Medicines optimisation – a research pharmacist’s

perspective

Dr David AlldredSenior Lecturer in Pharmacy Practice

23 January 2015 Bradford School of Pharmacy1

Presentation outline

• Medicines optimisation• Medicines optimisation research for

older people• Outcome measures• Impact• Future research

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Medicines optimisation – 4 principles

1. Understanding patient experience2. Evidence-based choice of medicines3. Ensuring safe use of medicines4. Making medicines optimisation routine practice

Patient-centred approach central to medicines optimisationMeasurement and monitoringImproving patient outcomes

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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)

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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

Sensitivities• 121 residents in 31 homes

• 31 (26%) had ≥1 sensitivity, 48 in total

• No. of sensitivities recorded:

GP 35 (73%)

Care home records 29 (60%)

Medicines administration record 3 (6%)

• Only 2 sensitivities documented on all three records

Sensitivities

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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)

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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

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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

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Collaboration

– Interdisciplinary– Multi-professional– Academics– Patients and

carers– Patient and carer

organisations– Practitioners

Collaboration

Impact

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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

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Medicines safety in care homes

NICE Managing Medicines in Care Homes

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

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Improving the safety and continuity of medicines management at caretransitions (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)

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Key points

• Patient-centred approach• Patient-oriented outcomes• Multi/inter-disciplinary• Collaboration• Well-designed, theoretically-based

interventions• Impact

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Selected referencesAlldred 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.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.

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