Medicines optimisation: a GP’s perspective

1. Medicines optimisation: a GP’s perspective Professor Tony Avery PRIMM Conference 23 January 2015

2. Plan • Introduction to medicines optimisation • Where does it go wrong in general practice? • What about polypharmacy? • Personal view on 4 guiding principles • Strategies for improvement

4. The four guiding principles of medicines optimisation

5. Where do things go wrong in general practice? • GMC PRACtICe study of the prevalence, nature and causes of prescribing errors • Preventable drug-related hospital admissions studies • Other studies

6. Aim of the PRACtICe Study To determine the prevalence, nature and causes of prescribing and monitoring errors in general practice.

7. Methods Quantitative approach Qualitative approach • Retrospective review of unique medication items prescribed over a 12 month period to a 2% sample of patients from 15 general practices across three Primary Care Trusts in England. • Descriptive analysis, and multivariable analysis of factors associated with error. • Interviews with 34 prescribers regarding 70 potential errors. • 15 Root cause analysis of potential prescribing or monitoring errors. • 6 Focus groups with Staff in General practice. • Data analysed qualitatively.

8. Characteristics of patients • Study involved examination of the records of a random sample of 1,777 patients. • Mean age of 39.3 years (standard deviation: 22.7 years). • 884 (49.8%) were female. • The study patients had a similar age distribution to the English population based on 2010 figures.

9. Results – Incidence of prescribing and monitoring errors • 6,048 unique prescription items were reviewed involving 1,200 (67.5%) patients. • The prevalence of prescribing or monitoring errors was 4.9% (95% CI: 4.4%-5.4%). • The vast majority of the errors were of mild to moderate severity. • 1 in 550 items were associated with a severe error.

10. Prevalence of prescribing or monitoring errors for different groups of patients (over the 12 month data collection period)

11. Frequency of different types of prescribing error

12. Factors associated risk of prescribing or monitoring errors • Increased risk: • Age • Less than 15 years (odds ratio 1.87 (95%CI 1.19-2.94, P=0.006) • Greater than 75 years (odds ratio 1.95 (95%CI 1.19-3.19, P=0.008) • Number of unique medication items prescribed (odds ratio 1.16, 95%CI 1.12-1.19, P<0.001, for each additional medicines prescribed) • Being prescribed preparations in the following therapeutic areas: • (cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin) • Reduced risk: • Practices with a list size of > 10,000 had reduced risk of error (odds ratio: 0.56 (95%CI 0.31-0.99, P=0.047)) • Female gender (odds ratio: 0.66, 95%CI 0.48-0.92, P=0 .013)

13. Causes of potential errors • A wide range of underlying causes of error were identified relating to: • The prescriber • Therapeutic training • Drug knowledge and experience • Knowledge of the patient • Perception of risk • Physical and emotional health • The patient • The team • The working environment • The task • The computer system • The primary/secondary care interface

14. Preventable medication-related hospital admissions • These account for around 1 in 25 hospital admissions • Common causes: • Prescribing problems: 31% • Adherence problems: 33% • Medication monitoring problems: 22% • 4 classes of drug account for over 50% of these admissions

15. Other studies • CQC report 2009 raised major concerns about managing patients medicines after discharge from hospital • CHUMS: two-thirds of care home patients are exposed to medication errors • Numerous studies have shown that clinical computer systems can reduce medication errors, but they can also increase the risks of some types of error

16. 30 November 2013 www.kingsfund.org.uk/publications/ polypharmacy-and-medicines-optimisation

17. Issues with polypharmacy • Polypharmacy is an expression that has been used for many years in medicine; it is generally understood as referring to the concurrent use of multiple medication items in one individual. • In the past polypharmacy has been frowned upon and considered something to be avoided. It is now accepted that in many circumstances polypharmacy can be therapeutically beneficial. • Polypharmacy may be harmful as it will increase the risk of drug interactions and adverse drug reactions, together with impairing medication adherence and quality-of-life as regimens may be too complex or unacceptable to patients.

18. Epidemiology of polypharmacy • Demographics • Increases in multimorbidity with age • Comorbidity of common conditions • Prevalence of polypharmacy

19. Estimated and projected age structure of the United Kingdom population, mid-2010 and mid-2035http://www.ons.gov.uk/ons/dcp171778_235886.pdf

20. Number of Chronic Disorders by Age GroupBarnett K et al. Lancet 2012; 380: 37-43.

21. Comorbidity of 10 common conditions among UK primary care patients Guthrie B et al. BMJ 2012;345:e6341

22. Prevalence of multiple medicines prescribing in a Scottish primary care population [Payne R, unpublished data]

23. Personal view on 4 guiding principles • Aim to understand the patient’s experience • Evidence based choice of medicines • Ensure medicine use is as safe as possible • Make medicines optimisation part of routine practice

24. Strategies for improving medicines optimisation • Educational initiatives. • Clinical Governance. • Addressing polypharmacy • ICT initiatives. • Pharmacist initiatives. • Improving safety systems.

