Tools to aid and identify patients for polypharmacy review Dr Pamela Mills Principal Pharmacist Redesign Jane Hall Principal Pharmacist Pharmacotherapy Rachel Falconer General Practice Clinical Pharmacist
Background • Polypharmacy guidance recommends criteria ✓ >50 yrs in care home ✓ Prescribed >10 medicines ✓ High risk medicine ✓ Approaching end-of-life • Non-specific - patient numbers exceed capacity
Patient Prioritisation • Tools developed to aid patient prioritisation ➢ Prescribed medicines [ E nhanced M edication S ummary (EMS)] ➢ Patient acuity [ A yrshire P olypharmacy A ttendance C ognition E valuation (APACE)]
Enhanced Medication Summary (EMS) tool Jane Hall
What is EMS? • A list of patients suitable for polypharmacy review - information from practice clinical system • Patients that meet the criteria outlined in the Scottish Polypharmacy guidance – > 65yrs on 10 or more meds or > 50yrs in a care home • A printable document for each patient to aid review • Reduces time spent on manual work up
Prescribing Indicators • IT system automatically checks if the patient triggers > or = 1 of ~120 prescribing indicators: – High risk prescribing – Potential over treatment – Monitoring required – Potential under-treatment • Patients ranked in order with patients triggering highest number of indicators at the top
EMS REPORT FOR MRS EB
Recent addition – falls review
APACE Tool Patient Identifiers: ➢ 10+ active repeat medicines ➢ Cognitive impairment ➢ Multi-morbidities ➢ Frailty score ➢ No. of GP consultations ➢ No. of A+E attendances ➢ Previous PPR, ACP, KIS, care home Score calculated to rank patients in order of priority
Patient Case 77 yr old female Dx: COPD, back pain, hypertension, osteoporosis, gastric ulcer, iron deficiency anaemia, memory loss 14 repeat medicines Blister pack Home visit, husband also present Main concerns: Worsening SOB, pain management, TATT
Polypharmacy Review Repeat Medicines: ➢ Adcal D3 caplets – two bd (indication?) ➢ Erythromycin 250mg tabs – rescue meds (over-ordering, remove from repeats) ➢ Ferrous fumarate 210mg – one bd (check FBC/haematinics) ➢ Ipratropium 500mcg/2ml nebules – not ordered since 06/17 (remove) ➢ Omeprazole 20mg caps – two daily (reduce to 20mg daily) ➢ Paracetamol 500mg/Dihydrocodeine 30mg tabs – two qds (only 42kg -reduce to 1 qds) ➢ Perindopril 4mg tabs – one daily (non-formulary, check BP) ➢ Prednisolone 5mg tabs – rescue meds (remove from repeats) ➢ Pregabalin 50mg caps – one at night (review ongoing need, trial stop?) ➢ Relvar Ellipta 92/22 – one puff daily (step up - add Incruse?) ➢ Salbutamol inhaler – 2 puffs prn (review use/issue spacer) ➢ Salbutamol 2.5mg nebules – one qds ➢ Sertraline 50mg tabs – one daily (review mood) ➢ Tramadol 50mg caps – one tds (effective? s/e? Reduce/stop? try topical NSAID?)
Key Findings from using APACE ➢ Patients identified and prioritised for review that may not have previously been flagged i.e. No ‘high risk indicators’ triggered but poor compliance/understanding due to cognitive impairment ➢ Opportunity to address any pharmaceutical care issues offer compliance aids as well as signpost to other services and healthcare professionals if required ➢ Use in conjunction with EMS tool (where available)
Key Findings ➢ Complex cases Many patients have mental health and social issues so require additional input, multiple visits and shared care to achieve treatment goals ➢ Opportunity for patient education & facilitate family/carer engagement Positive feedback so far when conducting visits
Conclusion • Tools achieve aim for patient prioritisation • Combination of medicine and patient factors • Polypharmacy reviews enhanced
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