Polypharmacy and anticholinergic burden Katherine Le Bosquet - PowerPoint PPT Presentation

Polypharmacy and anticholinergic burden Katherine Le Bosquet December 2018

3 rd WHO Global Patient Safety Challenge – Launched March 2017 WHO Global Patient Safety Challenge – Reduce the level of severe, avoidable harm related to medications by 50% over 5 years, globally 3 early priority actions: • Polypharmacy • High risk situations • Transfers of care 2 | 2 |

“ Patients and the public are not always medication-wise. They are “ Health care professionals sometimes too often made to be passive prescribe and administer medicines in recipients of medicines and not ways and circumstances that increase informed and empowered to play the risk of harm to patients” their part in making the process of medication safer”. " Medicines are sometimes complex and can be puzzling in their names, or packaging and sometimes lack “Systems and practice of medication sufficient or clear information. are complex and often dysfunctional, Confusing ‘lookalike sound alike’ and can be made more resilient to medicines names and/or labelling and risk and harm if they are well packaging are frequent sources of understood and designed”. error and medication-related harm that can be addressed." 3 | 3 | Presentation title

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Medicines Safety Programme and Medicines value Programme

Medicines are an important part of NHS care Achieving the NHS Five Year Forward and help many people to get well View (2014-19) However, quality, safety and For the NHS to meet the needs of future patients in a sustainable way, increasing costs continue to be we need to close three gaps: issues … • Around 5-8% of hospital Health and admissions are medicines related, Radical upgrade in prevention wellbeing gap many preventable • Bacteria are becoming resistant to antibiotics through overuse which Care and quality New Care Models and new support is a global issue gap • Up to 50% of patients don’t take their medicines as intended, Funding and meaning their health is affected Efficiency and investment efficiency gap • Use of multiple medicines is increasing – over 1 million people now take 8 or more medicines a Developed by the Care Quality Commission, Public Health England and NHS Improvement with day, many of whom are older the involvement of patient groups, clinicians and independent experts people We spend £18.2 billion a year on medicines (£1 in every £7 that the NHS spends) and they are a major part of the UK economy

There is growing pressure on the NHS drugs bill Due to people living longer, more complex and innovative medicines being developed, and more specialist medicines being used • Overall medicines spend 2016/17 was 20,000 £17.4bn, an increase of Primary care 33.7% from £13bn in Hospital & community health sector Total 2010/11. • 2017/18 Overall spend 15,000 was £18.2bn. Gross spend £m • Cost of medicines prescribed and 10,000 dispensed in primary care rose from £8.6bn in 2010/11 to £9.0bn in 5,000 2016/17, a rise of 3.6% • Cost of medicines used in hospitals increased from £4.2bn in 2010/11 0 to £8.3bn in 2016/17, a rise of 98.3% Medicines costs at list price (excl. VAT) before any discounts

The Medicines Value Programme has been set up to respond to these challenges Following the Next Steps on the NHS Five Year Forward View and Carter Report The NHS wants to help people to get the best results A whole system approach …. from their medicines – while achieving best value for • NHS England, NHS the taxpayer Improvement, NHS Digital, Health Education England Savings will be reinvested in improving patient care and providing new • Regional offices link with STPs, treatments to grow the NHS for the future ICSs, CCGs, and providers • Nationally coordinated with AHSNs, Getting It Right First Time, NHS Right Care and The NHS policy framework that governs Optimising the use of medicines 1 NHSCC 3 access to and pricing of medicines Developing the infrastructure to 2 The commercial arrangements that 4 support an efficient supply chain influence price

Optimising the use of medicines Four Regional Medicines Optimisation Committees (RMOCs), chaired by regional medical directors and supported by regional pharmacists Connecting CCGs and providers to take coordinated action Initial priorities: • Biosimilars • Generics • Polypharmacy • Effective prescribing in primary care • Patient safety www.england.nhs.uk

