Medication Reviews

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Medication Reviews

• Dianne Adams- Chief Pharmacist Richmond
  Twickenham Primary Care Trust

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Richmond Twickenham PCT

• Formed in April 2002 from Teddington Twickenham
  Hamptons (TTH) PCT and Richmond Primary Care
  Group (RPCG)
• 196,000 patients
• 31 GP practices
• 6 Nursing Homes
• Prescribing advice provided by a team of primary
  care pharmacists (1 per 6 practices)

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RT PCT Nursing Homes

• 554 patients in 6 nursing homes
• Royal Star Garter- 168 patients
• Lynde House-72 patients
• Royal Hospital Home for Neurodisability-285
  patients
• 3 other nursing homes with 30 patients

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NSF for Older People

• Some medicines are under-used
• Medicines not taken
• Inequivalence causes wastage
• Changes in medication after discharge
• Poor 2-way communication (primary/secondary)
• Repeat prescribing systems
• Dosage instructions on the label
• Access to surgery or pharmacy can be a problem

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NSF

• Many adverse reactions could be prevented
• Some long-term treatments can be successfully
  withdrawn
• Carers potential contribution and needs are often
  not addressed
• Detailed medication review minimises unnecessary
  costs- for every 1 spent 2 is saved

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Special considerations

• Stroke
• Falls
• Mental health
• Pain control

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Medicines Management Services Collaborative

• NHS Plan July 2000
• Pharmacy in the Future September 2000
• DoH funding
• First wave-26 sites (PCGs PCTs)Autumn 2001
• Second wave-40 sites (PCTs) Spring 2002
• Future waves

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Goals of the MMS

• Identifying addressing unmet pharmaceutical
  need
• Helping patients to get the best from their
  medicines
• Developing innovative medicines management
  approaches with patients needs uppermost-but also
  improving service efficiency and reducing waste
• Providing convenient access to a range of
  medicines management services in different
  environments

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MMS Nursing Home Measure

• The percentage of patients in registered nursing
  homes who have had a documented review of their
  medicines (according to guidelines agreed by the
  PCT) within the last twelve months

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Medication Review

• What is it?
• Whos involved?
• How do we do it?
• PCT guidelines

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SQA requirements

• The practice should be able to demonstrate that
  each patient and their care has been reviewed at
  appropriate intervals and an up to date list of
  repeat or continuing medication and a record of
  current and recent drug treatments (including
  dosages) kept within the patient record. The
  benchmark for achievement is 90

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Targeted medication review

• Polypharmacy
• Post-discharge
• In care homes
• Problems
• Patients over 75
• Following an adverse change in health

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Key problems with repeat medication

• Unnecessary therapy
• Ineffective therapy
• No or inadequate monitoring
• Inappropriate choice of therapy/dosing schedule
• Admitted non-compliance

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Medication Review Checklist other paperwork

• TTH PCT Prescribing incentive scheme 2001-02
  target led to development of the checklist
• Medication review form for use by nursing home
  staff, community pharmacist or practice
  pharmacist, prior to final review by GP

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Medication Review Checklist for Clinicians

• For patients taking 1 or more medicines review
  the following
• at least annually for all patients
• at least every 6 months for patients over 75 on 4
  or more medicines1

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Introduction

• Particular care is needed in relation to the
  prescribing of hypnotics, diuretics, NSAIDS,
  antiparkinsonian medicines, antihypertensives,
  psychotropics, digoxin and warfarin in older
  people. Possible consequences include confusion,
  toxicity, hypotension and falls.
• Is there an untreated indication which may
  require therapy? Bear in mind national guidelines
  e.g. aspirin, ACE inhibitors and osteoporosis.

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Monitoring (ideally done before the consultation

• Any monitoring required? e.g. BP, blood tests2.
• Try to organise blood tests a few weeks before
  review so results are available.

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Active Medicines Management (may be done before
the consultation)

• Does each drug have a documented indication and
  planned length of treatment? (ideally on
  computer)
• Any duplication of medicines? e.g. co-prox and
  paracetamol.
• Any potential interactions?
• Are any medicines being over- or under-used?
• Set computer to flag prescriptions requested too
  early (if poss)
• Is there a more cost-effective alternative?
• Any branded medicines that can be converted to
  generic, or generics that should be prescribed by
  brand name?
• Are all quantities aligned to last the same
  length of time?

