N P S National Prescribing Service Limited No. 7 February 2000 Prescribing Practice Review In this issue we include information to assist you to conduct a formal medication review with your patients. As GPs we informally review a patients medication every time a prescription is written. The Enhanced Primary Care new MBS items offer opportunities to conduct a formal medication review The review is part of a Health Assessment, Care Plan or Case Conference in addition to long consultations in the surgery or home. A medication review will be annual where it is part of the Health Assessment or DVA Health Assessment, however should be done at any time that it is clinically indicated. Medication review is a formalised and comprehensive review process The aim is to optimise the therapeutic management of your patients by assessing any need for changes in medications and ensuring the patient s understanding of the medication regimen. Provide reviews for patients at risk Medication misadventure is a common cause of morbidity and at times mortality. Suggested triggers for medication review are provided inside. Ask the patient about all medications and provide counselling on use Evidence shows we often are not aware of all the medications the patient is taking 1 especially over-the-counter and complementary medicines.the review involves a complete medication history with the patient and provision of education about wise use of medicines. Please find enclosed PPR issue no. 7, a medication review form and a sample leaflet to copy and give to patients explaining the purpose of the exercise and asking the them to bring all the medications to the medication review appointment. Yours sincerely Dr Stephen Phillips Chair, NPS Board Supporting quality prescribing in Australia National Prescribing Service Limited ACN 082 034 393 l 9 Leichhardt St Darlinghurst NSW 2010 Phone: 02 9332 3944 l Fax: 02 9332 3955
NP SPPR National Prescribing Service Ltd No. 7 February 2000 Prescribing Practice Review What is a medication review? You probably review each patient s medication every time you write a new prescription. In this PPR medication review is used to refer to a retrospective critical review of all prescribed, over-thecounter and complementary (herbal) medications. It is undertaken to optimise therapy and minimise medication related problems. A medication review may be undertaken in the surgery or home. Desirable frequency will vary from patient-to-patient. For example: for elderly patients and/or those with chronic but stable illness, an annual review may be appropriate; for patients with unstable disease, review at critical times such as on discharge from hospital. Medication reviews are widely carried out by: GP s and accredited pharmacists working together as a primary health care team; by GP s, accredited pharmacists and nurses in institutional settings; and by clinical pharmacists, medical specialists and nurses in a hospital setting. Reviews may be undertaken by the GP alone, using drug information resources however, it is often more valuable to involve an accredited, clinical or appropriate community pharmacist, medical specialist or community nurse. Medication review may be conducted as part of the new Medicare Benefit items. 1. Health Assessment Items 700-706 Health assessment for the elderly in the surgery or patient s home, for patients aged 75 years and over (or 55 years and older for Aboriginal and Torres Strait Islander people). Must include a medication review. 2. Care Plans Items 720-728 For patients with chronic illness and multidisciplinary care needs involving 2 health care providers. Includes discharge care plans from hospital.the patient must agree to the management goals. 3. Case Conferencing Items 740-773 Case conferencing with other providers in planning care for people with chronic conditions and multidisciplinary care needs. Includes discharge case conferencing from hospital. 4. Other As part of a long consultation or home visit where clinically appropriate.as part of a DVA Health Assessment.
