Medicines optimisation: a GP’s perspective Professor Tony Avery PRIMM Conference 23 January 2015 Thank you Peter, and thank you all for coming along this evening. It is a great honour for me to have so many people here this evening who represent different aspects of my life and work and I would like to express my thanks to you all before I start this lecture. I would like to thank my family and friends for all the support you have given me over the years. I would also like to thank all the other people here who have had an impact on my life including teachers from school and University together with GPs, hospital consultants and academics who have inspired me or influenced my career. I would also like to thank staff from the Division of Primary Care and colleagues from the Medical School and wider University. They, together with colleagues in my surgery and local GP and pharmacy community have been incredibly supportive over the years. Finally I am really pleased that we have a number of medical students in the audience this evening. Some of you will be doctors in just a few weeks time and I hope that you learn things from this lecture to help you practise safely. OK One of our guiding principles in medicine is “First do no harm”, and yet everyday patients are harmed by drugs and medical procedures. Sometimes this is simply due to bad luck. Sometimes, however, it is because we make mistakes. This may seem like a terrible admission and yet the fact is that doctors and other healthcare professionals are human and all humans are liable to make mistakes. The challenge, therefore, is to understand why we make mistakes and to find ways of preventing them. This is a challenge that I have taken up in recent years in relation to medication errors in general practice and this evening I would like to tell you what progress we have made.

Plan Introduction to medicines optimisation Where does it go wrong in general practice? What about polypharmacy? Personal view on 4 guiding principles Strategies for improvement This is the plan for the lecture. Firstly I will address the question “Why do we make mistakes?” Here I will draw upon what is known from psychology and human factors research to explain why we are all error prone and what relevance this has to understanding why doctors make mistakes. Secondly I will try to give some idea of the size of the problem presented by medical error by looking broadly at the impact of mistakes that doctors make. I will then move on to focus on medication errors in general practice. I will say a little about the prescribing of medicines in general practice and will then draw upon research that we and others have done to highlight: The scale of medication errors The nature of these errors The underlying causes Possible solutions Finally I will pull all of this together to summarise what I think can done to stop good doctors from making bad mistakes. Before moving on I just want to mention two things The first concerns the title of my lecture which was deliberately headline grabbing. The sorts of mistake I am going to mention in my lecture are generally those that any good doctor could make given the wrong circumstances. Also, in using the term “bad mistakes” I am really talking about the consequences of mistakes in terms of how they affect patients rather than making a value judgement on the nature of the errors that can lead to patient harm. The second thing I wanted to mention was that during the lecture you will see some photographs. These have been taken by Samantha Mason, a local photographer. They show some of the patients that I look after, and all of these people have given their written consent for their photographs to be used for this lecture. [SLIDE] None of the photographs relate directly to any of the examples that I am going to give. The reason for showing the photographs is to try to emphasise that behind all the statistics I am going to present this evening are real people. [SLIDE] As doctors we can have major impact on patients lives by providing them with effective treatments. This means that GPs, for example, can save lives through effective treatment of conditions such as coronary heart disease, hypertension and diabetes. [SLIDE] We also have a heavy responsibility, however, for ensuring that we use medications judiciously so that we avoid harming people. Over the course of the next 55 minutes I hope to show you that there are ways of minimising risks to patients. First I want to start by seeing whether anyone in the audience is prone to making mistakes and to do this I’m going to need some audience participation.

The four guiding principles of medicines optimisation

Where do things go wrong in general practice? GMC PRACtICe study of the prevalence, nature and causes of prescribing errors Preventable drug-related hospital admissions studies Other studies

Aim of the PRACtICe Study To determine the prevalence, nature and causes of prescribing and monitoring errors in general practice.

Quantitative approach Methods Quantitative approach Qualitative approach Retrospective review of unique medication items prescribed over a 12 month period to a 2% sample of patients from 15 general practices across three Primary Care Trusts in England. Descriptive analysis, and multivariable analysis of factors associated with error. Interviews with 34 prescribers regarding 70 potential errors. 15 Root cause analysis of potential prescribing or monitoring errors. 6 Focus groups with Staff in General practice. Data analysed qualitatively.

Characteristics of patients Study involved examination of the records of a random sample of 1,777 patients. Mean age of 39.3 years (standard deviation: 22.7 years). 884 (49.8%) were female. The study patients had a similar age distribution to the English population based on 2010 figures.

Results – Incidence of prescribing and monitoring errors 6,048 unique prescription items were reviewed involving 1,200 (67.5%) patients. The prevalence of prescribing or monitoring errors was 4.9% (95% CI: 4.4%-5.4%). The vast majority of the errors were of mild to moderate severity. 1 in 550 items were associated with a severe error.

Prevalence of prescribing or monitoring errors for different groups of patients (over the 12 month data collection period) Patient Group Prevalence All patients (n=1,777) 12% (95% CI 10.5%-13.6%) Patients who received at least one medication (n=1,200) 17.8% (95% CI 15.7%-20%) Patients who received at least one medication AND aged 75 years and older (n=129) 38% (95% CI 29.5%-46.5%) Patients who received five or more medications (n=471) 30.1% (95% CI 26.6%-35%) Patients who received 10 or more medications (n=172) 47% (95% CI 39%-54%) Prevalence of having one or more prescribing or monitoring errors over the 12 month data collection period

Frequency of different types of prescribing error

Factors associated risk of prescribing or monitoring errors Increased risk: Age Less than 15 years (odds ratio 1.87 (95%CI 1.19-2.94, P=0.006) Greater than 75 years (odds ratio 1.95 (95%CI 1.19-3.19, P=0.008) Number of unique medication items prescribed (odds ratio 1.16, 95%CI 1.12-1.19, P<0.001, for each additional medicines prescribed) Being prescribed preparations in the following therapeutic areas: (cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin) Reduced risk: Practices with a list size of > 10,000 had reduced risk of error (odds ratio: 0.56 (95%CI 0.31-0.99, P=0.047)) Female gender (odds ratio: 0.66, 95%CI 0.48-0.92, P=0 .013)

Causes of potential errors A wide range of underlying causes of error were identified relating to: The prescriber Therapeutic training Drug knowledge and experience Knowledge of the patient Perception of risk Physical and emotional health The patient The team The working environment The task The computer system The primary/secondary care interface ‘The Prescriber’ factors related to the following: therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and physical and emotional health. The Patient - patient characteristics (including personality, literacy issues, and language barrier) and the complexity of the individual case were found to have contributed to prescribing errors. Some particular examples highlighted a tension between the GP’s responsibility to improve or maintain their patient’s health, and their view on the patient's responsibilities for their own health. The Team - poor communication and nurses’ quasi-autonomous role within the team were considered to be two key conditions influencing the occurrence of prescribing errors in general practice. The communication between practice colleagues appeared to vary widely, with some feeling isolated whilst others felt very close and supported by their colleagues. Two important factors may explain these different GPs’ perspectives, including the length of time the GP had been working in the practice and the frequency of formal / informal meetings within the practice. The Working Environment – High workload, time pressures and associated stress were felt to be important factors making error almost inevitable. The failure of appointment systems to cope with patient demand was perceived as a particular source of stress. Distractions and interruptions were common for some GPs and thought to be an important cause of error because of their effects of disrupting prescribers’ thought processes. The Task – We focused on repeat prescribing systems and patient monitoring. Some safety issues were identified in the ordering and processing stage of repeat prescribing, but failure to properly review some patients was probably the most important cause of error. General practices had various systems aimed at ensuring timely blood-test monitoring for patients, but sometimes these broke down. The most important problem identified was in a practice where GPs prescribed warfarin without access to INR results. The computer system – There were many positive comments about the role of clinical computer systems in preventing error, but some problems were highlighted including selecting the wrong drug or wrong dosage instructions from pick lists; overriding important drug-drug interaction alerts; unnecessary/inappropriate alerts; the need to maintain an accurate electronic health record, and staff sometimes expecting too much from the computer system.

Preventable medication-related hospital admissions These account for around 1 in 25 hospital admissions Common causes: Prescribing problems: 31% Adherence problems: 33% Medication monitoring problems: 22% 4 classes of drug account for over 50% of these admissions

Other studies CQC report 2009 raised major concerns about managing patients medicines after discharge from hospital CHUMS: two-thirds of care home patients are exposed to medication errors Numerous studies have shown that clinical computer systems can reduce medication errors, but they can also increase the risks of some types of error

30 November 2013 www.kingsfund.org.uk/publications/ polypharmacy-and-medicines-optimisation

Issues with polypharmacy Polypharmacy is an expression that has been used for many years in medicine; it is generally understood as referring to the concurrent use of multiple medication items in one individual. In the past polypharmacy has been frowned upon and considered something to be avoided. It is now accepted that in many circumstances polypharmacy can be therapeutically beneficial. Polypharmacy may be harmful as it will increase the risk of drug interactions and adverse drug reactions, together with impairing medication adherence and quality-of-life as regimens may be too complex or unacceptable to patients.

Epidemiology of polypharmacy Demographics Increases in multimorbidity with age Comorbidity of common conditions Prevalence of polypharmacy

Estimated and projected age structure of the United Kingdom population, mid-2010 and mid-2035 http://www.ons.gov.uk/ons/dcp171778_235886.pdf

Number of Chronic Disorders by Age Group Barnett K et al Number of Chronic Disorders by Age Group Barnett K et al. Lancet 2012; 380: 37-43.

Comorbidity of 10 common conditions among UK primary care patients Guthrie B et al. BMJ 2012;345:e6341

Prevalence of multiple medicines prescribing in a Scottish primary care population [Payne R, unpublished data]

Personal view on 4 guiding principles Aim to understand the patient’s experience Evidence based choice of medicines Ensure medicine use is as safe as possible Make medicines optimisation part of routine practice

Strategies for improving medicines optimisation Educational initiatives. Clinical Governance. Addressing polypharmacy ICT initiatives. Pharmacist initiatives. Improving safety systems.