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Patient Assessment (must be done in consultation
with the patient)

• Does the patient understand the purpose of each
  medicine and length of treatment?
• Are all medicines still effective/required?
  remove from the repeat list any that arent.
• Does each drug have clear dosage instructions
  that the patient understands?
• Any adverse effects from the medicines? is
  there a more appropriate alternative?
• Any problems with compliance? e.g. if a patient
  has difficulty swallowing tablets, would a
  soluble preparation be more suitable, or a liquid
  form (preferably S/F)
• Is the patient taking any other medicines e.g.
  OTC, herbal, friends/relatives?

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Follow-up

• Record READ code for medication review (8B3S) and
  any relevant information.
• Set a recall date for next review (consider using
  birthday month).
• Re-authorise all repeats to last until review
  date or until next monitoring required.
• Make patient aware of review date.

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Additional Information Required for Review of
Nursing Home Patients

• Does the patient/nurse receive an explanation of
  the purpose of the review and the reason why
  periodic review is important?
• Does the patient/nurse understand the purpose of
  each medicine and length of treatment?
• Are the patients medicines self-medicated,
  self-administered or nurse-administered?
• Are medicines taken/given at the correct time?
  check charts to see if medicine taken/given at
  correct time, if not, why not? e.g. patient
  refusal.

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Contd.

• Is there a system for homes to dispense common
  prn medication to patients from bulk e.g.
  analgesics, laxatives, vitamins etc?
• Do patients have individual dosages for such
  medicines?
• Are patients included or exempted from the supply
  of such medicines by the GP, patient or nurse?
• Do the practice records match the nursing home
  records? if not, amend.

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MEDICATION REVIEW FORM

• Has . experienced any symptoms which
  may be related to the prescribed medication i.e.
  side effects? (Please list them)
• Does the MAR Chart contain any medicines that are
  no longer taken? If Yes, please list the
  medications and the date and reason they were
  discontinued
• Does the MAR Chart contain any medication with
  non-specific dosage instructions e.g. as
  directed. If Yes, please list.
•  

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Contd.

• If is self-medicating, has
• self-medicating assessment been carried out? YES
  / NO
• Has the GP been informed? YES / NO
• If is self-medicating, how do you
  evidence compliance? (please list)
• Does have any difficulty in taking the
  prescribed medication? If Yes, please describe
  any problems below.

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Medication Review in RT PCT

• Data collected since Feb 2002 from one GP
  practice with 69 patients at Lynde House-84
  (58/69 patients) have been reviewed in the last
  12 months (data accuracy to be checked)
• Other practices may have similar results but data
  not yet collected

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Future developments

• To collect data on medication review in all other
  nursing homes in the PCT
• Data handling with respect to documentation
  consistency and accuracy between practice
  nursing home records
• Resolve practicalities of data recording e.g.
  different practice computer systems (read codes)
• Develop a computer template for medication review

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References
Department of Health. Medicines and older people
implementing medicines related aspects of the
National Service Framework for Older People.
London DoH, 2001.     Department of Health.
Pharmacy in the future Implementing the NHS
Plan. A programme for pharmacy in the National
Health Service. London DoH, 2000.     Furniss,
L., S.K.L. Craig and A. Burns. 1998. Medication
use in nursing homes for elderly people.
International Journal of Geriatric
Psychiatry.13433-439.     Furniss, L., A. Burns,
S.K.L. Craig, S. Scobie, J. Cooke and B.
Faragher. 2000. Effects of a pharmacists
medication review in nursing homes. British
Journal of Psychiatry. 176563-567.     Furniss,
L. 2000. Medicines use in nursing homes. Primary
Care Pharmacy 1125-128.     Klepping, G. 2000.
Medication review in elderly care homes. Primary
Care Pharmacy 1 105-108.     Zermansky, A.G.,
D.R. Petty, D.K. Raynor, N. Freemantle, A. Vail
and C.J. Lowe. 2001. Randomised controlled trial
of clinical medication review by a pharmacist of
elderly patients receiving repeat prescriptions
in general practice. British Medical Journal.
3231-5.     Petty, D.R., A.G. Zermansky and D.K.
Raynor. Evidence shows medication reviews by
pharmacists point way forward. The Pharmaceutical
Journal. 267863-864.