A Drug-related Problem Risk Assessment Tool (DRP-RAT) for use by - PowerPoint PPT Presentation

A Drug-related Problem Risk Assessment Tool (DRP-RAT) for use by home care practical nurses Maarit Dimitrow, PhD (Pharm) University of Helsinki Finland www.helsinki.fi/yliopisto

Background • The demand for long-term home health care services for the aged is growing • Those needing home care (HC) are increasingly older and have more complex health problems • In Finland, practical nurses (PNs) have 3-year vocational education that concentrates mainly on technical nursing rather than pharmacotherapy www.helsinki.fi/yliopisto

Background • PNs working in HC are those who make regular home visits to the elderly => PNs are in a key position to monitor and notice changes in their clients´ health status including positive and negative outcomes of possible drug treatments • Due to lacking physician resources in HC, the physician-conducted home visits are rare => PNsʼ role in medication risk management is pronounced www.helsinki.fi/yliopisto

DRP-RAT • PNs need a practical tool for identifying problems related to drug treatments => • Development and validation an easy-to-use Drug- related Problem Risk Assessment Tool (DRP-RAT) for PNs caring for home- dwelling aged ≥65 years • PNs need training to use the Tool • PNs conduct the risk assessments during their normal home visits in collaboration with the HC client (if possible) • PNs report their risk assessments to other healthcare providers www.helsinki.fi/yliopisto

Development of the draft DRP-RAT Development Phase I 1. Two systematic literature reviews 2. Expertice of the research group 3. Consultation of a geriatrician not involved in the research group Content validation of the draft DRP- RAT • 3-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy Validation process Feasibility of the final DRP-RAT Phase II • Conducted among practical nurses in home care of two towns in southern Finland Testing the validity of the final DRP- RAT in clinical practice • An experienced geriatricianʼs reliability evaluation of PNsʼ risk assessments • Geriatrician identifyed the clinically most significant DRPs 23.11.2017 5

Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 6

Is there anyone who determines whether the client takes his/her medicines? (added based on the feasibility study)

Polypharmacy ” High risk ” medicines OTC

Involving the client Fall Symptoms tendency and his/her proxy to suggestive of ADRs clientʼs care

• Clientʼs health status • Potential problems with transfer of clinical patient data

Involving the client/care Adherence giver in clientʼs care

• Interventions for resolving the problems • Increases the awareness among PNs and the aged of options to improve medication safety

Symptoms suggestive of ADRs • When developing the DRP-RAT we had to take into account the PNʼs ability to answer the items of the tool • It is not useful to ask the PNs if the clients uses anticholinergic medicines, sedatives or medicines that may cause hyponatremia etc. • Thus, we decided to ask the PNs if their clients have symptoms suggestive of adverse drug reactions (ADRs) that these problematic medicines may cause • The symptoms listed in the Tool include ADRs of a wide range of medicines (e.g., anticholinergics, sedatives, neuroleptics, diuretics, hypoglycemic, diuretics, blood pressure medications, etc ….) www.helsinki.fi/yliopisto

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Main results of the feasibility study • Participants: 36 PNs • Time spent to complete the DRP-RAT • 10-45 minutes; mean 20±8 minutes • The PNs identified 88% of the risk medicines listed in the Tool • Challeges the PNs met in completing the tool • Generic names of medicines • Time resctrictions • Short client contacts Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 15

Geriatricianʼs reliability evaluation of PNsʼ risk assessments Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 16

Outline of the study Participants: • A clinically experienced geriatrician • 26 home care PNs • 46 home care clients 1. First phase of the study: • The PNs conducted risk assessment for their clients using the DRP-RAT during their normal home visits • The PNsʼ risk assessments were forwarded to the research geriatrician iFaculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 17

