Implementation of STOPP/START criteria in different settings

Transcription

1 Implementation of criteria in different settings Professor Cristín Ryan School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin. October 2017 PhD Thesis ( ), University College Cork Appropriate prescribing for older people Prof Denis O Mahony Prof Stephen Byrne 1

2 Tourist Attractions in Dublin 2

3 Irish weather But.. 3

4 National treasures Outline Development of Evidence to support routine use of Challenges of implementation across different settings & some potential solutions Example of the implementation of in community pharmacy 4

5 The ageing population Increased number of co-morbidities Lack of multi-morbid specific guidelines Physiological changes Pharmacokinetics Pharmacodynamics Increased susceptibility to Prescribing Cascade Drug Interactions Adverse Drug Reactions Inappropriate Prescribing What is? STOPP: Screening Tool of Older Person s Prescriptions START: Screening Tool to Alert doctors to Right Treatment Explicit and implicit criteria Aim: To improve prescribing and health outcomes for older people in all care settings Target: Over-prescribing, Mis-prescribing, Under-prescribing Use: In conjunction with clinical diagnoses by prescribers/ pharmacists Gallagher et al. Int J Clin Pharmacol & Ther 2008;46: O Mahony et al. Age and Ageing 2014;0:1-6 5

6 Development of Version 1 Version 2 Year Published Evidence Literature review Observational studies Clinical experience Literature review and advice from experts Consensus Method Delphi Validation Delphi Validation Expert Panel Number of Delphi Rounds Criteria Layout 18 experts from Ireland and United Kingdom STOPP: 2 START: 1 STOPP: 65 statements START: 22 statements Organised by physiological system 19 experts from 13 European countries STOPP: 2 START: 2 STOPP: 78 statements START: 33 statements Organised by physiological system Gallagher et al. Int J Clin Pharmacol & Ther 2008;46: O Mahony et al. Age and Ageing 2014;0:1-6 Content of Version 2 STOPP START Drug indication criteria 3 - Cardiovascular System 11 8 Antiplatelet/Anticoagulant Drugs 11 Central Nervous System 14 6 Renal System 6 - Gastrointestinal System 4 2 Respiratory System 4 3 Musculoskeletal System 9 7 Urogenital System 2 3 Endocrine System 6 1 Drugs that increase the risk of falls 4 - Analgesics 3 1 Antimuscarinic/anticholinergic drug burden 1 - Vaccines - 2 Total O Mahony et al. Age and Ageing 2014;0:1-6 6

7 Evidence to support the routine use of Is there a need? Does have an impact on: Mediation appropriateness The occurrence of adverse events Healthcare resource utilisation Cost Quality of life Mortality? Can it be reliably used in every day practice? STOPP: Screening Tool of Older Person s Prescriptions; START: Screening Tool to Alert doctors to Right Treatment Evidence to support the routine use of Is there a need? REGION SETTING STOPP (%) Patients Ireland Primary Care Secondary Care Nursing Homes START (%) Patients European Primary Care Secondary Care Nursing Homes STOPP: Screening Tool of Older Person s Prescriptions; START: Screening Tool to Alert doctors to Right Treatment 7

8 Evidence to support the routine use of Is there a need? Does have an impact on: Mediation appropriateness The occurrence of adverse events Healthcare resource utilisation Cost Quality of life Mortality Can it be reliably used in every day practice Evidence to support the routine use of Is there a need? Does have an impact on: 8

9 Evidence to support the routine use of Outcome Gallagher Dalleur Garcia-Gollarte Frankenthal Control STOPP: Baseline- Study end point (%) START: Baseline- Study end point (%) Intervention STOPP: Baseline- Study end point (%) START: Baseline- Study end point (%) Medication appropriateness N/M N/M Healthcare resource utilisation/ Event Falls No difference N/M Control: *; Int: * N/M Emergency Care Visits N/M N/A Control: *; Int: Unchanged Primary care visits Control:Unchanged Int N/M Control: Unchanged Int: * Quality of Life N/M N/M N/M No difference Cost (Drug) N/M N/M N/M Int * Mortality No difference N/M N/M N/M N/M N/M Adapted from Hill Taylor et al. J Clin Pharm T 2016;41: N/M: Not measured; Int = Intervention; * = p< 0.05 Evidence to support the routine use of Adapted from Hill Taylor et al. J Clin Pharm T 2016;41:

