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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?????