1. Medicines optimisation – a research pharmacist’s perspective Dr David Alldred Senior Lecturer in Pharmacy Practice 23 January 2015Bradford School of Pharmacy1

2. Presentation outline Medicines optimisation Medicines optimisation research for older people Outcome measures Impact Future research 23 January 2015Bradford School of Pharmacy2

3. Medicines optimisation – 4 principles 1.Understanding patient experience 2.Evidence-based choice of medicines 3.Ensuring safe use of medicines 4.Making medicines optimisation routine practice Patient-centred approach central to medicines optimisation Measurement and monitoring Improving patient outcomes 23 January 2015Bradford School of Pharmacy3

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5. Clinical medication review RCT in 661 care home residents Clinical medication review by a single pharmacist Significant reduction in falls RR 0.59 (95% CI 0.49-0.7) More drug changes in intervention group No effect on other outcomes (hospitalisations, mortality) 23 January 2015Bradford School of Pharmacy5

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7. Care Homes’ Use of Medicines Study (CHUMS) Mean age 85, on mean of 8 meds 7 out of 10 residents were exposed to at least one medication error (mean of 1.9 errors/resident) Prescribing errors 8.3% of medicines (39% of residents) Monitoring errors 14.7% of medicines (18% of residents) Dispensing errors 9.8% of medicines (37% of residents) Administration errors 8.4% (22% of residents) Barber et al 2009

8. Sensitivities 121 residents in 31 homes 31 (26%) had ≥1 sensitivity, 48 in total No. of sensitivities recorded: GP35 (73%) Care home records29 (60%) Medicines administration record 3 (6%) Only 2 sensitivities documented on all three records

9. Sensitivities 23 January 2015Bradford School of Pharmacy9

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11. Cochrane summary 8 RCTs 7653 residents in 262 care homes in 6 countries 6 cluster-RCT, 2 patient-RCT Diverse, multifaceted interventions (medication review, case-conferencing, education, clinical decision support) 23 January 2015Bradford School of Pharmacy11

12. Cochrane summary Heterogeneity No evidence of an effect on adverse drug events, hospital admissions and mortality No studies measured quality-of-life Medication-related problems resolved and medication appropriateness improved 23 January 2015Bradford School of Pharmacy12

13. Outcome measures – What? How? When? No. of medicines Interventions Prescribing appropriateness Medication errors Medicine-related problems Adverse drug reactions Hospital admissions GP consultations Falls Adherence Patient experience Biochemical markers Symptom control Cognitive assessment Assessment of ADL Mortality Quality-of-life Cost effectiveness 23 January 2015Bradford School of Pharmacy13

14. Collaboration – Interdisciplinary – Multi-professional – Academics – Patients and carers – Patient and carer organisations – Practitioners

15. Collaboration

16. Impact 23 January 2015Bradford School of Pharmacy16

17. Impact Raised profile Commissioning of local pharmacy-led services Commissioning of other services to improve medicines use in care homes Guidelines (RPS, NICE) Care homes projects CQC 23 January 2015Bradford School of Pharmacy17

18. Medicines safety in care homes

19. NICE Managing Medicines in Care Homes

20. Care Home Independent Pharmacist Prescribing Service (CHIPPS) NIHR programme grant £2m/5y WP1 Literature review and stakeholder consultation (service specification) WP2 Outcome measures WP3 Health economics WP4 IP training package WP5 Feasibility study WP6 Cluster-RCT 23 January 2015Bradford School of Pharmacy20

21. Improving the safety and continuity of medicines management at care transitions (ISCOMAT) WP1 - Mapping and evaluation of the cardiology medicines management transitions pathway WP2 Developing a patient-centred care pathway and communications package WP3 Feasibility Study Work Package 4 Evaluation of intervention effects and cost-effectiveness (cluster-RCT) 23 January 2015Bradford School of Pharmacy21

22. Key points Patient-centred approach Patient-oriented outcomes Multi/inter-disciplinary Collaboration Well-designed, theoretically-based interventions Impact 23 January 2015Bradford School of Pharmacy22

24. Selected references Alldred DP et al 2013. Interventions to optimise prescribing for older people in care homes. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD009095. DOI: 10.1002/14651858.CD009095.pub2. Alldred et al 2011. The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. BMJ Qual Saf DOI: 10.1136/bmjqs.2010.046318 Alldred et al 2010. The recording of drug sensitivities for older people living in care homes. Br J Clin Pharmacol 69:553-557 Barber ND et al 2009. The Care Homes’ Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care 18, pp.341-6. Available at http://qshc.bmj.com/content/18/5/341.abstracthttp://qshc.bmj.com/content/18/5/341.abstract Zermansky AG et al, 2006. Clinical medication review by a pharmacist of elderly people living in care homes - Randomised controlled trial. Age Ageing. 35(6)pp 586-591. 23 January 2015Bradford School of Pharmacy24