Prescribing and medication management

Background

Person-centred structured medication review (SMR) is associated with reduced polypharmacy, adverse drug reactions (ADRs), admission to hospital and mortality. Our service development aimed to explore the cost-efficacy of a multi-disciplinary team (MDT) providing SMR as part of a comprehensive geriatric assessment for care home (CH) residents.

Method

We established an MDT consisting of a consultant geriatrician, specialist clinical pharmacist, two general practitioners, clinical fellow, physician associate and frailty paramedic practitioner. Training on SMR was given by the pharmacist to other team members, with further support offered through the pilot.

Results

A total of 785 residents were reviewed across 20 CH sites during the initial 6-month pilot. Overall, polypharmacy was reduced by an average of 1.33 medicines per resident (8.32 to 6.99). The drug classes most commonly deprescribed were laxatives, antidepressants, lipid lowering drugs, opioids, and nutritional supplements. Medicines altered included three classes known to cause 40% of avoidable hospital admissions due to ADRs(1): diuretics (stopped/changed for 42 residents), antiplatelets (stopped for 34 residents) and anticoagulants (stopped/changed for 26 residents). Annual projected medication savings totalled £131,462(net), with an average saving of £169 per resident (range £63- £367). Drug classes with the largest cost impact were nutritional supplements (40% total savings), laxatives (12%), opioids (12%) and anticoagulants (11%). Carbon footprint savings from the 12 inhalers stopped during this phase totalled 1,323,098 gCO2e per annum: equivalent to 4562 car miles.

Conclusion(s)

A multi-disciplinary approach to medication review was shown to reduce inappropriate polypharmacy in care home residents. This intervention was associated with significant projected cost savings. Future work should aim to target SMR to patients with the highest rates of inappropriate polypharmacy.

References: 1. Howard, R. L. et al. Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology vol. 63 Preprint at https://doi.org/10.1111/j.1365-2125.2006.02698.x (2007).

Introduction:

The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents. We established a multi-disciplinary care home team providing comprehensive geriatric assessment (CGA), structured medication review (SMR) and advance care planning (ACP) to a pilot cohort of frail residents in 17 care homes. We aimed to explore the acceptability and perceptions of proactive ACP alongside CGA from the perspective of resident’s next-of-kin (NOK), primary care staff and care home managers (CHMs).

Methods:

Data was collected using standardised questionnaires between February-September 2022. Data were analysed using qualitative content analysis. This was undertaken independently by two lead authors, after which codes and categories were identified through a collaborative approach and triangulation.

Results:

Four categories emerged from NOK data: 1) Perceived benefit of frailty specialist review, 2) Perceived improved knowledge of the individual through holistic assessment, 3) Sensitive conversations were perceived to have been handled well, but this was sometimes challenging over the phone, 4) Families felt empowered in shared decision making. Six categories emerged from primary care feedback: 1) Perceived benefit of holistic reviews, 2) Improved information sharing using same clinical system, 3) Specialist frailty involvement supporting GP learning, 4) Challenges with set-up, 5) Perceived avoidance of admissions following reviews, 6) Time and financial savings for NHS Four categories emerged from CHM feedback: 1) Perception that medical reviews were overdue, 2) Reduced care home staff workload through saving of time, 3) Specialist review and 4) Empowering staff to avoid admissions.

Conclusions:

This evaluation identified key feedback themes in relation to the perceived value and acceptability of a dedicated care home team performing CGA based ACP. Stakeholders expressed positive views about the service, suggesting benefits for individual residents, primary and community healthcare staff, and the wider healthcare system.

Background: There is a growing number of older adults in India and accordingly a rising burden of non-communicable diseases (NCDs). Poor medication adherence among patients with NCDs is prevalent in India and is associated with adverse outcomes, increased mortality and consequently increased patient and healthcare system costs. Understanding the factors which influence adherence across India is vital to guide interventions towards improved adherence. This study examined the factors influencing medication adherence in older adults (50 years or older) with NCDs in India. Methods:. Data analysis was conducted from the second wave of the World Health Organisation’s ‘Study on global AGEing and adult health (SAGE)’ to identify socioeconomic, health-related, geographical and social support variables that influence medication adherence in adults with NCDs. Bivariate analysis and multivariate logistic regression modelling were conducted. Results: The average medication adherence rate was 51% across 2840 patients with one or more NCDs. The strongest factors predicting non-adherence were multimorbidity (odds ratio 0.49, 95% CI 0.41-0.58) and feelings of depression (0.48, 95% CI 0.32-0.70). Rural living (0.71, 95% CI 0.48-1.05), tobacco use (0.75, CI 0.58-0.97), never having attended school (0.75, 95% CI 0.62-0.92) and feelings of anxiety (0.83, 95% CI 0.67-1.02) were also independent associated with poor adherence. Older age (1.89, 95% CI 1.40-2.55) was associated with improved adherence while there was a weak association between increased wealth and medication use. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and low educational status.

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drug Tariff(1). Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.

