medicines optimisation – a research pharmacist’s perspective dr david alldred senior lecturer in...
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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
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
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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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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