Medication review Who should have a medication review? The triggers in the table below identify patients who may benefit from a comprehensive medication review and show how they can be used within the framework of the new MBS items. Triggers for medication review Health Care Case Long cons./ assessment plan conference home visit Annual Health Assessment or medicine check New patient to your practice Polypharmacy -patient using 5 medications or 12 daily doses Patient using psychoactive medications Patient with 3 co-existing disease states Elderly people with cognitive impairment, living alone Patient with compliance/concordance problems Patient with a complicated medication regimen - especially if taking drugs with high risk of adverse effects or which require therapeutic monitoring e.g. amiodarone, warfarin Post hospital discharge - especially if medication has changed Multiple prescribers including specialists and/or other GPs Recently initiated medications or 4 changes to medication regimen in last year Adverse event e.g. recent fall, allergy Patient has unexpected response to medication Change in health status In response to a clinical audit In response to a computer alert In response to abnormal laboratory/ clinical chemistry results Quick checklist for medication review Gain consent and cooperation of the patient, explain what you hope to achieve Allocate a specific appointment and allow sufficient time e.g. within health assessment or book a long consultation Take an accurate and complete medication history, preferably sighting all medications It may also be helpful to see unfilled prescriptions currently held by the patient Complete the medication review form (provided) with the patient Clarify the treatment goal for each medication e.g. reduction of blood pressure to target level Identify potential problems and assess clinical relevance Follow up on actions and continue to monitor. 2
In more detail. 1. Taking a medication history Use a non-judgmental technique and open-ended questions. Facilitated by physical inspection of all medications (the brown paper bag approach). Ask about: all prescription drugs, prescribed by you and other doctors over-the-counter (non-prescription) medications complementary (herbal, alternative, vitamin) products eye drops, inhalers, patches and topical treatments, as patients often forget to mention these also, alcohol, tobacco and illicit drugs. Ask about the patient s pattern of medication use For example: frequency, regularity, method and reason for use. Ask about perceived drug efficacy. Record all adverse drug events For example: allergic reactions, adverse reactions and other possible related events, such as falls. Discard any out-of-date medications or repeat prescriptions for drugs which are no longer needed. 2. Problem identification 2,3,4 The aim is to solve or avoid any medication-related problem/s that interfere with the desired patient outcome. Some problems may require further investigation. Are there any untreated indications? Is this the most appropriate drug for the indication(s)? Is the drug effective and is the treatment goal being achieved? Have there been changes in evidence/best practice since it was first prescribed? Have appropriate non-drug measures been instituted? Is there an ongoing need for this drug? Have any drugs been initiated to treat adverse drug effects? Is the dose, frequency and appropriate? Has the dose been individualised for the patient? Consider weight, age, renal function, etc. Is there duplication? Drugs in same therapeutic class, generic-brand duplication Does the patient have contraindications to any medications? Consider disease states, pregnancy, renal function, liver function, drug allergies etc and consider therapeutic alternatives Are there any actual or potential adverse effects occurring? Are there any clinically important interactions (drug-drug, drug-food)? Is the drug effect and/or side effects monitored appropriately? Are there any problems with compliance/concordance? Could the regimen be simplified? Is the regimen cost-effective for the patient and taxpayer? Continues on back page... 3
Continued from page 3... 3. Action/plan 3,4 In most cases no change is required i.e. treatment is appropriate and therapeutic outcomes have been achieved Dose/frequency changes For example: doses are sub-therapeutic or medication is taken improperly Discontinue medication For example: an inappropriate drug is being used Add an alternative or a new medication or institute non-drug therapy For example: drugs used are ineffective or therapeutic outcome has not been achieved Document in medical record Implement monitoring Medication counselling/instructions for patient/carer Research information on drug Such as approved product information, reference texts, drug information service, manufacturer, specialist, community or clinical pharmacist, clinical pharmacologist Contact or refer to other health professional For example: pharmacist, community nurse, other treating doctors, hospital/health service. 