1 "pharmaceutical care in the elderly - the uk experience" professor ian chi kei wong...
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"Pharmaceutical care in the elderly - the UK experience"
Professor Ian Chi Kei WongDepartment of Health Public Health Career Scientist
The School of PharmacyUniversity of London
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United Kingdom
• Population– England = 49.1 million– Wales 2.9 million– Northern Ireland = 1.7 million– Scotland = 5.1 million
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• National Health Service is a state-funded healthcare delivery model.
• Traditionally prescribing and dispensing are separate:– Medical practitioners are prescribers – Pharmacists are medication providers
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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
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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
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Traditional Service
• Traditional responsibilities of the pharmacist are:
– to prepare and dispense medication for patients
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Traditional Service
• Traditional responsibilities of the pharmacist are:
– to prepare and dispense medication for patients
– to provide advice for patients
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Evolution
• Pharmacy has evolved
• The role of the pharmacist has adapted from product-oriented custodian to service-oriented technologist.
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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
Pharmacist
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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.
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Medicines Management
• For the benefit of this talk
• Pharmaceutical care model in the US = Medicines management model in the UK
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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 studiesZermansky et al 2001
(1131 pts)
One practice pharmacist see patients mainly at practice
Age ≥ 65
≥ 1 repeat
Krska et al 2001
(332 pts)
Clinically-trained Pharmacist see patients at home
Age ≥ 65
≥ 4 repeat +
≥ 2 chronic illness
Holland et al 2005
(872 pts)
Pharmacists with PG training see patients at home
Age ≥ 80, discharge after emergency admission
Wong et al unpublished
(760 pts)
Pt’s usual community pharmacist see patients in community pharmacies
Age ≥ 75
≥ 5 repeat
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Zermansky et al 2001
• Leeds in West Yorkshire England
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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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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
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% of Patients with “Changes”
Type Intervention Control
New Drug 46% 49%
Drug Stopped 41% 33%
Switched drug 20% 17%
Dose changed 17% 11%
Changed to generic 11% 7%
Formulation changed 3% 2%
Frequency changed 1% 0%
Any of the above 75% 72%
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Changes in Treatment Between the Start and Finish of Study
Intervention Control P value
Mean No. of repeat medicines
4.8 5.0
Increased
by 0.2
4.6 5.0
Increased
by 0.4
0.01
Mean cost over 28 day (£)
29.3 31.1
Increased
by 1.80
28.3 34.9
Increased
by 6.52
0.001
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No changes in
• Number of GP consultations
• Number of out-patient appointment
• Number of hospital admission
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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.
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Krska et al 2001
• Grampian region of Scotland
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Grampianregion
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Krska et al 2001
• Grampian region of Scotland
• 332 patients
• Clinically-trained pharmacist saw patients at home
• Age ≥ 65
• ≥ 4 repeat
• ≥ 2 chronic illness
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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 Intervention % Resolved
Control % Resolved
P value
Potential/suspected ADR
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
Page 1 of 3
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Pharmaceutical Care Issues Resolutions (cont/d.)
Issues Intervention %
Resolved
Control %
Resolved
P value
Potential / actual compliance
68.9 30.4 <0.0001
Untreated indication
66.7 27.5 <0.0001
Drug with no indication
54.2 18.8 <0.0001
Repeat prescription no longer required
96.4 5.9 <0.0001
Inappropriate duration of therapy
72.1 29.1 <0.0001
Page 2 of 3
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Pharmaceutical Care Issues Resolutions (cont/d.)
Issues Intervention %Resolved
Control % Resolved
P value
Discrepancy between doses prescribed and used
96.4 3 <0.0001
Potential drug-disease interaction
7.2 47.1 0.1302
Others 82.3 59.2 <0.05
TOTAL 78.8 39.3
Page 3 of 3
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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.
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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.
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Holland et al 2005
• Norfolk and Suffolk in England
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Norfolk and Suffolk
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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
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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.
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Methods
• One follow up visit occurred at six to eight weeks after recruitment to reinforce the original advice.
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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).
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No Intervention Control
0 235 281
1 113 99
2 34 26
3 or more 15 8
TOTAL 234 178
Number of Emergency Hospital Re-admissions
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Survival Analysis over 6 months
P = 0.14
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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).
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Other outcomes
• No change in GP clinic attendance
• No change in number of prescription items
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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.
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Wong et al
• East Yorkshire
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East Yorkshire
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Wong et al
• East Yorkshire
• 760 patients
• Patients' usual community pharmacist see patients in community pharmacies
• Age ≥ 75
• ≥ 5 repeat
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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.
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Randomised multiple interrupted time series design
Qtr1
Qtr2
Qtr3
Qtr4
Qtr5
Qtr6
Qtr7
Qtr8
Qtr9
Qtr10
Qtr11
Recruit
TrainA
PC PC PC PC Revisit
Recruit
Control
TrainB
PC PC PC PC Revisit
Recruit
Control
Control
TrainC
PC PC PC PC Revisit
Recruit
Control
Control
Control
TrainD
PC PC PC PC Revisit
Recruit
Control
Control
Control
Control
TrainE
PC PC PC PC Revisit
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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.
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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.
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0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Time since recruitment start (Months)
Ave
rag
e M
AI
sco
re
East HullEast RidingWest HullYork and SelbyYorkshire Wolds and Coast
Mean UK-MAI scores
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Other outcomes
• Pharmaceutical Care has no significant effects on:– Number hospital admission– Number GP clinic consultation– Mortality rate– QoL SF-36
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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.
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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
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To debate
• Lack of transferability?
• Lack of effects?
• Lack of sensitivity?
• Are we measuring the right things?
• Anything else?????