1. 1 "Pharmaceutical care in the elderly - the UK experience" Professor Ian Chi Kei Wong Department of Health Public Health Career Scientist The School of Pharmacy University of London

2. 2 United Kingdom Population –England = 49.1 million –Wales 2.9 million –Northern Ireland = 1.7 million –Scotland = 5.1 million

3. 3 National Health Service is a state-funded healthcare delivery model. Traditionally prescribing and dispensing are separate: –Medical practitioners are prescribers –Pharmacists are medication providers

4. 4 Medical and Pharmaceutical Services Primary care medical service provided by General Practice –Also employ other health professionals such practice nurses and practice pharmacists Primary care pharmaceutical services are provided by community (retail) pharmacies

5. 5 Community pharmacy Community pharmacies are not employees of NHS Contractors On average each pharmacy provide 100 hours per week service to the NHS 80% of income is from the NHS Provide a range of services

6. 6 Traditional Service Traditional responsibilities of the pharmacist are: –to prepare and dispense medication for patients

7. 7 Traditional Service Traditional responsibilities of the pharmacist are: –to prepare and dispense medication for patients –to provide advice for patients

8. 8 Evolution Pharmacy has evolved The role of the pharmacist has adapted from product-oriented custodian to service-oriented technologist.

9. 9 New services New services are available such as –Smoking cessation programme –Supervised administration of methadone –Minor ailments scheme –Contraception including emergency hormonal contraceptive services –Anticoagulant Monitoring –Medicines Use Review Pharmacist

10. 10 Pharmaceutical Care Pharmaceutical care has been defined as: "The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life." (Hepler & Strand 1990 and adopted by UKCPA)

11. 11 Medicines Management Medicines management encompasses a range of activities intended to improve the way that medicines are used, both by patients and by the NHS. Medicines management services are processes based on patient need that are used to design, implement, deliver and monitor patient-focused care.

12. 12 Medicines Management For the benefit of this talk Pharmaceutical care model in the US = Medicines management model in the UK

13. 13 Results of four major RCTs in Elderly Clinical medication review trial (Zermansky et al 2001) Medication review trial (Krska et al 2001) HOMER medication review trial (Holland et al 2005) RESPECT Pharmaceutical Care trial (Wong et al unpublished)

14. 14 Basic details of the studies Zermansky et al 2001 (1131 pts) One practice pharmacist see patients mainly at practice Age ≥ 65 ≥ 1 repeat Krska et al 2001 (332 pts) Clinically-trained Pharmacist see patients at home Age ≥ 65 ≥ 4 repeat + ≥ 2 chronic illness Holland et al 2005 (872 pts) Pharmacists with PG training see patients at home Age ≥ 80, discharge after emergency admission Wong et al unpublished (760 pts) Pt’s usual community pharmacist see patients in community pharmacies Age ≥ 75 ≥ 5 repeat

15. 15 Zermansky et al 2001 Leeds in West Yorkshire England

16. 16

17. 17 Zermansky et al 2001 Leeds in West Yorkshire England 581 in intervention cases and 550 controls Practice pharmacist see patients at practice Age ≥ 65 and ≥ 1 repeat Duration of study = 1 year

18. 18 Clinical medication review (CMR) Pharmacist reviewed the patient, the illness, and the drug treatment. Evaluated –appropriateness and efficacy of treatments –progress of the conditions –compliance –actual and potential adverse effects interactions The outcome of the review was a decision about the continuation (or otherwise) of the treatment.

19. 19

20. 20 Results Pharmacist took ~ 20 minutes each review Intervention group more likely to have changes (P = 0.02) Mean number of changes per patient Interventions = 2.2 Control = 1.9

21. 21 % of Patients with “Changes” TypeInterventionControl New Drug46%49% Drug Stopped41%33% Switched drug20%17% Dose changed17%11% Changed to generic11%7% Formulation changed3%2% Frequency changed1%0% Any of the above75%72%

22. 22 Changes in Treatment Between the Start and Finish of Study InterventionControlP value Mean No. of repeat medicines 4.8  5.0 Increased by 0.2 4.6  5.0 Increased by 0.4 0.01 Mean cost over 28 day (£) 29.3  31.1 Increased by 1.80 28.3  34.9 Increased by 6.52 0.001

23. 23 No changes in Number of GP consultations Number of out-patient appointment Number of hospital admission

24. 24 Conclusions A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.

25. 25 Krska et al 2001 Grampian region of Scotland

26. 26 Grampian region

27. 27 Krska et al 2001 Grampian region of Scotland 332 patients Clinically-trained pharmacist saw patients at home Age ≥ 65 ≥ 4 repeat ≥ 2 chronic illness

28. 28 Methods Pharmacists reviewed 332 patients and identified the “Pharmaceutical Care Issues” Information obtained from the practice computer, medical records & interviews. In 168 patients, a pharmaceutical care plan was then drawn up and implemented. The 164 control patients continued to receive normal care. All outcome measures were assessed at baseline and after 3 months.