25. Educational initiatives • Greater emphasis needed on therapeutics and prescribing skills • in GP training and assessment • in CPD for GPs • We have developed 5 e-learning lessons for RCGP: • www.rcgp.org.uk • Online Learning environment • ‘Prescribing in General Practice • Used by >1000 GPs • Very well evaluated • Improvement in knowledge pre- vs post-course

32. 100 prescriptions project • Detailed pharmacist review of prescriptions of GP registrar • Production of a report • Feedback to registrar and trainer

33. Clinical governance • Conducting audits using prescribing safety indicators and making necessary changes • e.g. PINCER trial approach • Conducting significant event audits • Adhering to medication safety policies • e.g. repeat prescribing • Reporting adverse prescribing events • Yellow Card Scheme • National Reporting and Learning System

34. Addressing polypharmacy • Evidence-base for polypharmacy is poor • Nevertheless, prescribers are faced with difficult decisions when often all we have to go on is evidence-based guidelines for single conditions • In many cases, however, it does seem appropriate to prescribe multiple medications based on existing 'single condition' evidence provided that: • Benefits are likely to outweigh harms • Patient is willing and able to take the medication • Therapeutic cascade is avoided if at all possible • There are, however, circumstances where the evidence is not strong enough to justify continued treatment • NHS Scotland Polypharmacy Guidance, 2012, is helpful here • http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf

35. NHS Scotland Polypharmacy Guidance • Consider what is the outcome being avoided? • Consider using NNTs per annum to inform decisions of withdrawal of medication, e.g. NNTs of >50/year for: • Statins post MI (to prevent another major coronary event) • Statins post stroke (to prevent another stroke) • Metformin in overweight diabetic (to prevent MI, diabetes event or death) • BP <140 systolic in diabetes (to prevent stroke, diabetes event or death) • Alendronate + calcium/vit D to prevent further fracture • Consider where NNT>NNH, e.g. Sedative hypnotics in older people with insomnia

36. ICT initiatives • Encourage GP computer systems suppliers to make best use of existing clinical decision support technologies to: • Help prescribers give appropriate dosage instructions • Provide context-specific dosage guidance taking account of patient factors such as age and renal function • Alert the most common and important examples of hazardous prescribing • Alert to the need for blood test monitoring for certain high-risk drugs • Design systems to help prescribers make the right choices and minimise risk from ePrescribing

37. Pharmacist Initiatives • The PINCER trial approach: • Identification of patients at risk through GP computer searches • Educational outreach • Practical action/support to improve prescribing safety • Improving safety systems • Reviewing safety of prescribing, e.g. GPs in training • Medication review, particularly for complex patients • Helping to ensure that GP computer systems provide • the best support for safe prescribing, e.g. • highlighting formulary items and drugs for specialist use only, • ensuring that medication specific order sentences are appropriate

38. During this meeting I would like to feed back the results of the searches….. PINCER approach + Pharmacist intervention Simple feedback GP practice My computer 6 & 12 months Base-line Action plan Initial meeting FTP Results + Evidence Data-base FTP Actions recorded “Exit” meeting

39. PINCER resources • eLearning materials developed as a result of the PINCER study: • http://www.pulse-learning.co.uk/commissioning-modules/commissioning/how-we-reduced-prescribing-errors-with-pharmacists-support • Details showing how general practices can download the computer queries used in the PINCER trial: • Rodgers S. New PINCER Query Library Tool to support safer prescribing, Prescriber 2013; 24(6): 11-14 (19 March 2013) DOI: 10.1002/psb.1027 http://onlinelibrary.wiley.com/doi/10.1002/psb.1027/pdf • Rodgers S. Five steps to reducing prescribing errors using PINCER. Pulse Today 12 February 2013 http://www.pulsetoday.co.uk/your-practice/practice-topics/it/-five-steps-to-reducing-prescribing-errors-using-pincer/20001835.article • To download queries go to: • http://www.primis.nottingham.ac.uk/index.php/news/hot-news/813

40. Improving safety systems • Review the procedures for: • repeat prescribing, • medication monitoring, • medication reviews and • communication at interfaces in health care • to help ensure that these are as safe as possible in the context of high workload and multiple competing demands on staff • Primary care organisations, general practices, community pharmacies and acute trusts take account of recommendations for managing patients’ medicines after discharge from hospital • Review the procedures for minimising interruptions to clinical staff

41. Summary • There is room for improvement with respect to medicines optimisation in general practice, but it is a challenging environment to work in. • Strategies for improving medicines optimisation in general practice should focus on: • GP training, • Continuing professional development for GPs, • Clinical governance, • Effective use of clinical computer systems, • Pharmacist led initiatives, and • Improving safety systems within general practices