Non Medical Prescribing: medicines management and use review: are you prescribing cost effectively?

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1 Non Medical Prescribing: medicines management and use review: are you prescribing cost effectively? Dr Dianne Bowskill University of Nottingham School of Health Sciences.

2 Cost Effective Prescribing Medicines Management Medicine reviews Patients Prescriber Government & Health care organisations

3 Cost Effective Prescribing why is it Patient safety important? 5.8% of admissions are due to inappropriate use of medicines. Efficacy of therapeutic interventions Around 15 million people in England live with Long Term Conditions accounting for around 70% of healthcare spending. Cost of medicines. Estimated cost in England of waste medicines in excess of 300 million pounds. ( Drug spend billion)

4 Cost Effectiveness in a broader context I know that immunisation is one of the most cost-effective investments for the health and development of a child. The benefits go much beyond the medical they are also economic and societal. Dr Dorothy O. Esangbedo, President, Paediatric Association of Nigeria

5 How can we achieve Cost Effective Prescribing Principles of cost effective prescribing Safe for patients Meets the clinical need of patients Best value for money from NHS resources. (DH 2010) In practice: appropriate prescribing regular housekeeping through medication review

6 Prescribing appropriately ( to avoid Inappropriate prescribing) Potentially inappropriate prescriptions (PIPs): prescriptions in which the risks outweigh benefits (Beers 1991) Examples: prescribing without clinical need, duplicate prescribing, prescribing to treat side effects of other drugs prescribed, drugs which counteract the therapeutic action of another prescribed drug. Occurs in prescribing for all ages, commonly associated with older people. Studied in a variety of settings worldwide to identify potential for adverse drug events. The most common, Beers criteria and STOPP criteria (screening tool of older persons potentially inappropriate prescriptions)

7 Potentially inappropriate prescribing in older people 338,901 people over 70 years in Ireland (2007) Overall prevalence of PIP was 36% 3% were prescribed 3 or more potentially inappropriate medications Drug duplication was highly prevalent (particularly NSAIDs and Opiates) PIP was strongly associated with polypharmacy Cahir, et al (2010)

8 Polypharmacy the prescription of more drugs than is clinically justified Risk of adverse drug reactions A problem for older people 16% of the UK population is > 65 years (2011 census) Chance of satisfactory compliance Receive 52% of all prescriptions (MeReC Bulletin 2000) 36% of >75 years take 4 or more drugs (Hippesley Cox et al 2002)

9 The compliance, concordance, adherence conundrum Terms are used interchangeably throughout the literature. Compliance and non compliance are less frequently used today as considered negative and paternalistic. Concordance is the favored term however Latter reports the term in practice presents confusion. Snowden in his recent concept analysis of concordance found the term is applied differently in different healthcare disciplines NICE medicines guidance uses adherence

10 Some clarification of terms Compliance the extent to which patient behavior matches the prescriber s recommendations. Adherence the extent to which the patient s behavior matches agreed recommendations from the prescriber Concordance doctor and patient agree therapeutic decisions that incorporate their respective views, a wider concept which stretches from prescribing communication to patient support in medicine taking. Horne et al 2005

11 Medicine Review A definition of medication review is a structured, critical examination of a patient s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste. (Room for Review, 2002) Type 1 Type 2 Type 3 Prescription Review Compliance Concordance Review Clinical Medication Review

12 Medicine reviews: the literature Overall aim to improve the quality safety and appropriate use of medicines (principles of cost effective prescribing) Only 50% of long term medicines are taken as prescribed. Adherence decreases as the length of time medicine taken increases. Side effects and perceived lack of benefit are a key influence of adherence. (Blenskinsop ) Underlying message can be to identify non compliance or non adherence and through the process of the medication review improve compliance /adherence. Predominantly undertaken by pharmacists also by doctors and more recently nurses.