Medicines Safety Programme Set up following the recommendations of the Short Life Working Group 1. Patients 3. Healthcare professionals • • Improved shared care between health and care professionals Improved shared decision making, including when to stop medication • Training in safe and effective medicines use is embedded in • Improve information for patients and families, and undergraduate training • access to inpatient medication information Reporting and learning from medication errors • Repository of good practice to share learning • Encourage and support patients and families to raise • New defences for pharmacists if they make accidental any concerns about their medication medication errors 2. Medicines 4. Systems and practice • Increase awareness of ‘look alike sound alike’ drugs • The accelerated roll-out of hospital e-prescribing and medicines and develop solutions to prevent these being administration systems introduced • The roll-out of proven interventions in primary care such as • Patient friendly packaging and labelling PINCER • The development of a prioritised and comprehensive suite of • Ensure that labelling contributes to safer use of metrics medicines • New systems linking prescribing data in primary care to hospital admissions • New research on medication error to be encouraged www.england.nhs.uk

The burden of medication errors WHO Global Patient Safety Challenge – Reduce the level of severe, avoidable harm related to medications by 50% over 5 years, globally 3 early priority actions: polypharmacy, high risk situations, transfers of care Medication errors can include prescribing, dispensing, administration and monitoring errors. Medication error can result in adverse drug reactions, drug-drug interactions, lack of efficacy, suboptimal patient adherence and poor quality of life and patient experience The estimated NHS costs of An estimated 237 definitely avoidable ADRs are million medication £98.5 million per year, consuming 68.3 million errors (28% of total) errors occur in the 181,626 bed-days, causing 712 cause moderate or serious harm NHS in England every deaths, and contributing to 1,708 year deaths EEPRU report - PREVALENCE AND ECONOMIC BURDEN OF MEDICATION ERRORS IN THE NHS IN ENGLAND November 2017* www.england.nhs.uk

Polypharmacy www.england.nhs.uk

Appropriate polypharmacy: 'Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence.’ Problematic polypharmacy: 'The prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised.’ When risks of medications outweighs the benefits for the patient www.england.nhs.uk

Causes of Polypharmacy • A “pill for every ill” and psychosocial • Multiple morbidities issues • Poor communication between healthcare teams • • Increased longevity Patient, staff and carer demand • Advancements in drug therapy and preventative • Target driven therapeutic enthusiasm strategies and unrealistic expectations  Accessibility to medicines e.g. non prescription drugs • • Failure to individualise treatments • Prescribing cascade and set clear therapeutic goals • Guidance and targets e.g. QOF, NICE quality • Poor evidence base for prescribing standards drugs in older people • Multiple prescribers and pathways • Poor medicines reconciliation and medication review • Reluctance to discontinue drugs • Mistaking ageing for disease/inappropriate response to non-medical problems www.england.nhs.uk 14

Increased risks from Polypharmacy • Increase risk of ADR’s • Increased risk of interactions • >10 medication increases your risk of hospital admission by 300% • Complex regimes are increasingly confusing for patients • Poor compliance (30-50% of medicine for LTC not taken as intended) • Increase pill burden • Increase carer burden and healthcare time take for administering medication and clerking • Increased risk at transfer of care • Increased Anticholinergic burden www.england.nhs.uk 15

‘Problematic polypharmacy’ - prescribing of multiple medicines Polypharmacy inappropriately, or where the intended benefit is not realised • Average no. of prescription items per head in 2016 was 20, compared to 14.8 in 2006 • De-prescribing medicines in a controlled way reduces the risk of medicines related complications and this requires clinical medicines reviews • NHS England’s care home vanguards have reduced these risks and the NHS is rolling out the Enhanced Health in Care Homes Framework and developing a medicines optimisation in care homes scheme October 2017 data: patients prescribed 10 or more unique medicines • 5.15% of ALL patients • 8.19% (aged 65 and over); 9.76% (aged 75 and over); 10.46% (aged 85 and over) www.england.nhs.uk