10 Evidence to support the routine use of Is there a need? Does have an impact on: Mediation appropriateness The occurrence of adverse events Healthcare resource utilisation Cost Quality of life Mortality Can it be reliably used in every day practice Inter-rater reliability between pharmacists and physicians has been established Challenges of implementation & some potential solutions Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy 10

11 Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy Criteria Do not identify all errors in prescribing Number of the criteria Time taken to deploy the criteria Potential Solutions Adopt a peer learning approach Tailor criteria to your local population and prescribing needs Familiarity with criteria reduces time Physiological system based approach to review of prescriptions Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy Primary Care Prescribers willingness to change Previous failed attempt to change Prescription may have been initiated in secondary care Knowledge of patients perceptions Prescribers knowledge of and confidence in the recommendation Lack of alternative medication/ services Potential Solutions Early engagement and communication with prescribers Ensure an awareness of the services that do exist 11

12 Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy Secondary Care Acutely unwell patients Care priorities Potential Solutions Encourage opportunities to improve prescribing practices Engage with other pharmacists Engage with senior and junior prescribers Become involved in junior doctor training Communication: Face to face opportunity Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy Nursing Homes Older, frailer patients Length of treatment time Expected changes in outcomes e.g. changes in quality of life may not be achieved Prescribers willingness to change Potential Solutions Priorities care needs Manage expectations (outcomes) Engage with prescribers 12

13 Criteria Primary Care Secondary Care Nursing Homes Community Pharmacy Community Pharmacy Availability of clinical & biochemical data Availability of/ rapport with the prescriber Resources (personnel) Potential Solutions Understand what is achievable Tailor the criteria to the level of information available Integrate the criteria into other services in line with National Policies in Community Pharmacy Aim of service: To adopt a holistic person centred approach to patient care to enhance the effectiveness of the patient s medicines and to improve lifestyle in order to improve their quality of life Service developed based on: National priorities: Person centred care, evidence based prescribing Patients needs The remit of community pharmacy and pharmacists specialists knowledge Twigg et al PLOS ONE 12 (4):E

14 in Community Pharmacy Review of Patients Medication Record Nice Guidance Modified Falls Risk Medication Review (Prior to consultation) Discussion with patient Reasons for prescribed medicines Patients beliefs about medicines Medication taking behaviour Barriers to adherence Personal goals Recommendations to prescriber Support and advice to patients to encourage adherence Tailored lifestyle advice Support services referral Patient care plan Agreement with patient Adapted from: Twigg et al PLOS ONE 12 (4):E in Community Pharmacy Progress Successful Patients recruited Baseline analysis suggests potential for impact Many patient goals have been successfully set Reflections Reasons for success Initiative driven by management Responsive to national priorities Training provided for pharmacists and support staff Early engagement with local prescribers Initial review undertaken prior to consultation Standardised GP referral form Ongoing Challenges Resources Pharmacists role in patient care Referrals Goals Adapted from: Twigg et al PLOS ONE 12 (4):E

15 Concluding Remarks Prescribing for older people is challenging, and needs to be optimised Implementing a guideline such as can improve prescribing practices The implementation of criteria irrespective of setting does not guarantee success. Input from and engagement with physicians is essential in all care settings Engage with key stakeholders prior to implementation One size does not fit all : Individualisation and tailoring of intervention to setting and population is required A further challenge is to ensure that patients take their medicines as prescribed Acknowledgements University College Cork, Ireland Professor Stephen Byrne Professor Denis O Mahony Queen s University Belfast Prof Carmel Hughes University of Auckland New Zealand Prof Ngaire Kerse PhD Students: Dr Anna Millar, Dr Karen Cardwell 15

16 Thank You References Castillo-Paramo et al. Eur J Gen Pract 2014;20: Gallagher et al. Int J Clin Pharmacol & Ther 2008;46: Hill-Taylor et al. J Clin Pharm Ther 2016;41: Lesende et al. European Geriatric Medicine 2013;(4): Millar et al. Int J Clin Pharm 2017;39(3): O Mahony et al. Age and Ageing 2014;0:1-6 Storms et al. Eur J Gen Pract 2017;23(1): Twigg et al. PLOS ONE 2017;12(4):e Lavan et al. Clin Int Aging 2016;11: Bryant JIPP 2011;19: Verdoorn et al. EJCP 2015;71: Frankenthal JAGS 2014;62: