1. Medicines Optimisation
Jane Portlock
Professor of Pharmacy Education
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2. What is medicines optimisation?
The changes in terminology over the last 30 years
Pharmaceutical care 1980s
Medicines Management 1990s
Medicines Optimisation 2000 onwards
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3. Activities under the heading of medicines optimisation
Clinical checking – already covered in dispensing, law and practice
Clinical medication review*
Medicines Use Review (MUR)*
New Medicines Service (NMS)*
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4. Clinical Medication Review
A definition of clinical medication review is “a structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste”. (Room for Review, 2002)
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5. Clinical Medication Review
Principles of Clinical Medication Review
· All patients should have a chance to raise questions and highlight problems about their medicines.
· The medication review seeks to improve or optimise impact of treatment for an individual patient.
· The review is undertaken in a systematic and comprehensive way, by a competent person.
· Any changes resulting from the review are agreed with the patient.
· The review is documented in the patient’s notes/PMR
· The impact of any change is monitored.
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6. Clinical Medication Review
Ensure patients are on optimum therapy by reviewing and making recommendations to improve therapy to the prescriber: • effectiveness of treatment; • appropriateness of treatment based on latest evidence; • adverse drug effects; • test results, interpreting them and acting on them where required; and • whether the recommendations of previous reviews have been acted upon; • recommend new treatments, e.g. aspirin or statins in CHD patients; and • if the pharmacist is a prescriber they would be able to make changes to the patient’s treatment as agreed with the doctor
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7. Clinical Medication Review
Improve patient adherence with therapy by: • providing an opportunity for the patient to discuss concerns and ask questions about their medicines; • improving the patient’s understanding of their medicines; • simplifying the medication regimen and drug ordering process where appropriate; • identifying practical problems in medicine taking and referring the patient for assessment of support required if necessary; • providing advice and support to the patient and carer, including referral to specialist centres or other health and social care professionals where appropriate; and • ensuring that there is active participation of the patient, with shared decision making and agreement about any changes.
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8. Clinical Medication Review
Patients at risk of medicines-related problems
· taking four or more medicines every day
· on a complex medication regimen or more than 12 doses in a day
· recently discharged from hospital
· recently transferred to care home
· frequent hospital admissions
· with multiple diseases
· receiving medicines from more than one source e.g. specialist and GP
· significant changes to the medication regimen in the past 3 months or more than 4 changes in medication in the past 12 months
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9. Clinical Medication Review
· Patients at risk of medicines-related problems continued
- Patients taking higher risk medicines - those requiring special monitoring e.g. lithium; those with a wide range of side effects e.g. NSAIDs; or a narrow therapeutic range e.g. digoxin; or on drugs not commonly used in primary care
· symptoms suggestive of an adverse drug reaction
· longstanding use of psychotropic medication
· where non-adherence is suspected or known
· high incidence of self medication
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10. Clinical Medication Review - patients with potential higher level of needs
·older people · residents in care homes · learning difficulties · sensory impairment e.g. sight or hearing · physical problems e.g. arthritis, swallowing difficulties · mental states such as confusion, depression, anxiety, serious mental illness · communication difficulties · literacy or language difficulties · minority ethnic groups · refugees and asylum seekers · living alone or poor carer support · recent falls
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11. Clinical Medication Review
J Clin Pharmacol Ther Feb;46(2): STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
Abstract
OBJECTIVE:
Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment).
METHODS:
A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets.
RESULTS:
STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START.
CONCLUSION:
STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses.
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12. STOPP and START review STOPP See E: Musculoskeletal system
When is it inadvisable to prescribe a NON STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) in an older person and why?
See A: Cardiovascular system
What are the consensus recommendations for the prescribing of ASPIRIN in an older person and why?
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13. STOPP and START review START See A: Cardiovascular system
Which medicines should be considered for people over 65 years of age and why?
See E: Musculoskeletal system
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14. Medicines Use Review Medicines Use Reviews (MURs)
A “concordance” based review between patients and an
accredited pharmacist
Establishes picture of use of medicines
Chance to identify
Poor/ineffective use of medicines (Rx and OTC)
Side effects
Interactions
Potential cost savings
Lifestyle interventions
‘MEDICINES CHECK-UP’
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15. Medicines Use Review NOT a clinical review No access to patient notes
Not a full discussion of conditions
Chance to improve
Patient care
Patients’ experience of taking medicines
Relationships with GPs
Job satisfaction
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16. MUR – an example Mrs Ida Bray
Spend 5 minutes reading the patient details and
prescribing history section of your handout:
Current prescription
Patient Medication Record
Repeat prescription
Consider
Likely conditions
What are the main issues you would like to ask the patient about for each drug.
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17. MUR Case study
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18. Consent and patient details
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19. Patient information
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20. MUR procedure
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21. Aspirin issues
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22. Ferrous sulphate issues
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23. Furosemide issues
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24. Istin issues
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25. Co-codamol issues
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26. Summary of conversation on MUR form
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27. Other questions to ask
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28. What recommendations could be made?
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29. What recommendations could be made?
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30. Recommendations on last page of MUR form – go to GP
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31. The final stages
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32. By the way……
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33. MURs in 2012
At least 50% of all MURs undertaken in a year (01 April – 31 March) must be on patients who fall within one of the national target groups. There are three national target groups which are:
Patients taking high risk medicines
High risk medicines are those listed in the following British National Formulary (BNF) sections:-
NSAIDs
Anticoagulants (including low molecular weight heparin)
Antiplatelets
Diuretics
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34. MURs in 2012 Patients recently discharged from hospital
This group covers patients recently discharged from hospital who had changes made to their medicines while they were in hospital. Ideally patients discharged from hospital will receive an MUR within four weeks of discharge but it is recognised that this might not always be practical so the MUR can take place up to eight weeks after discharge. A registered pharmacist should use their professional judgement to determine where a patient will benefit from such an MUR more than four weeks after discharge from hospital.
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35. MURs in 2012 Patients prescribed certain respiratory medicines
This group covers patients taking a respiratory medicine included in the following BNF subsections:
Adrenoceptor agonists
Antimuscarinic bronchodilators
Theophylline
Compound bronchodilator preparations
Corticosteroids
Cromoglicate and related therapy, leukotriene receptor antagonists and phosphodiesterase type-4 inhibitors
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36. New Medicines Service (NMS)
Four conditions/therapy areas were selected to be included in the initial rollout of the NMS. These are:
asthma and COPD
type 2 diabetes
antiplatelet/anticoagulant therapy
Hypertension
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37. Make sure you read the service spec before providing NMS!
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38. NMS intervention
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39. NMS intervention
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40. NMS follow-up
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41. NMS follow-up
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42. Evaluation of NMS
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