1. Medication Safety and admissions avoidance: A perspective Steve Williams Consultant Pharmacist in Medicine & Medication Safety Honorary Clinical Lecturer, Manchester Pharmacy School June 2015

2. Outline for Session –How big is the issue? –Is the situation getting better or worse? –Does the NHS take Medication Review seriously enough? –What should we all be doing about it ?

3. How many non elective admissions to English hospitals every year are due to medicines? –Think of a number…..

4. Important academic references –11.2% patients had adverse drug events (ADEs) causing hospital admission (47.6% preventable) –Patient age, time since starting new medicine and total number of medicines independently predictors of admission –Antiplatelets, anticoagulants, diuretics, ACE inhibitors and anti – epileptics major culprits Kongkaew, C., Hann, M., Mandal, J., Williams, SD, Metcalfe, D., Noyce, P. & Ashcroft, D. Risk Factors for Hospital Admissions Associated with Adverse Drug Events. Pharmacotherapy 2013; 33: 827-837

5. Important academic references –6.5% UK hospital patients admitted due to Adverse Drug Reactions (ADRs) (72% preventable) Pirmohamed et al BMJ 2004;329:15-19 –Preventable drug related problems accounted for 3.7% of hospital admissions. Antiplatelets, Diuretics, NSAID’s accounted for 50% of all admissions Howard et al BJCP 2007;63:136-4 –20.8% patients readmitted to hospital due to ADR within 1 year of first admission. Diuretics & Antiplatelets most frequent culprits Davies EC et al BJCP 2010;70:749-55

7. BUT under recognised because under reported ? –International Classification of Disease (ICD) coding from hospital databases are not reliable for identifying ADRs Hohl CM,Karpov A, Reddekopp Let al. ICD-10 codes used to identify adverse drug events in administrative data: a systematic review J Am Med Inform Assoc 2014;21:547–557 –Only 9% of adult patients admitted to a UK hospital with a confirmed medication related harm (ADRs, medication errors, non-adherence) had a related ICD code docume nted. Reynolds M et al. A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients’ medical records. BMC Health Service Research 2014; 14: 257 –Hohl CM,Karpov A, Reddekopp Let al. ICD-10 codes used to identify adverse drug events in administrative data: a systematic review J Am Med Inform Assoc 2014;21:547–557

8. BUT under recognised because under reported ? (2) –31.5% of children admitted to a UK hospital with a confirmed ADR had a related ICD code documented Bellis et al. BMC Pharmacology and Toxicology 2014, 15:72. Clinical coding of prospectively identified paediatric adverse drug reactions – a retrospective review of patient records

9. And the situation is only getting (and will get even) worse

11. Polypharmacy meets Multi-morbidity

12. Does the NHS take Medication Review seriously enough?

13. We have some evidence

14. And there are plenty of tools to help –NICE Medicines Optimisation guidance –Kings Fund, Scottish and Welsh Polypharmacy documents (CPPE focus too 2016) –Seven steps to managing polypharmacy: Specialist pharmacy Services document –Reducing Inappropriate Polypharmacy: The Process of Deprescribing Scott IA et al JAMA Intern Med 2015. doi:10.1001/jamainternmed.2015.0324 –STOPP START Gallagher P et al Int J Clin Pharmacol Thera 2008;46:72-83 –No Tears Using the NO TEARS tool for medication review. T Lewis. BMJ 2004;329:434

15. Does the NHS take Medication Review seriously enough? Can we compare it with a routine Total Knee Replacement (TKR) ?

16. Total Knee Replacement –Preoperatively (50 mins) –Preop assessment clinic (30 minutes Nurse + 20 minutes Doctor) –Tests: ECG, bloods, and MRSA swabs –Consent form –Day of Surgery (150mins) –Anaesthetic pre-op assessment (10 min) –Anaesthesia-spinal or GA (20 min) Anaesthetist plus ODP or nurse –Surgery (90mins) 2 scrub nurses, 2 surgeons,1 anaesthetist, 1 runner

17. Total Knee Replacement (2) –Post operatively –Recovery (60 mins) 1 Anaesthetic nurse –3-4 days on ward, OT and PT twice a day –Post discharge –Continue physiotherapy for several weeks individually in a group depending on the patients needs –Follow up clinic appt with doctor

18. A typical Medication Review? –Play video

19. A typical Medication Review? –1 GP (10 mins)

20. Does the NHS take Medication Review seriously enough? –Fail to plan, plan to fail!

21. So what could the NHS be doing about it ?

22. Thomas J. A multidisciplinary approach to reducing avoidable medication-related harm/hospital admissions. Clinical Leadership Conference 2013. www.learningwales.tv/group_items/view/1354 www.learningwales.tv/group_items/view/1354

24. 2020: NHSE Medicines Optimisation Dashboard to include Medication related admissions per CCG ?

25. –But it is going to need some levers

29. But finally what could YOU be doing about it ?

31. Is balancing the Prescription Equation your key to medication related admissions avoidance? “If we just keep adding, and not subtracting, we just multiply the medication problems”

32. Thanks for listening –Any questions?