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17- 19 october 2016, Barcelona

Interface Management of Pharmacotherapy

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Maite Perez-Rodriguez Primary Care Pharmacist

Consorcio Sanitario Integral

Medication review and pharmaceutical strategies. Interface management

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• Optimizing drug therapy is an esential part of caring • The process of prescribing a medication is complex and

includes: – Deciding that a drug is indicated – Choosing the best drug – Determining a dose and schedule appropriate for the

patient’s physiologic status – Monitoring for effectiveness and toxicity – Educating the patient about expected side effects and

indications for seeking consultation

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– Primary Health Care: • Only 5-10 minutes/visit • Great number of chronic patients (30% of assigned population) • High medicalization of common conditions. • High clinical complexity, comorbidities, polypharmacy, and older

population. • 20% older patients have >10 drugs prescribed as chronic treatment.

– Guidelines can make GP overact (evidence based on results of clinical

trials) as most clinical trials often exclude: • Geriatric patients, • Patients with comorbidities and polypharmacy, • So approved doses may not be appropriate for older adults • Uncertainty of the effectiveness of chronic drug treatments

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Increased risk for:

– an adverse drug event (ADE)

– medication related problems (MRPs)

– Hospital admission, emergency and medical visits

– drug-drug interactions, or drug-medical condition interactions

– prescription of potentially inappropriate medications

– overprescribing and underprescribing

– problems with medication adherence

– Possibility of prescribing cascades (misinterpret an ADE as a new

medical condition and prescribe additional drug therapy to treat the

new medical condition)

• …

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Escitalopram

Lorazepam

Quetiapina (Nurse Home Care after hip surgery)

Haloperidol (Day Center for agressivity)

Tramadol for pain

Donepezilo for dementia

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Medication Review is a structured, critical examination of a patient’s medicines with the objective of optimizing medicines use and improving health outcomes, minimising the number of medication related problems.

• MultidisciplinaryTeam • Reach an agreement with patient about treatment • Final objective improve health outcomes and safety • High time-consuming • Systematized process

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Improvement in short and long term disease management: 1. Improve patient safety and reduce drug related problems

– Withdrawing not needed medication (overprescription) – Reducing underutilization of appropriate medication – Detect and resolve adverse drug events – Reduce hospital admissions, emergency and medical visits. – Improve health outcomes and increase control of the patient’s

disease 2. Simplifies treatments removing me-too drugs.

Improvement in communication between the patient and the rest of the health team. • Active involvement of the patient in his treatment improves the

adherence and the therapeutic outcomes.

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Type 1. Review of pharmacological prescriptions Type 2: Review of adherence and concordance (agreements) Type 3: Clinical review (it comprises type 1 and 2)

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Type 1. Review of pharmacological prescriptions

• Evaluation of the patient’s drug therapy

• The patient is not present

• Objective: improve safety and efficiency

• Review: overlaps, interactions, contraindications, drugs not

recommended in certain age groups (elderly, paediatric,…), etc

• Clinical work station ECAP has assisted electronic prescription

tools

– PREFASEG when they are prescribing

– SELF-AUDIT potential DRP in patient

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Type 1. Review of pharmacological prescriptions

• Not clear clinical outcomes benefits

• Improvement of indicators of quality of prescription, reduction of problems associated with medication, incorporation criteria START/STOP...

• Improvement of a variable clinical concrete -> improves level cognitive by withdrawal of psychotropic drugs Drugs Aging 2008;25:1021-31

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Type 1. Review of pharmacological prescriptions • Partial review: concrete drug or therapeutic group • Review of all patient’s with a chronic prescription of PPI • Leaflet for patient -> information about benefits and harms

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Type 1. Review of pharmacological prescriptions • Session Primary Health Care Team (GP + nurses) • Quick Reference Leaflet +

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Type 1. Review of pharmacological prescriptions • Table of therapeutic equivalence between the diferent PPI for

each authorized indication

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• Elaborate a dossier/GP with all his patients with a potentially inappropriate PPI prescription

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527

442

198 197

62 37

270 238

93 78 55

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0

100

200

300

400

500

600

Sin indicaciónclínica

Gastroprotección Dispepsia Hernia de Hiato ERGE Historia Ulcus

Pacientes con tratamiento potencialmente no adecuado preintervenciónPacientes con tratamiento adecuado postintervención

Adequacy of potentially suitable treatments before-after intervention

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Management Area Primary Health Care Centers

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Type 1. Review of pharmacological prescriptions • Pharmacists time-consuming • Systematic: Review of

medication of all patients with chronic treatments of each GP

• Dossier to each GP with all patient’s with some possible incidence once a year

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Type 1. Review of pharmacological prescriptions • Resume. The basis for Clinical Review • Clinical relevant interactions (not included PREFASEG) • Contraindications (Drug-Health Problem) • Overlaps (two simultaneous prescription benzodiazepines or

calcium supplement with vitamin D plus vitamin D supplement) • Drugs with unfavorable risk benefit ratio • New drugs with therapeutic alternatives • Selection and Adequacy (PPI, IECA/ARAII, Calcium

supplement/diet,…) • Etc.

