The benefits of medication review for patients and practice based commissioners

1. The benefits of medication review for patients and practice based commissioners Dr Duncan Petty Lecturer Practitioner University of Leeds Practice Pharmacist

2. What is a clinical medication review? Aims Optimise the treatment Identify and solve problems Improve compliance and patient involvement Reduce waste Requirement of The nGMS contract Older peoples NSF

3. Aims of medication review Optimising the treatment regimen Is the medicine needed? Is it working? Is the dosage evidence based? Does the patient have any under-treated conditions? Does the patient have any untreated problems

4. Aims of medication review Identifying problems Are the medicines being ordered? Is the patient able to take it? Is the medicine interacting with other medicines? Is the medicine contraindicated? Are there any adverse drug reactions (ADRs), either reported by the patient or evident from tests?

5. Aims of medication review Patients� views and preferences Does the patient want to take the medicine? Does the patient have any information needs about their condition and its treatment? Does the patient understand the purpose of the medicine? Are the prescription directions clear and practical?

6. Aims of medication review Waste reduction Branded to generic Unwanted medicines Unneeded medicines Over ordering

7. Benefits of medication review Improve the use of medicines Improve outcomes for nGMS measures Improve outcomes for NSFs Formulary implementation Reduce medicine risk Adverse events Litigation Effect on hospitalisation (?)

8. Benefits of medication review Reduce practice workload Appointments for review and re-authorisation of medicines. Review of discharge advice notes and letters Home visits to the vulnerable Improve patient satisfaction with medicines Questioning answering and education Shared decision making (or concordance) Reduce medicine waste

9. Who is at risk of repeat hospital admissions. It�s hard to say!

10. Who is at risk of repeat hospital admissions Patients with multiple emergency admissions are often identified as a high risk group for subsequent admissions �Patients aged >65yr with 2+ admissions were responsible for 38% of admissions in the index year but fewer than 10% in following year and just over 3% 5 years later.� Roland R. BMJ 2005;330:289-292

11. Research evidence Drug related admissions Potentially preventable drug-related morbidity is associated with 5-17% of admissions. Cunningham G. Age Ageing 1997 Mannesse CK BMJ 1997 Pirmohamed et al BMJ��2004;329:15-19� Howard RL et al. Br J Clin Pharmacology 2006;June 26th About 20% of patients experience an adverse event after discharge. Forster A. Ann Intern Med 2003 Forster A. CMAJ 2004 Poor discharge can result in unplanned re-admission. Williams EI. BMJ 1998

12. Effect of medication review on hospital admissions All studies, Odds Ratio 0.64 (0.43-0.96) Only RCTs, Odds Ratio 0.91 (0.8-1.4) i.e. Medication review studies show only a weak effect on reducing hospitalisation Royal, S et al. Qual Saf Health Care 2006;15:23-31

13. Targeted reviews may be beneficial in reducing poor outcomes Patients Poor adherence Polypharmacy Reduced drug handling Very elderly Living on own Living in a care home Multiple pathology Unplanned hospital admissions

14. Targeted reviews may be beneficial in reducing poor outcomes Medicines Risky medicines Areas of dangerous or inappropriate prescribing Too few beneficial medicines Lack of monitoring Recent hospital admission

15. Hepler definitions for classification of drug related admissions Score = 1: inappropriate prescribing. Score = 2: inappropriate delivery (unavailable when needed, inappropriate formulation, failure to administer, dispensing error). Score = 3: inappropriate behaviour by the patient (non-compliance). Score = 4: patient idiosyncrasy (response to drug, mistake, or accident). Score = 5: inappropriate monitoring. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533�43.

16. Medication-related risk factors associated with poor health outcomes Lack of routine for taking medicines Multiple storage locations Therapeutic duplication Hoarding of medicines Confusion with medicines names e.g. branded and generic Multiple prescribers Still using discontinued repeat medicines Poor adherence Older age Increasing number of medicines found in home Sorensen L et al. Medication management at home: medication-related risk factors associated with poor health outcomes. Age and Ageing 2005:34;626-632.