29. 29 Pharmaceutical Care Issues Resolutions IssuesIntervention % Resolved Control % Resolved P value Potential/suspected ADR 84.3%57.8%<0.0001 Monitoring issues94.6 %78.4<0.0001 Potential ineffective therapy 57.1%24.3<0.0001 Education required80.7%18.4<0.0001 Inappropriate dosage regime 78.3%17.9<0.0001 Page 1 of 3

30. 30 Pharmaceutical Care Issues Resolutions (cont/d.) IssuesIntervention % Resolved Control % Resolved P value Potential / actual compliance 68.930.4<0.0001 Untreated indication 66.727.5<0.0001 Drug with no indication 54.218.8<0.0001 Repeat prescription no longer required 96.45.9<0.0001 Inappropriate duration of therapy 72.129.1<0.0001 Page 2 of 3

31. 31 Pharmaceutical Care Issues Resolutions (cont/d.) IssuesIntervention %Resolved Control % Resolved P value Discrepancy between doses prescribed and used 96.43<0.0001 Potential drug- disease interaction 7.247.10.1302 Others82.359.2<0.05 TOTAL78.839.3 Page 3 of 3

32. 32 Other outcomes No change in medicines cost No change in health–related quality of life No change in hospital clinic attendance Slightly fewer hospital admissions but number was too small to be tested statistically.

33. 33 Conclusion Pharmacist-led medication review has the capacity to identify and resolve pharmaceutical care issues and may have some impact on the use of other health services.

34. 34 Holland et al 2005 Norfolk and Suffolk in England

35. 35 Norfolk and Suffolk

36. 36 Holland et al 2005 Norfolk and Suffolk in England Home based medication review 872 patients Pharmacists with post-graduate qualification and training Saw patients at home Age ≥ 80, discharged after emergency admission

37. 37 Methods Patient's discharge letter was sent to review pharmacists Pharmacists arranged home visits Assessed ability to self medicate & adherence Educated the patient and carer Removed out-of-date drugs Reported possible ADRs or interactions to the General Practitioner and the need for a compliance aid to the local pharmacist.

38. 38 Methods One follow up visit occurred at six to eight weeks after recruitment to reinforce the original advice.

39. 39

40. 40 Results 178 emergency readmissions occurred in the control group 234 in the intervention group The Poisson model indicated a 30% greater rate of readmission in the intervention group Rate ratio = 1.30, (95% CI 1.07 to 1.58, P = 0.009).

41. 41 NoInterventionControl 0235281 111399 23426 3 or more158 TOTAL234178 Number of Emergency Hospital Re-admissions

42. 42 Survival Analysis over 6 months P = 0.14

43. 43 Quality of Life Utility scores EQ-5D decreased in both groups, but the changes were not significantly different between the groups Scores on the visual analogue health scale also fell; the difference of 4.1 (95% CI 0.15 to 8.09) units in favour of the control group (P = 0.042).

44. 44 Other outcomes No change in GP clinic attendance No change in number of prescription items

45. 45 Conclusion Home based medication review for older people recently discharged from hospital increased hospital admissions and worsened patients' quality of life. Patients may have adhered better to their drugs, with a resultant increase in adverse effects. Alternatively, intervention may have provoked better understanding and help seeking behaviour.

46. 46 Wong et al East Yorkshire

47. 47 East Yorkshire

48. 48 Wong et al East Yorkshire 760 patients Patients' usual community pharmacist see patients in community pharmacies Age ≥ 75 ≥ 5 repeat

49. 49 Designs Randomised multiple interrupted time series design in which five Primary Care Trusts implemented Pharmaceutical Care at quarterly intervals and in random order. We followed patients, who also acted as their own controls, for 36 months between recruitment and final visit, including their 12 months in Pharmaceutical Care.

50. 50 Randomised multiple interrupted time series design

51. 51 Pharmaceutical Care Both pharmacists and GPs attended training before starting the intervention. Pharmacists interviewed patients at the community pharmacy and developed a Pharmaceutical Care Plan (PCP). Shared the PCP with the patient’s GP. Undertook monthly medication reviews for one year.

52. 52 UK Medication Appropriateness Index (UK-MAI). Primary outcome was UK-MAI. Anglicised this from the US version. The resulting score depends on the number of drugs being prescribed and the appropriateness of each. As a drug can score between 0 (completely appropriate) and 20 (completely inappropriate), the lower the score the better.

53. 53

54. 54 Other outcomes Pharmaceutical Care has no significant effects on: –Number hospital admission –Number GP clinic consultation –Mortality rate –QoL SF-36

55. 55 RESPECT Conclusion We judge that this lack of evidence stems from our experience that Pharmaceutical Care is difficult to implement in full in a community setting.

56. 56 Summary of all 4 studies Pharmacists are able to identify pharmaceutical care issues and initiate changes However, traditional research instruments are unable to detect positive changes in clinical outcomes

57. 57 To debate Lack of transferability? Lack of effects? Lack of sensitivity? Are we measuring the right things? Anything else?????