Medication review. The Fleetwood Model of pharmaceutical care: what worked, what didn t work and why

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1 Medication review. The Fleetwood Model of pharmaceutical care: what worked, what didn t work and why Carmel M. Hughes School of Pharmacy Queen s University Belfast

2 Outline of talk Overview of issues Development of an intervention Implementation of an intervention What worked, what didn t work and why Next steps

3 Nursing home carebasic facts The waiting room for heaven Emerged from Victorian workhouses Dumping ground for the elderly Vulnerable population Average age is 80 Over 70% are women Tend to be more physically and mentally disabled than those living in their own homes Need help with a range of activities Receive more medication than age-matched patients who live in the community

4 Control Influences on prescribing in care homes Regulation and choice Context Characteristics of a care homes Culture The way we do things around here Collaboration Professions working together

5 Collaboration Pharmacists working with doctors to improve the quality of prescribing beyond the OBRA drugs Reduction in the use of inappropriate medication Tackles undertreatment of medical conditions Seeks to reduce adverse drug events Promotion of evidencebased practice Trial undertaken in N. Carolina and N. Ireland

6 From USA to UK US Fleetwood model developed for the US nursing home arena Relevance to UK? Undertook qualitative work to adapt model for UK use Access to records, access to prescribers and access to nursing home residents Focus on psychoactive medicines Patterson et al., PWS 2007; 29:

7 Fleetwood N.I. Project- Design Cluster randomised controlled trial 12 months duration Focus on psychoactive drugs Anxiolytics, hypnotics, antipsychotics Primary outcomes Change in proportion of residents receiving inappropriate psychoactive drugs Secondary outcomes Change in the number of residents who fall Changes in direct healthcare costs over time Professional satisfaction Patterson et al., JAGS 2010; 58: 44-53

8 Fleetwood N.I. Project- Design cont d 11 matched pairs of nursing homes randomly assigned as intervention or usual care 15 residents per home recruited, total=334 9 prescribing support pharmacists delivered intervention to 11 homes Training provided on intervention and medicines for older people

9 Fleetwood N.I. Project - Intervention Monthly visits by prescribing support pharmacists to homes Algorithm to assess appropriateness of psychoactive drug prescriptions Liaison with GPs and other healthcare professionals Documentation on pharmaceutical care plan Outcomes assessed at 3, 6 and 12 months

10 Data collection for falls Total number of falls recorded in home accident book Falls in year prior to study year Number of falls resulting in need for healthcare intervention Number of falls reported to the regulatory body

11

12 Northern Ireland baseline findings Residents Number of participants Mean age Women Nos. receiving 1-5 meds 6-10 meds 10+ meds Psychoactive drugs Inappropriate psychoactive drugs Intervention 173 (51.8%) 82.5 years 125 (72.2%) 19 (11%) 60 (34.7%) 94 (54.35%) 113 (65.6%) 92 (81.4%) Control 161 (48.2%) 82.7 years 119 (73.9%) 21 (13.%) 66 (41%) 74 (46%) 108 (67%) 79 (72%)

13 Number of interventions Pharmacists recorded interventions in 91.4% cases Total of 396 interventions Mean of 2.8 ± 3.3 interventions per resident Prescriber was contacted >90% of all interventions (n=376) Mean of 2.3 ± 3.5 recommendations per resident 72.4% of pharmacists recommendations accepted by the prescribers Patterson et al., J Appl Ther Res 2010; 7: 91-99

14 Types of interventions undertaken by pharmacists 25% 5% 3% 3% 8% 3% None Indication-Add/Monitor 37% Indication-unnecessary Efficacy-wrongdrug Efficacy-dose low Safety-ADR Safety-dosehigh Adherence 7% 9% Technical

15 Northern Ireland 12 months findings Drug category Intervention Control Inappropriate psychoactive 28/128 (22%) 72/125 (58%) Inappropriate hypnotic/anxiolytic 20/128 (16%) 52/125 (42%) Inappropriate antipsychotic 8/128 (6%) 20/125 (16%)

16 Impact of the intervention After one year the odds of a resident receiving an inappropriate psychoactive drug in an intervention home = 0.26 (95% CI: 0.14, 0.49) compared to a resident in the control group of homes Patterson et al., JAGS 2010; 58: 44-53

17 Other outcomes No differences in rates of falls between intervention and control sites High levels of satisfaction from participating health care professionals Cost-effective (?)

18 Impact on falls Time period Control (Falls per 100 resident months) Intervention (Falls per 100 resident months) P value (t-test at cluster level) Pre-study year Study year Change in falls rate Change (95% CI) Change (95% CI) P value (t-test at cluster level) Study year-prestudy year 1.91 (-1.21, 5.04) 4.91 (0.26, 9.57) 0.25

19 What worked Training of pharmacists Highly committed group Medication review Impact on prescribing Documentation Low-tech Collaboration between professions Professional satisfaction very positive

20 What didn t work Impact of intervention on falls Why? No standard definition Poor data Poor documentation Poor recording Study not powered Medications not the only factor

21 What do we need to think about? Cochrane review Consider conduct and methodology of studies Target multiple risk factors Involve a multidisciplinary team

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