Polypharmacy & mindful prescribing

Alpana Mair Therapeutic Partnership Lead

Multimorbidity in Scotland-Would Multimorbidity in Scotland-Would require an extra £3.5 billion 2031require an extra £3.5 billion 2031

• 62% projected rise in over 65s 2006-31

• 144% projected rise in over 85s 2006-31

• Increased prevalence of LTC, esp COPD and Diabetes

• 24% projected rise in older people admitted as emergencies by 2016

Audit Scotland

Mercer, Guthrie, Wyke:

Scottish School of Primary Care

Increase in polypharmacyIncrease in polypharmacy

Pr. Bruce Guthrie, Dundee

Multidisplinary across Health boards with Patient Representation

• Model of Care• Materials to Aid Decision Support and Person

Centred Information • Identification of Patients and Data for

Improvement• Engagement and Infrastructure to Sustain

Model

Who is the guidance for?

• Health boards to inform how best to deliver

• Tools are for health boards to put into a pack for clinicians

• Advises on what is currently delivered under QOF- Med level 2

Which patients to target?- iSPARRA

• Patients that have a 40-60% risk of admission in last 12 months

• Over age 75• Taking 10 or more Medicines in BNF categories including

a High Risk medication• In a care home• Then 65+ or 5-9 BNF Categories

Number

CRITERIA / CONSIDERATIO

NSPROCESS/GUIDANCE

References / Further reading or Examples

1

Is there a valid and current indication? Is the dose appropriate?

Identify medicine and check that it does have a valid and current indication in this patient with reference to local formulary. Check the dose is appropriate (over/under dosing?)

e.g. PPIs- minimum dose to control symptoms should be used- risk of c.difficle and fracture

e.g quinine use- see MHRA advice re safety e.g. long term antibiotics

2

Is the medicine preventing rapid symptomatic deterioration?

Is the medicine important/essential in preventing rapid symptomatic deterioration? If so, it should usually be continued or only be discontinued following specialist advice.

e.g. Medications for Heart failure, medications for Parkinson’s Disease are of high day to day benefit and require specialist input if being altered. review of doses may be appropriate e.g. digoxin

3

Is the medicine fulfilling an essential replacement function?

If the medicine is serving a vital replacement function, it should continue.

e.g. thyroxine and other hormones

4

-Is the medicine causing:

-Any actual or potential ADRs?

-Any actual or potentially serious drug interactions?

Contraindicated drug or high risk drugs group?

Strongly consider stopping

See High Risk Drug section e.g is the patient on a high risk combination “ triple Whammy”

Ref. “STOPP” ListBNF Sections to Target

Poorly tolerated in frail patients? For guidance on frailty see Gold National Framework

Consider stopping

Particular side effects?

May need to consider stopping

5

Is the medicine effective for this patient?

For medicines not covered by steps 1 to 4 above, compare the medicine to the ‘Drug Effectiveness Summary’ which aims to estimate effectiveness.

Ref. Drug Effectiveness SummaryRef NNT/NNHMedication used for dementia patients- see Gold

NF

6

Are the form of medicine and the dosing schedule appropriate? Is there a more cost effective alternative with no detriment to patient care?

Is the medicine in a form that the patient can take supplied in the most appropriate way and the least burdensome dosing strategy? UKMI Guidance on choosing medicines for patients unable to swallow solid oral dosage forms should be followed

Consideration should be given to the stability of medications

7

Do you have the informed agreement of the patient/carer/welfare proxie?

Once all the medicines have been through steps 1 to 6, decide with the patient and/or carer what medicines have an effect of sufficient magnitude to consider continuation/discontinuation.

Drug Review Process- A4 summary with links

NNT and NNH- drug effectiveness tables

• The ‘Number Needed to Treat’ (NNT) is a measure used in assessing the effectiveness of a particular medication, often in relation to reduction in risk over a period of time. The NNT is the average number of patients who require to be treated for one to benefit compared with a control in a clinical trial.

• ‘Number Needed to Harm’ (NNH) is a related measure which is the average number of people exposed to a medication for one person to suffer an adverse event

Outcomes so far…..

• Highland

• Tayside

• Lothian

• Forth valley

• Multidisplinary approach

• GP, Pharmacist, Geriatrician

Data Collection and evaluation

• Number of patients reviewed from list given by iSPARRA and CHI numbers

• Number of high risk medications stopped and why

• Medications started

• Cost benefit

Next Steps

1. Guidance document will be reviewed after 6 months for revisions June 2013

2. Development of iSPARRA to help track changes in medication and potentially other health outcomes

3. Development of indicators as PIS data develops4. Development of coding for polypharmacy reviews nationally5. Analysis of Scotland wide data for Polypharmacy6. patient tools to help them actively take a role in polypharmacy

reviews7. Development of tools for the clinicians undertaking

polypharmacy reviews8. Development of IT systems to enable extraction of data from GP

prescribing systems by national read codes.

