o Anticholinergics (incl. TCAs) (27) o Combination analgesics High-risk clinical scenarios See ADR table o Metformin + dehydration o ACEI/ARBs + dehydration o Diuretics + dehydration o NSAIDs + dehydration o NSAID + ACEI/ARB + diuretic o NSAID + CKD o NSAID + age >75 (without PPI) o NSAID + history of peptic ulcer o NSAID + antithrombotic o NSAID + CHF o Glitazone + CHF o TCA + CHF o Warfarin + macrolide/quinolone o?2 anticholinergics (see Anticholinergics)