2. Second phase of the study: DRP risk assessments and medication reviews by the geriatrician The geriatrician reviewed the same clientsʼ medications using three different review methods: • Method 1 : Review based on the PN-completed DRP-RAT information and the medication list printed from the health centerʼs medical records • Method 2: Review based on the health center’s medical records (“gold standard” ) of the study) • Medical records encompass the following patient data: a) visits in health center, b) clinical examinations (health status, anamnesis, conclusions), c) medication lists, d) laboratory test results, e) hospitalizations, f) HC workers’ open comments about their home visits • Method 3: Review based on Methods 1 and 2 together = all client information available Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 18

Geriatricianʼs assessment of clinical importance of the items in identifying risks for clinically significant drug-related problems in study sample • Based on each review the geriatrician was asked to classify the patients “as an risk patient” or “not an at risk patient” • Risk patient: a patient is at risk for clinically significant DRPs needing more comprehensive medication review • If the geriatrician classified the client as “an at -risk patient” based on Method 1 (PN -completed DRP- RAT information and medication list) she was asked to tick those PN-identified risk predicting notes in the Tool that she regarded as clinically significant risk factors Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 19

”Traffic lights” of risks Risk predicting factor Prevalence Clinical Importance of in the study the of the questions in sample identifying risks for clinically significant drug-related problems Has the client had any of the following symptoms in the 40 (yes) 26 last 4 weeks? drowsiness, fatigue, skin rash or itch, (91%) dizziness, urination problems, muscle pains, nausea, diarrhea, constipation, dizziness when getting up, recurrent falls, swellings, memory problems, confusion, visual problems, stiffness, troubles in walking, low blood pressure; systolic pressure under 110 mmHg (n=44) Does the client have more than one physician 22 (yes) 20 (50%) involved in his/her care? (e.g., general practitioners, specialists, private practitioners) (n=44) Has the client had more than one fall in the past 12 18 (yes) 18 months? (n=44) (41%) Does the client use any of the following medicines 16 (yes) 14 (please check the ones used)? amiodarone, (36%) carbamazepine, digoxin, fluoxetine, lithium, methotrexate, theophylline, warfarin (n=44) Faculty of Pharmacy / Maarit Dimitrow 23.11.2017 20

”Traffic lights” of risks Risk predicting factor Prevalence Clinical Importance of in the study the of the questions in sample identifying risks for clinically significant drug-related problems Has the client had troubles in a) remembering to take the 30 (yes) 11 medicines? b) following the medicines regimen? c) (68%) knowing what his or her medicines are used for? d) affording the medicines (i.e., economic problems)? e) opening the drug bottles or packages or managing with medicines related therapeutic devices? (n=44) Does the client use medicines that a) relieve pain by 35 (yes) 8 reducing inflammation (does not apply to paracetamol)? (80%) b) elevate the rate of urination (diuretics)? c) are intended to lower the cholesterol level (statins)? ) d) the physician does not know about? (n=44) Have the client's relatives/proxies expressed their 7 (yes) 7 concern about the client's medicine use? (n=43) (16%) Has the client started a new medicine in the last 4 7 (yes) 6 weeks? (excluding different brands of the same active (16%) incredient) (n=44) Farmasian tiedekunta / Henkilön nimi / Esityksen nimi 23.11.2017 21

Implications for practice • DRP-RAT: • Can assist in identifying clients needing medication review • Provides additional information for pharmacists who conduct medication reviews • Educational implications www.helsinki.fi/yliopisto

An example of an operational model (case Lohja, Toivo et. al. 2017) Coordinating Coordinating Practical Nurses pharmacist pharmacist and • Update of the physician Preliminary medication lists assessent of the Shared decision- • Risk assessment medication using making for further with DRP-RAT • • Medication lists (Clinical tests) actions • Risk assessments Physician, nurse, • Available pharmacist databases • (pharmacokinec Case-spesific and -dynamic actions, e.g., prescription review, interactions) MR, CMR (physician) • Carrying out the decided actions (pharmacist) • Follow up after 3 months (nurse)

First assignment • Think ideas how to implement the DRP-RAT in your health care system? • Other ideas to benefit the DRP- RAT? Faculty of Pharmacy / Maarit Dimitrow www.helsinki.fi/yliopisto 23.11.2017 24