13 Mrs Brown s Medication Review

14 what significant medical history do you have? Not sure what she means, significant sounds serious my heart problem is serious, I will tell her about that. what drugs are you prescribed I bought my bag of drugs in with me Do you take any other drugs? No drugs, no, (senna and garlic are from plants so not drugs and the other stuff is a gel so that s not a drug) Do you take these as it says here? Yes but they often don t work.. what about these ones then? oh yes, (she /he doesn t want to know about those other ones I take, they cant be important.) you really should not be doing that, they are the same drug cant you see? but they have different names and the doctor told me to take them.

15 Two to tango Successful collaborative therapeutic relationships require input from both parties

16 The Concordant Consultation Involves the patient and enables professional acceptance of patient and professional attitudes and beliefs about illness, symptoms, personal prejudice and bias, personality. Large numbers of patients are disappointed in the lack of opportunity to have a say in clinical decisions (National patient survey 2010) Patient perception of need for medication information in contrast to nurse perception information needs low or non existent (Ekman et al 2007) Some people want to follow prescribed courses of treatment without participating in the decision (Marland & Cash 2005) Some want to be part of the consultation process but not make the final decision (De las Cuevas et all 2011) Agreement that relationship building was a positive outcome of concordance the benefit of this remained unclear (Snowden et al 2014)

17 The Patient Voice Improving the use of medicines for better outcomes and reduced waste An Action Plan Report and Action Plan of the Steering Group on Improving the Use of Medicines (for better outcomes and reduced waste) October 2012 the patient perspective was a welcome and transformative one no decision about me without me some recommendations may result in an increase in workload in the short term until new ideas embed in practice

18 Patient Centred Prescribing This may be scary for clinicians, we might have to understand why they don t want to take them, and we might have to agree to suboptimal use that contravenes current clinical guidelines, it might mean giving patients permission to use drugs in a way that we might not feel comfortable with and the associated legal and ethical difficulties this might bring. (Dowell et al 2007)

19 National Influence Decrease paternalism Increase self care Reduce waste Improve access to services Quality Care Cost Effective Prescribing Patient Voice Patient centred care Improving the patient experience Patient safety Reduction of risk

20 Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC: Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991, 151: Blenkinsopp A. Bond C. Raynor DK (2012)Medication Reviews. British Journal of Clinical Pharmacology Cahir C. Fahey T. Teeling M. Jeljeur C. Feely J. Bennett K (2010) Potentially inapprpropriate prescribing and cost outcomes for older people. A national population study.british Journal of Clinical Pharmacology De las Cuevas c. Rivero A. Perestelo-Perez L. Gonzalez M. Perez J. Penate W(2011) Psychiatric patients attitudes towards concordance and shared decision making. Patient Education and Counselling 8593) Dowell J, Williams B. Snadden D (2007) Patient Centrered Prescribing seeking concordance in practice. Radcliffe publishing Oxford. Department of Health (2012) Improving the use of medicines for better outcomes and reduced waste. Department of Health Crown. DH 2010 Strategies to achieve cost effective prescribing, guidance for primary care trusts and clinical commissioning groups DH. Ekman I, Schaufelberger M, Kjellgren K I, Swedberg K, Granger BB. (2007) Standard Medication information is not enough:poor concordance of patient and nurse perceptions. Journal of Advanced Nursing. 60(2) Horne R. Weinman J. Barber N. Elliot R, Morgan M(2005) Concordance adherence and compliance in medicines taking Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). Latter S. Maben J. Myall M. Young A(2007) Perceptions and practice of concordance in nurses prescribing consultations. Findings from a national questionnaire survey and case studies of practice. England. International Journal of Nursing Studies. 44(1) Marland GR. Cash K. (2005) Medicine taking decisions: Schizophrenia in comparison to asthma and epilepsy. Journal of psychiatric and mental health nursing. 12(2) Snowden A. Martin C. Mathers B. Donnell A (2014) Concordance: a concept analysis. Journal of Advanced Nursing. 70(1)46-59.