Educational initiatives Greater emphasis needed on therapeutics and prescribing skills in GP training and assessment in CPD for GPs We have developed 5 e-learning lessons for RCGP: www.rcgp.org.uk Online Learning environment ‘Prescribing in General Practice Used by >1000 GPs Very well evaluated Improvement in knowledge pre- vs post-course

100 prescriptions project Detailed pharmacist review of prescriptions of GP registrar Production of a report Feedback to registrar and trainer

Clinical governance Conducting audits using prescribing safety indicators and making necessary changes e.g. PINCER trial approach Conducting significant event audits Adhering to medication safety policies e.g. repeat prescribing Reporting adverse prescribing events Yellow Card Scheme National Reporting and Learning System

Addressing polypharmacy Evidence-base for polypharmacy is poor Nevertheless, prescribers are faced with difficult decisions when often all we have to go on is evidence-based guidelines for single conditions In many cases, however, it does seem appropriate to prescribe multiple medications based on existing 'single condition' evidence provided that: Benefits are likely to outweigh harms Patient is willing and able to take the medication Therapeutic cascade is avoided if at all possible There are, however, circumstances where the evidence is not strong enough to justify continued treatment NHS Scotland Polypharmacy Guidance, 2012, is helpful here http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf

NHS Scotland Polypharmacy Guidance Consider what is the outcome being avoided? Consider using NNTs per annum to inform decisions of withdrawal of medication, e.g. NNTs of >50/year for: Statins post MI (to prevent another major coronary event) Statins post stroke (to prevent another stroke) Metformin in overweight diabetic (to prevent MI, diabetes event or death) BP <140 systolic in diabetes (to prevent stroke, diabetes event or death) Alendronate + calcium/vit D to prevent further fracture Consider where NNT>NNH, e.g. Sedative hypnotics in older people with insomnia

ICT initiatives Encourage GP computer systems suppliers to make best use of existing clinical decision support technologies to: Help prescribers give appropriate dosage instructions Provide context-specific dosage guidance taking account of patient factors such as age and renal function Alert the most common and important examples of hazardous prescribing Alert to the need for blood test monitoring for certain high-risk drugs Design systems to help prescribers make the right choices and minimise risk from ePrescribing

Pharmacist Initiatives The PINCER trial approach: Identification of patients at risk through GP computer searches Educational outreach Practical action/support to improve prescribing safety Improving safety systems Reviewing safety of prescribing, e.g. GPs in training Medication review, particularly for complex patients Helping to ensure that GP computer systems provide the best support for safe prescribing, e.g. highlighting formulary items and drugs for specialist use only, ensuring that medication specific order sentences are appropriate

Pharmacist intervention PINCER approach + Simple feedback Pharmacist intervention During this meeting I would like to feed back the results of the searches….. My computer GP practice Base-line Action plan Initial meeting FTP Results + Evidence Data-base So what did the study involve for simple feedback practices? Practices were provided with: Results of Quest Browser searches with individual patients identified Summaries of evidence-base for each of the outcome measures Data sent by FTP using QC software Had up to 12 weeks to address any issues identified by the searches QB searches repeated at 6 months and 12 months post-intervention In addition, letters sent to patients identified at baseline asking for consent to access medical records So what did the study involve for pharmacist intervention practices? Once baseline searches were done, the pharmacist sets up a meeting with the practice. At the meeting the pharmacist: Provided feedback from Quest Browser searches Discussed the information provided with the aim of producing an action plan aimed at addressing any problems identified Over a 12 week period the pharmacists: Checked the records of patients identified by the computer searches and update the practice computer with relevant information Discuss with GPs appropriate actions for patients considered “at risk” Worked with the practice to identify and implement changes to systems within the practice with the aim of preventing future problems FTP 6 & 12 months Actions recorded “Exit” meeting

PINCER resources eLearning materials developed as a result of the PINCER study: http://www.pulse-learning.co.uk/commissioning-modules/commissioning/how-we-reduced-prescribing-errors-with-pharmacists-support Details showing how general practices can download the computer queries used in the PINCER trial: Rodgers S. New PINCER Query Library Tool to support safer prescribing, Prescriber 2013; 24(6): 11-14 (19 March 2013) DOI: 10.1002/psb.1027 http://onlinelibrary.wiley.com/doi/10.1002/psb.1027/pdf Rodgers S. Five steps to reducing prescribing errors using PINCER. Pulse Today 12 February 2013 http://www.pulsetoday.co.uk/your-practice/practice-topics/it/-five-steps-to-reducing-prescribing-errors-using-pincer/20001835.article To download queries go to: http://www.primis.nottingham.ac.uk/index.php/news/hot-news/813

Improving safety systems Review the procedures for: repeat prescribing, medication monitoring, medication reviews and communication at interfaces in health care to help ensure that these are as safe as possible in the context of high workload and multiple competing demands on staff Primary care organisations, general practices, community pharmacies and acute trusts take account of recommendations for managing patients’ medicines after discharge from hospital Review the procedures for minimising interruptions to clinical staff

Summary There is room for improvement with respect to medicines optimisation in general practice, but it is a challenging environment to work in. Strategies for improving medicines optimisation in general practice should focus on: GP training, Continuing professional development for GPs, Clinical governance, Effective use of clinical computer systems, Pharmacist led initiatives, and Improving safety systems within general practices