Medicines Use Services

1. Medicines Use Services E. Karen Rosenbloom BSc(Pharm) MSc PhD Senior Research Fellow, King’s College London Clinical Effectiveness Lead Hertfordshire LPC

2. I don't have any problems with side effects, but I wouldn't know if they were side effects. (female, 87)

3. Background • Between 33 and 50% of medicines prescribed for long-term conditions may not be taken as recommended • Adherence is the extent to which the patient’s actions match agreed recommendations • Addressing non‑adherence is not about getting patients to take more medicines • Non-adherence represents a limitation of the delivery of healthcare

4. Medicines adherence Implementing NICE guidance 2009 NICE clinical guideline 76

6. Interventions • Haynes (2008)Cochrane Systematic review “these complex strategies for improving adherence with long-term medication prescriptions are not very effective despite the amount of effort and resources they consume” (p.19)

7. How can we evaluate? • Local issues • Patient perspective • Patient Reported Outcome Measures (PROMs) measure quality from the patient perspective.

8. Evaluation: costs and savings • The guideline on medicines adherence is unlikely to result in a significant change in resource use in the NHS • Implementation may result in a future reduction in hospital admissions resulting from patients not taking medicines as prescribed

9. Increase patient involvement • Help patients make decisions based on likely benefits and risks rather than misconceptions • Accept that patients: • may have different views from healthcare professionals about risks, benefits and side effects • have the right to decide not to take a medicine if they have the capacity to, and have the information to make an informed decision • If the patient decides not to take a medicine and you think this could be harmful, record the decision and the information you provided on risks and benefits

10. Visual Rx creates smiley face plots to visually communicate the risks and benefits of treatments. A recent patient information guide associated with NICE guidance- lipid modification “People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: presents individualised risk and benefit scenarios presents the absolute risk of events numerically uses appropriate diagrams and text.”

11. Contractor support • What is available? • What support can the LPC offer? • Who should be offered support? • Pharmacists • Technicians • Counter staff • Complete the LPC questionnaire and give us your views!

12. People at moderate risk of CV events (20% over 10 years) However, if those same 100 people each take a statin for 10 years: • About 5 people will be ‘saved’ from having a CV event by taking a statin • About 80 people will not have a CV event–but would not have done even if they had not taken a statin. • About 15 people will still have a CV event, even though they take a statin.

13. But remember • It is impossible to know for sure what will happen to each individual person. • All 100 people will have to take the statin for 10 years.

14. Imagine 1000 people with chronic asthma. If none of these people use an ICS, about 390 of them will experience an episode of worsening asthma over 12–16 weeks, and 610 people will not.

15. If those same 1000 people each inhale beclometasone (BDP) ≤400 microg/day for 12–16 weeks: • About 199 people will be ‘saved’ from having worsening asthma • About 610 people will not have worsening asthma — but would not have done even if they had not taken BDP ≤400 microg/day • About 191 people will still have worsening asthma, even though they take BDP 400 microg/day.

16. It is impossible to know for sure what will happen to each individual person. • Every person has to use the ICS inhaler at the specified dose for the full 12–16 weeks.

18. Summary of results • Physicians identified as the preferred healthcare professional who should counsel patients about: • Directions for taking continued medication • Dose • Follow up and medication monitoring • Onset of medication effects • Prior experience with medication

19. Pharmacists identified as the preferred healthcare professional who should counsel patients about: • Medication name • What if extra medication is taken

21. Significant differences between groups

22. Research • MUR evaluation (2010) 1000 forms distributed in Trafford and 2400 distributed by Hertfordshire • Response • 126 Trafford • 264 Hertfordshire.

23. Results • 60% did not feel that they needed help with their medicines when they were offered the MUR

24. Results cont • What they actually learnt • why they needed their medicines (27%) • how to take their medicines (31%) • when to take their medicines (32%) before the MUR only 53% of patients perceived that they already knew about all three issues

25. Results • 94% felt that they benefitted from the service and 95% would use the service again • 98% the advice given to them was useful • 95% would use the service again • 99% got to talk about what they were worried about

26. Multi –disciplinary audit (2009) • GPs 25 of 111(22.5%) • Community pharmacies 149 of 239 (61%)

27. Key findings (2007/8) • Patient clinical records in GP surgeries were not up to date due to a failure in the local communications pathways • GPs had a reduced awareness of patients’ INR values if they were managed in secondary care based anticoagulant clinics. • Community pharmacists were not advised of patients' INR values.

28. Typical errors 2007/8 • Patients’ clinical conditions did not require warfarin treatment • Patients had INR ranges higher than the stated guidelines • Patients were on the wrong duration of treatment for warfarin. • Patients were indicated to be on warfarin for life when they should only use warfarin for three to six months.

29. W- MUR evaluation Pharmacists knew: patients’ INR therapeutic ranges • 2007/8: 34.5% 2009/10: 69.7% patients duration of treatment  2007/8: 13.5% 2009/10: 81.1% pharmacists failed to record any INR values  2007/8: 79.0% 2009/10: 35.7%

30. Safety issues Warfarin prescribed as the number of tablets  2007/8: 50.0% 2009/10: 24.3% Warfarin prescribed as Marevan™  2007/8: 10.0% 2009/10: 3.0%

31. Patients’ views • I had very little information before on what actually affected my Warfarin INR. Now I have a full list of items, which I will take in moderation (i.e. greens). • Explaining always to keep a weeks supply of Warfarin, and that if necessary can always get some in emergency on producing yellow card.

32. The hypothesised relationship between understanding, memory, satisfaction and compliance. Ley Communicating with Patients 1988 Understanding Satisfaction Compliance Memory

33. Health Threat Symptom Medical diagnosis Illness representation What is it? What caused it? How long will it last? EMOTIONAL REACTION change change ACTION PLAN e.g. taking medicine APPRAISAL Has it worked

34. Access support material! http://www.nntonline.net/visualrx/examples/ http://www.npc.nhs.uk/publications_resources.php http://www.nntonline.net/ebm/topics/evidence_and_practice.asp