Patient Engagement‘Safe to ask’

Authoritarian Physicians And Patients’ Fear of Being Labelled ‘Difficult’ Among Key Obstacles to Shared Decision Making

D.L. Frosch et al

Health Affairs May 2012 Vol 31 no.5 1030-1038

If you’re not part of the solution then you are part of the problem….

“When you confront a problem you begin to solve it.”

Rudy Giuliani

Lack of a shared mental model?

‘Given additional pain killers and not explained why’

‘I am still not sure about the medicine I am taking’

‘Given the wrong drugs to take home’

Improve Understanding

• What you are taking• Why you are taking it• When you should take it• How you should take it• How long you should take it for

Who needs to ask questions?

• Doctors, Nurses, Pharmacists and other healthcare professionals.– Why? – Don’t they know what I take?

• Patients– Why?– What if I forget to ask when I see the doctor?

Make it easy

“Good ideas are not adopted automatically. They must be driven into practice with

courageous patience”

Jennifer.ross@nhs.net

@med_safety_bird

Hyman Rickover

180 day Rapid Cycle Improvement Project in

Medicines ReconciliationDr Gregor Smith

One man may hit the mark, another blunder; but heed not these distinctions. Only from the alliance of the one working with and through the other, are great things born.

Antoine de Saint-Exupery

Background to 180d RCIP

• Commissioned by the Quality Alliance Board• Five Boards (NHS Lanarkshire, Tayside, Highland,

Grampian and Forth Valley)• Aims:

– Build on and accelerate the work in med rec– Improve breadth clinical engagement– Share learning between and beyond participating

Boards– Develop capacity and capability for rapid cycle

improvement work

Project Measures

Admission

1. Current medicine list (using 2 or more sources)

2. Plan

3. Demographics

4. Allergy Status

5. Accurate Cardex

Discharge

1. Current medicine list

2. Documented Changes

3. Demographics

4. Allergy status

5. Accurate interim discharge letter

Medicines Reconciliation: Definition

The process of obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medications accurately communicated

Project Structure and Process

• 3 phases: Scoping and Planning, Testing and Improvement, Implementation and Assurance

• Weekly / bi-weekly calls• Milestone meetings• Strong links with Medicines Reconciliation Network and

hosting on their Community Site

• Problem sharing / solving; developing test strategies; reporting and spreading successes or challenges

High compliance with 2 source

reconciliation and formation plan

Project Pause over Festive

holiday Reduced use of ECS in 2

source reconciliation

Changeover junior medical staff: reduced

access to ECS

Consultant engagement

Consultant spread and junior audit

Ward round pause; MDT rounds; IDL

audits

Introduction of new cardex

Potential correlation between reduced use of ECS and Accurate Medication History

Med Rec Audit Data 180 Day Project

Total

Total Take Audit

0

10

20

30

40

50

60

70

80

90

100

Week beginning

Perg

en

tag

e

Total compliance Total accurate (%) Total

Medicines Reconciliation - Med. Rec. by Consultant

0

10

20

30

40

50

60

70

80

90

100

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12

Acute Care

Ageing & Health

General Medicine

Surgery

Learning and Recommendations

• Education and training• QI capacity and capability• Professional Leadership• Clinical Quality Strategies• Consultation• Process and System Solutions• eHealth• Workforce

Mindful PrescribingEmpowering people to make informed choices,

providing innovative and holistic care using appropriate decision support materials that enable meaningful conversations and anticipatory care planning

Effective Therapeutic

CareUsing Risk Prediction tools to

target specific cohorts of people for Chronic Medication Service,

Medication Reviews and Stewardship, and telehealth support for managing medicines

Safer Medicines improving the communication

and reconciliation of medicines at times of transition and administration of medicines

for vulnerable people in hospital and community

Sustainable Safe, Effective, Efficient and Person Centred care

associated with medicines requires a multi-professional

approach

Acknowledgements

Alexa Wall, SPSP Fellow, NHS LanarkshireJane Ross, Improvement Advisor, HIS

Susan McGaff, Policy Officer, HISJennie Ross, NHS Grampian

Dr Alison Graham, NHS Lanarkshire

Jason Leitch, Clinical Director, Quality UnitDr Anne Hendry, National Quality Lead

Carol Sinclair, Better Together Programme

And participants from all the Boards for their patience, diligence and innovation

Gregor.smith@lanarkshire.scot.nhs.uk

Discussion Questions

What examples of improvement work relating to medicines are you involved in with your organisations?

What gaps in the care related to medicines have you identified?

What approaches might NHSScotland take to accelerate improvement in the care associated with medicines?