4. Communication with the patient Explain the purpose of the medication review and the benefit for the patient, this will establish trust to ensure complete medication history and disclosure of compliance Does the patient understand how to take the medication and any special precautions? Check that written consumer medicine information has been provided where appropriate Check comprehension and literacy regarding labelling, consumer medicines information Consider appropriate aids for compliance, equipment for administration or monitoring Referral to a pharmacist may assist, also check use and maintenance of equipment such as nebulisers, spacers, peak flow meters, and blood glucose level meter. Acknowledgment The medication review form design is based on the work of medication review projects conducted in Divisions of General Practice (DiNCQUM GP with Central Coast, Central Sydney, Fremantle Regional and Osborne Divisions of General Practice; Domiciliary Project, University of Sydney with St. George and Canterbury Divisions of General Practice; and QUM-Medication Review in Inner SE Melbourne Division of General Practice). References: 1. Atkin PA, Stringer RS, Duffy JB, Elion C, Ferraris CS et al. The influence of information provided by patients on the accuracy of medication records. MJA 1998;169:85-88. 2. Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam G. Drug-related problems: their structure and function. Annals of Pharmacotherapy 1990;24:1093-97. 3. Mant A. Thinking about prescribing; a handbook for quality use of medicines. Sydney: McGraw-Hill Co.; 1999. 4. Kradjan WA, Koda-Kimble MA, Young LY, Guglielmo BJ. Assessment of therapy and pharmaceutical care. In: Young LY, Koda-Kimble MA, eds. Applied therapeutics: the clinical use of drugs. 6th ed. Vancouver: Applied Therapeutics Inc; 1995. 5. Australian Medicines Handbook. 1st ed. Adelaide: Australian Medicines Handbook; 1998. The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decisions based on this information should be made in the context of the individual clinical circumstances of each patient N P S National Prescribing Service Limited Our goal To improve health outcomes for Australians through prescribing that is : safe effective cost-effective. Our programs To enable prescribers to make the best prescribing decisions for their patients, the NPS provides information education support and other resources. National Prescribing Service ACN 082 034 393 Level 1/31 Buckingham Street, Surry Hills 2010 Phone: 02 9699 4499 l Fax: 02 9699 5155 l email: nps@zip.com.au
Date: _ Medical record/file no: Patient name: Form N P S Medication History Medication Problems Plan of Action Medication Prescribed dose/ Actual dose/ Treatment goal Actions/instructions to patient eg: (generic/brand frequency frequency/ (reason for medication) Tick those that apply dose change, cease, new medication, name and strength) method of use medication counselling, compliance aids
Instructions for using this form This form (consisting of two pages, this page and overleaf ) is to assist with the process of a medication review.the form is made up of 5 rows, one row for each medication. Photocopy this form as many times as is needed for each patient. Complete Patient Details Fill in the date of review, patient name and medical history in the space provided in the box opposite and at the top of the form overleaf. Medication History Take a medication history with the patient, then complete the four sections on the form, as outlined below. 1. Medication : list all medications currently used regularly or intermittently. Include all prescription drugs prescribed by you and other doctors, over-the-counter medicines and complementary medicines (herbal, alternative and vitamin perparations) as well as medications not previously recorded on your medical records. 2. Prescribed : record dose and frequency of medication as prescribed (if applicable) e.g. 10mg at night. 3. Actual : record dose and frequency of medication taken by patient eg: 10 mg at night prn when symptoms occur. 4. Therapeutic goal : record the desired clinical outcome e.g. target blood presure level, pain control. Medication Problems Tick any which apply, for other, specify problems. Plan of Action Record action plan e.g.reduce dose, order biochemistry. For further assistance or information please contact the National Prescribing Service on (02) 9699 4499 or refer to the Prescribing Practice Review No. 7, on. Patient Details N P S Date of review: _ Patient name: Age: Weight: Allergies: History of adverse drug reactions: Alcohol and tobacco use: Renal function: Serum creatinine: Estimated Cl cr* : Liver function: *Calculating an Estimate of Renal Function 5 Renal function declines with age. The estimated creatinine clearance rather than the serum creatinine indicates renal function. Use a formula such as Cockcroft - Gault to estimate renal clearance, especially in the elderly who may have a normal serum creatinine Creatinine clearance Cl cr (ml/min) (males) = (140 age ) x (body weight (kg)) 815 x serum creatinine (mmol/l) (females) = 85% of above - Creatinine clearance <10 ml/min - - renally excreted drugs may be contraindicated - Creatinine clearance 10-25 ml/min - significant dosage adjustment will be necessary for renally excreted drugs - Creatinine clearance 25-50 ml/min - most renally excreted drugs will need dosage adjustment Note this formula is invalid in severe renal insufficiency or with rapidly changing renal function. Drug Interactions: See www.nps.org.au for information on interactions with the top 10 drugs used on PBS. Other resources: Australian Medicines Handbook;Therapeutic Guideline series