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Type 3. Clinical Review

• Review the indication of the medication,

• The appropriateness of each drug for the age or clinical

conditions (renal or hepatic failure),

• The appropriateness of the dose, schedule and duration of

treatment

• The effectiveness of the therapy in relation to the therapeutic

objective

• Drugs safety to avoid DRP

• And accomplish treatment adherence

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Methodology 1 Step: Hierarchise diseases taking into account the professional criterion and the patient preferences 2 Step: Associate the drugs to the pathologies 3 Step: Establish the therapeutic objective for each treatment, taking into account the patient’s age and clinical situation 4 Step: Apply the clinical review algorithm

It requires time to think, virtual visit

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Patient Selection

• Priorizitizing patients with greater clinical benefit of the Clinical Review

• ≥ 75 years old

• Multiple pathologies and multiple contacts with other assistential levels

• Polypharmacy

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Dessigned a structured procedure (May 2010) 1. Clinical review circuit

2. Adherence and drug knowledge patient Check-List

3. Clinical Medication Review Check-List (Clinical review algorithm

resume)

4. Two Training Workshops GP and nurses 4 hours (april 2011,

july 2012)

5. Presentation to the Team of a Clinical Review by each Basic

Health Care Unit (UBA) (GP+Nurse) monthly.

6. Include the Clinical Review in the DPO (Objectives) of UBA

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1. UBA select the patient

– Prioritize diseases and health problems and they recorded

them in the Adherence and Clinical Review Checklists in the

same order

– Associate each drug with the corresponding disease or

health problem

– They register the dose, posology and duration of treatment

– The nurse will phone the patient and appoint him for a visit

related to the review of his chronic treatments. He must

take all drugs and herbal products to the visit.

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1. Nurse initial interview

PACIENT: __________________________ Number HCAP _________________

AGE: ______ years

Interview date:_____/____/_______ Initial interview Reinforcing interview

Test de Haynes-Sackett (self-fulfilling communication). Perform to the patient/caregiver the following question

1 - Most people have difficulty taking tablets, do you have difficulty taking them?

YES NO

2 - If the answer is yes, ask: In the last 7 days of taking pills, how many have you stopped taking?

Number forgotten tablets = Number tablets prescribed (in one week) =

% Tablets taken Good treatment adherence (% >80% and < 110%) Bad treatment adherence

Test de Morisky-Green (assesses whether the patient takes the correct attitudes regarding therapy)

1. Do you ever forget to take yourmy medication? YES NO

2. Do you take medications at specified hours? YES NO

3. When you feel good, sometimes do you leave to take them? YES NO

4. If you ever feel bad, Do you stop taking the medication? YES NO

YES NO

ADHERENCE QUESTIONNAIRE

Good treatment adherence (correct answer to all questions: No, Yes, No, No)

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1. Nurse initial interview

PACIENT: _________________________________________________ AGE: ______ years Num HCAP: _____________ Sex: Male Female

How many drugs are you currently taking?: (number)_______________Do you think that you are taking too many drugs? YES NO Date interview:__/__/____ Initial interview Reinforcing interview

Medicació Clinical History (HCAP)

Medication taken by the patient

Diagnosis/Health Problem HCAP

Patient/Caregiver Perception Dose HCAP

Dose patient / caregiver

related

Posology HCAP

Posology patient/car

egiver related

pag 1/2 (HCAP________)

CHECK-LIST ADHERENCE-KNOWLEDGEMENT OF CHRONIC MEDICATION

How do you take it? With a glass of water,…

Patient/Caregiver observations (possible

advers events, excess of medication,….

Medication

Impo

rtan

ce

patie

nt/c

areg

iver

(+/-)

Why would you take it? (Diagnosis or Health Problem)

How many doses (tablets, capsules,…) do you take

each time?

When are you taking it during the day?.

Before breakfast, with dinner,…

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1. Nurse initial interview

* For your health status, which are the drugs that you believe are:

most important?: __________________________________________________________________

and less important?________________________________________________________________

Of all of them, which do you think you can not stop taking any dose?

and which you can skip a dose? pag 2/2

(HCAP________)

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1. Nurse initial interview

• At the end give an appointment with the doctor in fifteen

days (two weeks) to review his chronic medication

2. GP Clinical Review

• With the information about knoledgement and adherence the

GP do the clinical review process

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2. GP Clinical Review

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2. GP Clinical Review

• In the visit appointment with the patient/caregiver changes in

medication will be raised one by one so its possible identify the changes (good or bad) and relate them with the drug change

• He must reach an agreement with patient about treatment

• He will have a control appointment to see the evolution and the knowledgement of the changes by the patient

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maite.perez@sanitatintegral.org

Thank you very much