17. Targeted interventions that can reduce poor outcomes Around 4.3% of admissions due to medicines Most common cause of medicine related admissions: Diuretics 16% Antiplatelets 16% NSAIDs 11% Anticoagulants 8% Howard RL et al. Br J Clin Pharmacology 2006;June 26th

18. Adverse drug reactions as cause of admission to hospital Drugs causing adverse drug reactions Drug group No (%) of cases Adverse reactions  NSAIDs 363 (29.6) Aspirin (218) GI bleeds Others (145) Haemorrhagic CVA Renal impairment Diuretics 334 (27.3) Renal impairment, Hypotension, Electrolyte disturbances Warfarin 129 (10.5) GI bleeding Haematuria Haematoma  Pirmohamed et al BMJ��2004;329:15-19�

19. Medicines associated with drug related risk Warfarin NSAIDs Diuretics (in older people) Hypotensives (in older people) Hypnotics (in older people) Antipsychotics (in older people) Digoxin Amiodarone Tricyclic antidepressants (in older people) Hypoglycaemics (especially long-acting sulphonylureas) Medicines with a narrow therapeutic index e.g. antiepileptics, lithium, theophylline

20. Reasons for medicine admissions Prescribing (35%) e.g. NSAIDs with 2 or more risk factors for GI bleed Antiplatelets with 2 more risk factors for GI bleed Monitoring (26%) e.g. Diuretics � not monitoring fluid balance, renal function. Sulphonyrueas � failure to monitor blood glucose Digoxin � failure to monitor dig levels/renal function Adherence (30%) e.g. Loop diuretics � CCF exacerbation Antiepileptics � fitting Inhaled steroids � asthma exacerbation

21. Targeting medication reviews at medicine risk Target at patients prescribed Diuretics - risk/monitoring/adherence Antiplatelets - risk NSAIDs - risk Antiepileptics - adherence Digoxin - monitoring Benzodiazepines - falls risk

22. Targeting medication reviews at patients at risk Decreased renal function � because medicines accumulate and some medicines can further worsen renal function e.g. NSAID, ACE-I. Risk of falls � hypnotics and antihypertensives can be a cause of falls Older people handle medicines less well and need smaller doses. Care home residents Polypharmacy, drug handling, lack of review, autonomy.

23. Clinical medication review by a pharmacist of elderly people living in care homes- randomised controlled trial Zermansky AG, ALLDRED DP, Petty DR et al. Age and Ageing 2006 35: 586-591 Outcomes during six months follow-up period Intervention Control Difference (RR 95%CI P value) GP consultations 2.9 (1 to 4) 2.8 (1 to 4) 1.03 �Number (IQR) (0.93 to 1.15) 0.50 Falls �Mean 0.8 (0 to 1) 1.3 (0 to1) 0.59 (0.49 to 0.70) (IQR) <0.0001

24. Clinical medication review by a pharmacist of elderly people living in care homes. Cont.. Patients hospitalised Number (%) Intervention Control OR P value 47 (14.2%) 52 (15.8%) 0.89 (0.56 to 1.41) 0.62 Medication review by doctor Number (%) 58 (17%) 62 (19%) 0.88 (0.56 to 1.37) 0.55

25. Medication review as part of falls assessment Review need for medicines Review, in particular sedatives and hypotensives. e.g. withdraw of psychotropic medicines in care home residents reduced relative risk of falls by 0.34 (95% CI 0.16-0.74). Campbell et al. J Am Geriatr Soc 1999;47:850-3

26. Targeting medication reviews at cost PPIs � high dose to low dose Clopidogrel (�440/patient/year) Atorvastatin switch to simvastatin (�190/patient/year) Therapeutic switching e.g. PPIs Branded generic switching e.g. Becloforte Reducing unnecessary medicine use (Our RCT showed saving of �61/patient/annum. BMJ 2001;323:1340)

27. Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: Periodic telephone counselling by a pharmacist improved compliance and reduced mortality After two years 31 (52%) of the defaulters had died 38 (17%) of the control group had died 25 (11%) of the intervention group had died After adjustment for confounders, telephone counselling was associated with a 41% reduction in the risk of death (relative risk 0.59, 95% confidence interval 0.35 to 0.97). Wu JYF et al etal BMJ��2006;333:522,

