how to reduce hospital admissions due to high risk drugs dr martin duerden [email protected]...
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Which drugs?
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Adverse drug reactions as cause of admission to hospitalPirmohamed M et al. BMJ 2004;329:15-19
• 18,820 patients admitted over six months to a Liverpool Hospital assessed for cause of admission
• Prevalence 6.5%, with ADR directly leading to the admission in 80% of cases – 4% of hospital capacity
• Overall fatality was 0.15% (2% of those admitted with ADR)• Most reactions predictable – 72% were deemed either
definitely or possibly avoidable• Drugs most commonly implicated in causing these
admissions: aspirin and NSAIDs (30%); diuretics (27%); warfarin (10%); ACEIs/ARBs (8%)
• The most common ADR was gastrointestinal bleeding
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Other evidence – drugs and preventable admissionsHoward R, et al. Systematic review, Br J Pharmacol 2007;63:136-147.
4 drug classes:
1. Antiplatelets
2. Diuretics
3. NSAIDs
4. Anticoagulants
50% of drug related admissions
With opioids, beta-blockers, ACEI/ARB, diabetes, digoxin, & corticosteroids
=75% of admissions
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Other evidence – drugs and medication errorsSaedder EA, et al. Systematic Review. Eur J Clin Pharmacol 2014;70:637-645
• 47 % of all serious MEs were caused by 7 drugs or drug classes:
1. Methotrexate
2. Warfarin
3. NSAIDs
4. Digoxin
5. Opioids
6. Aspirin
7. Beta-blockers; • The top ten drugs involved in fatal events accounted for 73 % of all
drugs identified.
“Increasing focus on seven drugs/drug classes can potentially reduce hospitalizations, extended hospitalizations, disability, life-threatening conditions, and death by almost 50 %”
Beware NSAIDs – summary of hazards
• NSAIDs, including coxibs. associated with:• CV adverse outcomes – AMI and stroke• GI adverse events – including GI bleeding• Renal adverse events – including AKI
• Risk of CV adverse events is particularly high with coxibs and diclofenac.
• Low-dose ibuprofen (≤ 1200 mg/day) and naproxen associated with lowest CV risk
• Concomitant use of an NSAID/coxib with either an SSRI, an anticoagulant, an antiplatelet drug or a corticosteroid increases GI bleeding risk.
• Concomitant use of an NSAID/coxib with an ACE inhibitor/ARB/ aliskiren and/or diuretic or increases risk of renal impairment or failure
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Age and hospitalisations associated with NSAIDs
Seager and Hawkey BMJ 2001; 323: 1236-1239
Other drugs that are tolerated poorly in frail patients (www.nhsgrampian.com/grampianfoi/files/PolyPh_538_0912.pdf)
• Antipsychotics, e.g. quetiapine, haloperidol • Tricyclic Antidepressants, e.g. amitriptyline • Benzodiazipines (particularly long acting, e.g.
nitrazepam, diazepam) • Phenothiazines, e.g. prochlorperazine (Stemetil®,
Buccastem®) • Digoxin at a dose of 250mcg + • Opiate containing painkillers, e.g. co-dydramol,
dihydrocodeine, MST® • Anticholinergics and other drugs that increase the
anticholinergic burden
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Which patients?
Which patients are most at risk?• Risk of an ADR resulting in hospital admission is
particularly high in the following groups:
• Elderly and/or frail
• Patients with multimorbidity
• Patients on many drugs – polypharmacy
• Patients with acute medical problems (e.g. AKI)
• Patients with impaired renal function
• Patients with impaired cognition
• Patients with poor dexterity, vision, hearing
• Patients with poor adherence to prescribed medication
• People who have recently been in hospital
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Number of Chronic Disorders by Age GroupBarnett K et al. Lancet 2012; 380: 37-43.
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Potentially serious drug-drug interactions between drugs recommended by clinical guidelines for three index conditions and drugs recommended by each of other 11 other guidelines. Dumbreck et al. BMJ 2015;350:bmj.h949
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Payne et al. Eur J Clin Pharmacol 2014;DOI 10.1007/s00228-013-1639-9
Prevalence of polypharmacy in a Scottishprimary care population.
Polypharmacy – identifying high risk
• A pragmatic approach to identifying higher-risk polypharmacy in practice is to focus on patients at particularly high risk.
• For example:• Those receiving 10 or more regular
medicines, or • Those receiving 4 to 9 regular
medicines together with other unfavourable factors (examples include: a contraindicated drug; where there is potential for drug-drug interaction; or where medicine taking has proved a problem in the past).
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PRACtICe Study – How common are GP prescribing errors over one year? Avery et al, 2012. www.gmc-uk.org/about/research/12996.asp
• Patients who had received at least one medication (n=1,200): 17.8% (95% CI 15.7%-20%)
• Patients aged 75 years and older who had received at least one medication (n=129): 38% (95% CI 29.5%-46.5%)
• Patients who had received five or more drugs over the data collection period (n=471): 30.1% (95% CI 26.6%-35%)
• Patients who had received 10 or more drugs over the data collection period (n=172): 47% (95% CI 39%-54%)
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So what can you do?
