Download "Pharmaceutical care in the elderly

"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
1
United Kingdom
• Population
– England = 49.1 million
– Wales 2.9 million
– Northern Ireland = 1.7 million
– Scotland = 5.1 million
2
• National Health Service is a state-funded
healthcare delivery model.
• Traditionally prescribing and dispensing
are separate:
– Medical practitioners are prescribers
– Pharmacists are medication providers
3
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
4
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
5
Traditional Service
• Traditional responsibilities
of the pharmacist are:
– to prepare and dispense
medication for patients
6
Traditional Service
• Traditional responsibilities
of the pharmacist are:
– to prepare and dispense
medication for patients
– to provide advice for
patients
7
Evolution
• Pharmacy has evolved
• The role of the pharmacist has adapted
from product-oriented custodian to
service-oriented technologist.
8
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
9
Pharmacist
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)
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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.
11
Medicines Management
• For the benefit of this talk
• Pharmaceutical care model in the US =
Medicines management model in the UK
12
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)
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Basic details of the studies
Zermansky
et al 2001
(1131 pts)
Krska et al
2001
(332 pts)
One practice pharmacist
see patients mainly at
practice
Age ≥ 65
≥ 1 repeat
Clinically-trained
Pharmacist see patients
at home
Age ≥ 65
≥ 4 repeat +
≥ 2 chronic illness
Holland et al Pharmacists with PG
2005
training see patients at
home
(872 pts)
Wong et al
unpublished
(760 pts)
Pt’s usual community
pharmacist see patients
in community
pharmacies
Age ≥ 80,
discharge after
emergency
admission
Age ≥ 75
≥ 5 repeat
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Zermansky et al 2001
• Leeds in West Yorkshire England
15
16
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
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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.
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19
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
20
% of Patients with “Changes”
Type
Intervention
Control
New Drug
Drug Stopped
Switched drug
Dose changed
Changed to generic
Formulation changed
Frequency changed
Any of the above
46%
41%
20%
17%
11%
3%
1%
75%
49%
33%
17%
11%
7%
2%
0%
72%
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Changes in Treatment Between the
Start and Finish of Study
Intervention
Mean No. 4.8  5.0
of repeat Increased
medicines by 0.2
Control
4.6  5.0
Increased
by 0.4
P value
0.01
Mean cost 29.3  31.1 28.3  34.9
over 28
Increased
Increased
0.001
day (£)
by 1.80
by 6.52
22
No changes in
• Number of GP consultations
• Number of out-patient appointment
• Number of hospital admission
23
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.
24
Krska et al 2001
• Grampian region of Scotland
25
Grampian
region
26
Krska et al 2001
• Grampian region of Scotland
• 332 patients
• Clinically-trained pharmacist saw patients
at home
• Age ≥ 65
• ≥ 4 repeat
• ≥ 2 chronic illness
27
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.
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Pharmaceutical Care Issues
Resolutions
Issues
Potential/suspected
ADR
Intervention
Control
P value
% Resolved % Resolved
84.3%
57.8%
<0.0001
Monitoring issues
94.6 %
78.4
<0.0001
Potential ineffective
therapy
57.1%
24.3
<0.0001
Education required
80.7%
18.4
<0.0001
Inappropriate dosage
regime
78.3%
17.9
<0.0001
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Page 1 of 3
Pharmaceutical Care Issues
Resolutions (cont/d.)
Issues
Potential / actual
compliance
Untreated
indication
Drug with no
indication
Repeat prescription
no longer required
Inappropriate
duration of therapy
Intervention Control
P value
%
%
Resolved Resolved
68.9
30.4
<0.0001
66.7
27.5
<0.0001
54.2
18.8
<0.0001
96.4
5.9
<0.0001
72.1
29.1
<0.0001
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Page 2 of 3
Pharmaceutical Care Issues
Resolutions (cont/d.)
Issues
Discrepancy
between doses
prescribed and
used
Potential drugdisease
interaction
Others
TOTAL
Intervention Control % P value
%Resolved Resolved
96.4
3
<0.0001
7.2
47.1
0.1302
82.3
59.2
<0.05
78.8
39.3
31
Page 3 of 3
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.
32
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.
33
Holland et al 2005
• Norfolk and Suffolk in England
34
Norfolk and
Suffolk
35
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
36
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.
37
Methods
• One follow up visit occurred at six to eight
weeks after recruitment to reinforce the
original advice.
38
39
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).
40
Number of Emergency Hospital
Re-admissions
No
Intervention
Control
0
235
281
1
113
99
2
34
26
3 or more
15
8
TOTAL
234
178
41
Survival Analysis over 6 months
P = 0.14
42
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).
43
Other outcomes
• No change in GP clinic attendance
• No change in number of prescription items
44
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.
45
Wong et al
• East Yorkshire
46
East
Yorkshire
47
Wong et al
• East Yorkshire
• 760 patients
• Patients' usual community pharmacist see
patients in community pharmacies
• Age ≥ 75
• ≥ 5 repeat
48
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.
49
Randomised multiple interrupted
time series design
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
Qtr
1
2
3
4
5
6
7
8
9
10
11
Rec Train PC PC PC PC
ruit
A
Rec Con Train PC PC PC
ruit trol
B
Rec Con Con Train PC PC
ruit trol trol
C
Rec Con Con Con Train PC
ruit trol trol trol
D
Rec Con Con Con Con Train
ruit trol trol trol trol
E
PC
PC
PC
PC
PC
PC
PC
PC
PC
PC
Re
visit
Re
visit
Re
visit
Re
visit
Re
visit
50
Pharmaceutical Care
• Both pharmacists and GPs attended
training before starting the intervention.
• Pharmacists interviewed patients at the
community pharmacy and developed a
Pharmaceutical Care Plan (PCP).
• Shared the PCP with the patient’s GP.
• Undertook monthly medication reviews for
one year.
51
UK Medication Appropriateness
Index (UK-MAI).
• Primary outcome was UK-MAI.
• Anglicised this from the US version.
• The resulting score depends on the
number of drugs being prescribed and the
appropriateness of each.
• As a drug can score between 0
(completely appropriate) and 20
(completely inappropriate), the lower the
score the better.
52
Mean UK-MAI scores
4.5
4
Average MAI score
3.5
3
2.5
2
1.5
East Hull
East Riding
West Hull
York and Selby
Yorkshire Wolds and Coast
1
0.5
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
Time since recruitment start (Months)
28
30
32
34
36
53
Other outcomes
• Pharmaceutical Care has no significant
effects on:
– Number hospital admission
– Number GP clinic consultation
– Mortality rate
– QoL SF-36
54
RESPECT Conclusion
• We judge that this lack of evidence stems
from our experience that Pharmaceutical
Care is difficult to implement in full in a
community setting.
55
Summary of all 4 studies
• Pharmacists are able to identify
pharmaceutical care issues and initiate
changes
• However, traditional research instruments
are unable to detect positive changes in
clinical outcomes
56
To debate
•
•
•
•
•
Lack of transferability?
Lack of effects?
Lack of sensitivity?
Are we measuring the right things?
Anything else?????
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