28. Cost savings identified in RCTs Zermansky et al (2001) �61/patient/year Rodgers et al. (1999) �63/patient/year Mackie et al (1999) for every �1 spent on pharmacists �2 per year was saved on medicine costs. 1.Zermansky AG, Petty DR, Raynor DK et al. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. British Medical Journal. 2001:323; 1340-1343. 2. Rodgers et al Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs. Brit J Gen Pract 1999; 49: 717-720 3. Mackie CA et al. A randomized controlled trial of medication reviews in patients receiving polypharmacy in general practice. Pharm J 1999; 263:R7

29. Targeting medication reviews at supporting nGMS measures Why? QoF markers are for long-term conditions Long-term conditions are mostly managed with medicines If medicines are not prescribed optimally or patients are not taking them then outcomes will not be achieved. Helps GPs

30. Interventions to reduce risk from highest risk drugs NSAIDs Stop treatment Change to safer NSAIDs Counsel patient to use less Provide PPI cover Antiplatelets Ensure use is needed Provide PPI cover if at risk Reduce combined use of clopidogrel with aspirin.

31. Odds ratios for major gastrointestinal complications with NSAIDs by age and sex

32. Interventions to reduce risk from highest risk drugs Loop diuretics Stop use for gravitational oedema Ensure patient know how to take it Monitoring U+Es frequently Ensure lowest necessary dose is used Thiazide diuretics Ensure patient know how to take it Monitoring U+Es frequently Ensure lowest necessary dose is used

33. Unplanned hospital admissions Emergency admissions by ACS condition 2003/04 ACS condition No. of spells COPD 106,517 Angina (uncomplicated) 79,228 ENT infections 72,831 Convulsions and epilepsy 64,664 Congestive heart failure 62,582 Asthma 61,264 Delivering quality and value. Institute for Innovation and Improvement. www.institute.nhs.uk accessed October 1st 2006.

34. Increasing prescribing to reduce health care use COPD Long acting beta agonists, long acting anticholinergics, inhaled steroids. Heart Failure ACE-I, beta blockers, spironolactone Atrial fibrillation Warfarin Falls and fractures Vitamin D (calcium), bisphosphonates

35. COPD treatments - Numbers need to treat to prevent one exacerbation per year Carbocysteine 1 = probably not effective Inhaled steroids 2 = 5 Tiotroprium 3-5 = 2 to 5 Salmeterol 6 = 4 to 5 NNT to prevent a hospitalisation Pulmonary rehabilitation7 = 80 1. Decramer M. Lancet 2005:36:1518-20 2. Inhaled steroids for COPS. Bandolier www.jr2.ox.ac.uk/bandolier 3. Casaburi R. Eur Respir J 2002;19:217�224 4. Vincken W,. Eur Respir J 2002;19:209�216.� 5. Brusasco V,. Thorax 2003;58:399�404 6. Sin DD. JAMA 2003;290:2301-12 7. Unpublished data

36. Benefits of beta blockers in heart failure Mild to moderate heart failure (already on an ACE-I and loop diuretics). For every 100 patients treated for 1 year, 3 deaths and 4 hospital admissions will be prevented. Beta blockers for heart failure. Clinical Evidence. Available online at http://www.clinicalevidence.com/ceweb/conditions/cvd/0204/0204_I6.jsp Accessed on 27th April 2005.

37. Review medicines at discharge Highly risky time Unintentional changes occur. Ensures that: correct medicines are on medication record patient knows about the changes a care plan for monitoring, dose titration and stopping are put in place. non-formulary medicines are not continued.

38. Interventions to improve adherence Simplified dosing Reminders (tailoring regimen to daily habits) Reminder pill packing Appointment and repeat prescribing fill reminders Telephone follow up/automated telephone More instructions and medicine and condition being treated. Involving patients more in their care Family intervention Health lay mentoring Comprehensive pharmaceutical care services. Haynes et al. Cochrane Database of Systematic Reviews 2005;4.

39. Conclusion Medication reviews underpins the management of long-term conditions. They may have some effect on hospitalisation. A lack of review will result in increased risk of medication errors; poor outcomes and increased medicines costs. Face to face reviews are vital for involving patients in the management of their own condition and they may have some effect positive effect on compliance. Pharmacist medication reviews are cost neutral and may save more money then they cost.