Reference

1.            Public Health Scotland, Scottish Drug Tariff,

INTRODUCTION: Frailty assessment in stroke is not commonly integrated into clinical practice, despite current clinical recommendations. Pre-stroke frailty is associated with longer-term mortality, length of admission, and disability. Similarly, anticholinergic burden (ACB) is not routinely reviewed, even though it is associated with cognitive and physical impairment, increased hospital admissions, and higher mortality in older people. Healthcare Improvement Scotland-Frailty (HIS-Frailty) is a novel tool for the evaluation of frailty in older people. Our aim was to compare and correlate the identification and severity of frailty with HIS-Frailty to the Rockwood Clinical Frailty Scale (CFS) in stroke. We also used the ACB Score to determine if there was a difference in ACB between hospital admission and discharge in these patients.

METHODS: We conducted a prospective, observational, single-center study in a stroke unit. Patients with a cerebrovascular diagnosis were included. We compared frailty assessment through linear correlation and ACB through mean difference in scores. Results were considered statistically significant if p-value < 0.05 and highly statistically significant if p-value < 0.005. SPSS® 26.0 was used to perform data analysis.

RESULTS: We included 145 patients. 110 (76%) were older than 60 years and 75 (52%) were male. Most admissions were due to ischemic stroke (67%), closely followed by TIA (14%). Forty-eight (32%) were classified as frail. There was a strong positive correlation between HIS-Frailty and the CFS (r = 0.95; p <0.00001; R2 = 0.91). Seventy-nine (55%) patients had significant ACB. There was no significant difference between ACB at admission and discharge (MD = 0.010, CI 95% -0.52 to 0.54; p = 0.97).

CONCLUSION: HIS-Frailty may prove to be a consistent and easy tool for the systematic identification of frailty in stroke patients, in accordance with best clinical practice guidelines. We should standardise measures to reduce ACB after stroke.

Introduction

Across inpatient HSC settings ward based medicines management pharmacy technicians support ward based multi-disciplinary teams.  The aim of this study was to explore the potential role and impact of a medicines management pharmacy technician and ‘stock solution’ in a Care Home facility.

Method

A 30 bedded private Care Home was identified for the pilot.  A medicines management pharmacy technician liaised with senior nursing staff to review and understand the monthly medication ordering process.  The technician audited the Care Home’s medication destruction records for 4 months and reviewed all the medication documentation i.e. T-MARs, kardexes and MAR charts.  A ‘PRN medication stock solution’ with standard operating procedure (SOP) for use was devised and trialled for 2 months. 

Results

The monthly medication ordering process took a minimum of 12 hours, if no discrepancies/queries.  This process could be completed by a medicines management pharmacy technician. 

From destruction records the combined wastage of medications, controlled drugs and topical medications extrapolated to £11163.66 per year. 

An average of 2.33 discrepancies per resident were identified between kardex and MAR.  87.7% were classed as Eadon grade 4 i.e. intervention is significant and results in an improvement in the standard of care.  The remainder were Eadon graded 3.  An average of 0.2 discrepancies per resident were found between the T-MAR and MAR/Kardex.  These discrepancies were classed as Eadon grade 3 - Intervention is significant but does not lead to an improvement in patient care.

Following stock solution trial nursing staff completed questionnaires.   Questionnaire response rate was 71%.   The majority of responses were positive about the trial.

Conclusion

Use of a Medicine Management pharmacy technician, together with a ‘PRN medication stock solution’, similar to medicines management in a hospital ward would lead to a reduction of waste, cost savings and an improved standard of care.

Introduction
Timely administration of medication for people living with Parkinson’s Disease (PwP) is critical. Missed or delayed Parkinson’s Disease (PD) medication can lead to motor complications, swallow impairment, and in some cases a neuroleptic malignant type syndrome. This can lead to morbidity and mortality and longer hospital stays. Our local policy on the nil by mouth (NBM) guidance for PwP is available on the intranet. We wanted to audit knowledge of, and adherence to this policy.

Method
An audit tool was used to collect responses from nursing and medical staff in the Clyde sector, including Royal Alexandra Hospital, Inverclyde Royal Hospital and Vale of Leven Hospital. Paper copies and QR code linking to the questionnaire were distributed across the wards between November 2022 to January 2023.

Results
A total of 124 responses were obtained, where 84 were prescribers. The responses showed some pre-existing understanding on the NBM policy for PwP, with 77% agreeing that Rotigotine patches should be considered if the oral or enteral feeding route is unavailable. 67% also knew the frequency for Rotigotine patches to be changed. Of the responses, only 52 (50%) have seen the trust’s NBM policy. Prescribers were also asked on how to calculate the dose for Rotigotine patches, 37 (52%) knew of the online calculator or referring to a guideline, with the remaining unsure or leaving the question unanswered. 41 (33%) knew the location of the emergency stock for PD meds.

