Polypharmacy & mindful prescribingAlpana Mair Therapeutic Partnership Lead
Multimorbidity in Scotland-Would require 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 2016Audit Scotland Mercer, Guthrie, Wyke: Scottish School of Primary Care
Increase in polypharmacyPr. 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
Drug Review Process- A4 summary with linksNu CRITERIA / References / Further reading PROCESS/GUIDANCE CONSIDERATIONS or Examples Is there a valid and Identify medicine and check that it does e.g. PPIs- minimum dose to control symptoms should current have a valid and current indication in be used- risk of c.difficle and fracture1 indication? Is the this patient with reference to local e.g quinine use- see MHRA advice re safety dose appropriate? formulary. Check the dose is e.g. long term antibiotics appropriate (over/under dosing?) Is the medicine Is the medicine important/essential in e.g. Medications for Heart failure, medications for preventing rapid preventing rapid symptomatic Parkinson’s Disease are of high day to day2 symptomatic deterioration? If so, it should usually be benefit and require specialist input if being deterioration? continued or only be discontinued altered. review of doses may be appropriate following specialist advice. e.g. digoxin Is the medicine If the medicine is serving a vital e.g. thyroxine and other hormones fulfilling an replacement function, it should3 essential continue. replacement function? -Is the medicine Contraindicated drug or Strongly causing: high risk drugs group? consider -Any actual or potential stopping ADRs? Poorly tolerated in frail Consider -Any actual or See High Risk Drug section e.g is the patient on a high patients? For stopping potentially serious risk combination “ triple Whammy”4 guidance on frailty drug interactions? Ref. “STOPP” List see BNF Sections to Target Gold National Framework Particular side effects? May need to consider stopping Is the medicine For medicines not covered by steps 1 to 4 Ref. Drug Effectiveness Summary effective for this above, compare the medicine to the Ref NNT/NNH5
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 • Multidisplinary• approach Tayside • GP, Pharmacist,• Lothian Geriatrician• Forth valley
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 Steps1. Guidance document will be reviewed after 6 months for revisions June 20132. Development of iSPARRA to help track changes in medication and potentially other health outcomes3. 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.
Authoritarian Physicians And Patients’ Fear of BeingLabelled ‘Difficult’ Among Key Obstacles to SharedDecision 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
‘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’ Lack of a shared mental model?
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?
“Good ideas are not adopted automatically. They must be driven into practice with courageous patience” Hyman Rickover Jennifer.firstname.lastname@example.org @med_safety_bird
180 day Rapid Cycle Improvement Project in Medicines Reconciliation Dr Gregor Smith
One man may hit the mark, anotherblunder; but heed not thesedistinctions. Only from the alliance ofthe one working with and through theother, 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 MeasuresAdmission Discharge3. Current medicine list 3. Current medicine list (using 2 or more sources) 4. Documented Changes4. Plan 5. Demographics5. Demographics 6. Allergy status6. Allergy Status 7. Accurate interim7. Accurate Cardex discharge letter
Medicines Reconciliation: DefinitionThe process of obtaining an up-to-date and accuratemedication list that has been compared with the mostrecently available information and has documented anydiscrepancies, changes, deletions or additions resultingin a complete list of medications accuratelycommunicated
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 Project Pause with 2 source over Festive Changeover reconciliation and holiday junior medical Reduced use staff: reduced formation plan of ECS in 2 access to source ECS reconciliation Consultant spread and junior audit Introduction Ward round of new pause; MDT Consultant cardex rounds; IDLengagement audits
Potential correlation between reduceduse of ECS and Accurate MedicationHistory
Learning and Recommendations• Education and training• QI capacity and capability• Professional Leadership• Clinical Quality Strategies• Consultation• Process and System Solutions• eHealth• Workforce
Mindful Prescribing Empowering people to make informed choices, providing innovative and holistic care using appropriate decision support materials that enable meaningful conversations and anticipatory care planning Effective Safer Medicines Therapeutic improving the communication Care and reconciliation Using Risk Prediction tools to of medicines at times of transition target specific cohorts of people and administration of medicines for Chronic Medication Service,for vulnerable people in hospital and community Medication Reviews and Stewardship, and telehealth support for managing medicines Sustainable Safe, Effective, Efficient and Person Centred care associated with medicines requires a multi-professional approach
Acknowledgements Alexa Wall, SPSP Fellow, NHS Lanarkshire Jane Ross, Improvement Advisor, HIS Susan McGaff, Policy Officer, HIS Jennie Ross, NHS Grampian Dr Alison Graham, NHS Lanarkshire Jason Leitch, Clinical Director, Quality Unit Dr Anne Hendry, National Quality Lead Carol Sinclair, Better Together ProgrammeAnd participants from all the Boards for their patience, diligence and innovation Gregor.email@example.com
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?