scottish polypharmacy programme: synthesis of case ... - ific

This presentation is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020)

Scottish Polypharmacy Programme:

Synthesis of case studies, PESTEL and SWOT

Alpana Mair Martin Wilson



The evolution of polypharmacy in Scotland

A history lesson


1980s

Early papers encouraging move from pharmacists as dispensers to pharmacists practice and involvement in prescribing and review

Nuffield Committee of Inquiry Pharmacy. A Report to the National Foundation 1986

The way forward for hospital pharmaceutical services 1988 HC88(54) London and 1988 (GEN) 32 in Scotland

1980s

Prescribing GP and consultant led. Much variability.

Lower prescribing rates


1990s

• Moves to highlight potential positive impact of Pharmacy profession to future healthcare

Strategy for the Future of Pharmacy RPSGB 1995

Clinical pharmacy in the hospital pharmaceutical service: a framework for Practice Scottish Office 1996

From compliance to concordance, achieving shared goals in medicines taking RPS (1997).

Clinical pharmacy practice in primary care: a framework for the provision of community-based NHS Pharmaceutical Services Scottish Office 1999

1990s

• Rise of evidenced based medicine• Cochrane Data Base

• SIGN 1993

• NICE 1999

• Profusion of RCTs driving prescribing

• Primary and Secondary Prevention


2000s

• 2001 Health and social care act amended to allow non medical prescribers inc Pharmacy

• 2007 regulations allow Pharmacist Prescribers

2000s

• Standardisation of prescribing around evidenced based medicine

• QOF 2004


2010 +

• Increase in Pharmacist Prescribers

• Prescription for Excellence 2013• Pharmacist integration to

primary care

2010 +

• 2010 to 2012• Local areas develop

polypharmacy guidelines• Highland, Tayside

• Lothian Poly reviews and ACP

• 2012 1st Edition National Guideline

• 2014/15 Polypharmacyintroduced to QOF

• 2015 2nd Edition• Most downloaded doc on

SIGN website.


Hospital

Intermediate / Care homes

Primary care

Community pharmacy

National

Regional

Pilot

No programme


Key Concepts - Clinical

•Development and reinforcement of structure to drug review / prescribing

•Adult specific goals•Opened the box on ‘Bang for Buck’ on guideline medications•Focus on drug safety.


Game changing concepts

If guideline says Prescribe X drug it is GUIDANCE not INSTRUCTION and not prescribing may well be acceptable (and often desirable) in a range of situations

One size does not fit all.....


Why did you jump off a cliff?

Because the Guideline told me to.


Designed to encourage multidisciplinary practice

• Aim of improving working between• Community Pharmacy• [Prescribing support pharmacists]• Hospital Pharmacy• GP• Hospital Consultants

• Getting these links to work well main way to make progress.


Urgency

“not to put people on drugs they don't need” (GP Senior manager)

Although concerns were not new, the timing was right to do something ”those involved took the opportunity raised from concerns over financial and patient safety concerns to drive the issue forward at a good time for it to be taken up” (Consultant) focus gp


Build powerful coalition: Enlist a Volunteer Army & Remove barriersPolypharmacy national Programme: guidance : consensus 7 steps

GP contract and commitment to practice based pharmacists £16.2M(Scot) + £31M in England


Domain Steps Process

Aims 1. What matters to the patient

Review diagnoses and identify therapeutic objectives with respect to: Identify objectives of drug therapy Management of existing health problems Prevention of future health problems

Need

2. Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice) Drugs that have essential replacement functions (e.g.

thyroxine) Drugs to prevent rapid symptomatic decline (e.g. drugs

for Parkinson’s disease, heart failure)

3. Does the patient take unnecessary drug therapy?

Identify and review the (continued) need for drugs with temporary indications with higher than usual maintenance doses with limited benefit in general for the indication they

are used for with limited benefit in the patient under review (see

Drug efficacy & applicability (NNT) table)

Effectiveness 4.

Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy in order to achieve therapeutic objectives to achieve symptom control to achieve biochemical/clinical targets to prevent disease progression/exacerbation

Safety 5.

Does the patient have ADR or is at risk of ADRs? Does the patient know what to do if they’re ill?

Identify patient safety risks by checking for drug-disease interactions drug-drug interactions (see ADR table) robustness of monitoring mechanisms for high-risk

drugs drug-drug and drug-disease interactions risk of accidental overdosing

Identify adverse drug effects by checking for specific symptoms/laboratory markers (e.g.

hypokalaemia) cumulative adverse drug effects (see ADR table) drugs that may be used to treat ADRs caused by other

drugs Sick Day rule cards

Cost-effectiveness 6.

Is drug therapy cost-effective?

Identify unnecessarily costly drug therapy by

Consider more cost-effective alternatives (but balance against effectiveness, safety, convenience)

Patient centeredness 7.

Is the patient willing and able to take drug therapy as intended?

Identify risks to patient non-adherence by considering

Is the medicine in a form that the patient can take?

Is the dosing schedule convenient?

Is the patient able to take medicines as intended?

Might the patient benefit from the Chronic Medication Service (CMS)?

Is the patient’s pharmacist informed of changes to regimen?

Ensure drug therapy changes are tailored to patient preferences by

Discuss with the patient/carer/welfare proxy therapeutic objectives and treatment priorities

Decide with the patient/carer/welfare proxies what medicines have an effect of sufficient magnitude to consider continuation or discontinuation

Identify objectives-“What Matters to you?”

“Realistic medicine”


VISION:prescribe well:avoidharm

IMS Report “ Advancing responsible use of medicines” & WHO, World Bank Global data set across 186 countries: 4% of total avoidable costs due to polypharmacy.Total of ).3% global health expenditure could be saved = $18bn

For patients receiving 5 meds-30.1%; 47% with 10 or more in 12 months- increases with increase in no

“you need a few visionary leaders who can understand the strategic context in which they're working to come up good ideas and then you need to take it through whatever part of the system it needs to go through, the healthcare provider management group takes the decision” (Board, GP Senior manager)


Risk Stratification :Polypharmacy Guideline 2015.

Prior to the launch of the national guidance, the NHS Lothian pharmacy service was “already engaged with a number of practices in a service level agreement”“Lothian had prescribing advisors in strategic positions who could allocate a very small resource to needy practices who had prescribing medicines management, medicines optimisation issues”

Volunteer Army


Enable by removing barriers-Practice models:

Link with anticipatory care plans

Different models tested in different boards

Barriers were removed to enable action in terms of contractual arrangements. Polypharmacy was linked with other contractual services“we've linked the polypharmacy work in people's minds, whenever possible, with anticipatory care planning and anticipatory care planning for general practice was also born in Highland and these two things happened together” (GP Senior manager)


Generate short term wins & sustain: Economic Case


What has been successful?

Growth in prescribing in % terms.

Items dispensed

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

2010 2011 2012 2013 2014

Scotland

England

Wales

N Ire


Outcome Duration NNT Annualised NNT

Any Diabetesrelated end point

10 years 20 200

Diabetes related death

10 years 91 910

Microvascularcomplication

10 years 36 360

Aiming blood sugar < 6 v < 15[achieved 7% v 8 %]


Sustain Acceleration


Institutionalising change- Creating Adaptive Practice models:

GP contract link with care pathway for

Anticipatory care plans

This presentation is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020)The SIMPATHY project has received funding from the European Union’s Health Programme (2014-2020)

www.simpathy.eu

https://twitter.com/simpathyproject

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