Conclusion
Our study has shown a gap in the awareness of the NBM trust policy for PwP and highlights the need for more staff education. Educating medical staff at their weekly teaching and signposting them to the local guidance will be a starting point for our intervention. For the wider hospital staff, further training will be provided during PD awareness week.
 

Introduction: Older people in care homes with atrial fibrillation (AF) have complex health needs and would benefit from taking part in research. This study assessed the feasibility of pharmacist implementation of the Atrial Fibrillation Better Care (ABC: Anticoagulation; Better symptoms; Cardiovascular comorbidity management) pathway, and collection of an AF-specific, resident-centred outcome.

Methods: Older residents (aged ≥65 years) with AF were recruited from care homes within Liverpool and Sefton and randomised to receive the pharmacist intervention, or continue their existing treatment. Resident quality of life was assessed using the Atrial Fibrillation Effect on Quality of Life Questionnaire (AFEQT).

Results: Twenty-two care homes were approached about the study, and seven signed up to take part between 28 September 2020 and 29 April 2021. Time taken to recruit care homes ranged from 0 to 122 days. There were 83 residents identified as potentially eligible to take part, but after screening only 28 residents (34%) were invited. Overall, 21 residents were recruited. Eleven residents received the pharmacist intervention and three had ABC recommendations made to their GPs. Two out of four recommendations were implemented. The pharmacist administered the AFEQT questionnaire to 17 residents with capacity and completion rates were 94% and 93% at baseline and six-months, respectively. Residents found the questionnaire difficult; most were unable to distinguish if symptoms were AF-related (n=3), or did not know they had AF (n=8), and questions related to physical activity were not applicable to any of the residents who were bed bound (n=5) or had severely limited mobility (n=12).

Conclusion: There were procedural (encountered before research starts), system (encountered during research) and resident-specific barriers that impacted this study. Barriers need addressing before wider implementation, and AF-specific quality of life measures need to be developed and validated for care home residents. A detailed commentary has been accepted for publication.

Introduction: Vitamin D deficiency remains an important condition affecting our elderly population, with particular relevance to bone health, frailty syndromes and falls risks. We aimed to improve prescribing practices for deficient patients through the implementation of a prescribing tool and order set on our electronic system.

Methods: We retrospectively analysed data from patients admitted to two of our wards in July (pre-introduction of the order set) and November 2021 (post-introduction) respectively, paying particular attention to whether their vitamin D levels were measured as an inpatient, and then focusing on whether replacement was prescribed as an inpatient, on discharge and in the community, from their Greater Manchester GP Care Record.

Results: After review of a total of 266 patient records, following implementation of the prescribing guideline and order set, improvement was seen in prescribing practices in those identified as having low vitamin D on admission. 96% of deficient patients had a form of vitamin D replacement prescribed as an inpatient (compared with 84.4% pre-implementation), and 100% of patients had a form of vitamin D prescribed on discharge from hospital (compared with 90.7%). Despite seeing an improvement in identification of vitamin D deficient patients, a significant proportion of patients did not have their vitamin D level measured on admission.

Conclusion(s): Despite improvement seen in the initial identification of vitamin D deficiency and consistency of prescribing practices, we are failing to measure vitamin D levels on admission in a significant number of patients. Ways in which we can further develop this project include aiming to raise awareness of the importance of measuring vitamin D levels locally, and promoting continued use of the order set and frailty blood set amongst our junior doctors.

Background Polypharmacy is a recognised burden on patients with frailty. Medication reviews as part of comprehensive geriatric assessment (CGA) ensure appropriate prescribing and minimise harms. This project aimed to develop and initiate a pharmacist delivered frailty medication review tool to enhance existing CGA within our acute frailty service. Methods A structured in-patient medication review tool was developed based on the STOPIT and STOPPFRAIL tools for patients with a clinical frailty score (CFS) of >4. Initial work tested this on 20 patients in our frailty ward evaluating usability and efficacy. A sample of patients seen by the acute frailty team were audited against this tool. Data was collected on falls risk medications, Anticholinergic Burden (ACB), medications stopped, medications to review and cost savings. On identifying the potential benefits, this tool was trialled by pharmacists on all elderly care wards with similar outcomes collected. Results. Twelve acute frailty inpatients’ CGAs were audited against the tool. Five had some evidence of a polypharmacy review but no FRAX or ACB scores were completed. 58% of patients were on 3 or more 'falls medications. Overall, 19 medications should have been stopped, 5 medications could have been reduced and 14 medications highlighted for review in primary care, with a potential cost saving of £956.35/year. After initiating pharmacist reviews with the tool, 34 of 34 patients had a review, 80% of FRAX scores were documented, ACB score was completed for all patients. All patients were taking medications that increased risk of falls (average 3.5/patient) with 16 patients on ≥4. Eighty-five medications were stopped, 10 medications reduced and 33 medications highlighted for review in primary care, with a cost saving of £2755.29/year. Conclusions This project developed a pharmacist delivered acute frailty polypharmacy tool which enhanced existing frailty medication reviews with potential cost savings.