"Pharmaceutical care in the elderly - the UK experience"

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

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

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

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

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

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. Basic details of the studies

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

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. 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.

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. % of Patients with “Changes”

22. Changes in Treatment Between the Start and Finish of Study

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

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. Krska et al 2001 • Grampian region of Scotland

26. Grampian region

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. 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. Pharmaceutical Care Issues Resolutions Page 1 of 3

30. Pharmaceutical Care Issues Resolutions (cont/d.) Page 2 of 3

31. Pharmaceutical Care Issues Resolutions (cont/d.) Page 3 of 3

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

35. Norfolk and Suffolk

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

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. Number of Emergency Hospital Re-admissions

42. Survival Analysis over 6 months P = 0.14

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

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. Wong et al • East Yorkshire

47. East Yorkshire

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

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. Randomised multiple interrupted time series design