Defining medicines optimisationNICE, Medicines Optimisation Guideline NG1, March 2015.
• A person‑centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.
• Medicines optimisation applies to people who may or may not take their medicines effectively.
• Shared decision‑making is an essential part of evidence‑based medicine, seeking to use the best available evidence to guide decisions about the care of the individual patient, taking into account their needs, preferences and values.
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Supporting practices• Reviewing systems – repeat prescriptions, drug
monitoring protocols, response to hazard/warnings• Significant event reviews, audits• Identifying and targeting those:
• on high risk drugs• at risk ((polypharmacy, multimorbidity, frail etc.)• on inappropriate/unsafe drugs
• Post discharge and reconciliation reviews• Support to care homes• Medication reviews – medicines optimisation• Case management• Supporting Unplanned Admission Enhanced Service (or
equivalent)
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Get with the programme• Many GP practices are involved with Reducing Unplanned Admission
Enhanced Service (or equivalent)• Risk stratification – 2% of practice population• Case management - personal care plans• Reviewing and auditing unplanned admission
• Identifying patients:• Previous unplanned admissions particularly if COPD (8%), HF (5%)• 10 or more medicines, particularly if risky medicines• Those requesting frequent home visits• End of life (where admission best avoided)
• Use of IT tools, such as:• PINCER query tool (unsafety indicators), STOPP/START (inappropriate Rx)• SPARRA (Scotland)• QAdmissions and IQ Risk Stratification
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Examples of prescribing (un)safety indicators used in the PINCER trialAvery et al. BJGP 2014;64:259-261
1. Patients with a history of peptic ulcer who have been prescribed an NSAID without co-prescription of a PPI
2. Patients with a history of asthma who have been prescribed a beta-blocker.
3. Patients aged ≥75 years who have been prescribed an ACEI/ARB or a loop diuretic long term who have not had a computer-recorded check of their U&E in the previous 15 months.
4. Patients receiving methotrexate for at least 3 months who have not had a recorded FBC or LFT within the previous 3 months.
5. Patients receiving warfarin for at least 3 months who have not had a recorded check of their INR within the previous 12 weeks.
6. Patients receiving amiodarone for at least 6 months who have not had a thyroid function test within the previous 6 months.
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QAdmissions: predictorsHippisley-Cox J and Coupland C. BMJ Open 2013;3:e003482
• Age, sex, BMI• Ethnicity• Deprivation• Strategic Health Authority• Smoking & alcohol• Lab values
• Abnormal LFTs• Anaemia• Raised platelets
• Medication• Anticoagulants• Antidepressants• antipsychotics• NSAIDs• Steroids
• Prior admissions• Type of Diabetes• CVD, AF, CCF• Chronic renal disease• Venous thrombosis• Cancer• Asthma/COPD• Manic depression or
schizophrenia• Malabsorption• Chronic liver/pancreas disease• Falls
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Measuring your effectiveness
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Pharmacist-led interventions to reduce unplanned admissions for older people: a systematic review and meta-analysis of RCTsThomas R et al. Age Ageing (2014) 43 (2): 174-187.
• 27 RCTs were identified; 7 trials were excluded• The 20 included trials:16 for older people; 4 for older
people with heart failure. • Interventions led by hospital pharmacists (7 trials) or
community pharmacists (9 trials) did not reduce unplanned admissions in the older population (RR 0.97 95% CI: 0.88, 1.07; 1.07 95% CI: 0.96, 1.20).
• 3 trials in older people with heart failure showed that hospital pharmacist interventions reduced the RR of admissions.
• These trials were heterogeneous in intensity and duration of follow-up. One trial had a high risk of bias.
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Measuring your impact• Therefore there is insufficient evidence to demonstrate
reduced admissions from pharmacist interventions, but…• There is evidence that optimising medicines use by
pharmacists reduces prescribing errors, and reduces harmful ADRs (e.g. PINCER study).
• Some evidence that medication review/optimisation improves quality of life (and reduces waste)
• The likelihood is that doing this where risk is high reduces admissions
• Important to keep a record of interventions that have improved safety – particularly involving the drugs most closely associated with unplanned admissions
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Conclusions• Antiplatelets, diuretics, NSAIDs, anticoagulants (+NOACs?)
represent high risk drugs and increase the chances of unplanned admissions due to ADRs
• Methotrexate (DMARDs), opioids, digoxin, ACEIs/ARBs are also risky
• Multimorbidity and polypharmacy compound these risks• Frail, older people on these drugs will be at even greater risk• Primary care pharmacists and technicians can do much to
mitigate these risks through focusing on them, improving prescribing systems and safety, and via medication reviews
• It is highly likely that this work will help reduce unplanned admission
• Reducing unplanned admissions is a high priority and a ‘hot topic’ in the NHS