Wessex AHSN and SPS

5th July 2017

Clare Howard FFRPS FRPharmS Clinical Lead

Medicines Optimisation Polypharmacy Prescribing Comparators

• In 2002, there were 617 million items dispensed, in 2012, there were 1,000.5 million (an increase of 62%)

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• In 2015, 1,083.6 million prescription items were dispensed overall, a 1.8 per cent increase (19.1 million items) from 2014. This is an increase of 50.4 per cent (363.4 million) on the number dispensed in 2005; 720.3 million items

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• The average number of prescription items per head of the

population in 2015 was 19.8, compared to 19.6 items in the previous year and 14.3 in 2005 and 13 in 2003

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• One third of over 75’s now take at least six medicines 3

IS IT HAPPENING IN ENGLAND?

POLYPHARMACY

So what?

• A person taking ten or more meds is 300% more likely to be admitted to hospital (4)

• 6.5% of hospital admissions are for adverse effects of medicines this rises to 17% in the over 65 age group.

• 30 – 50% of people do not take their medicine as intended by the prescriber.

• Over 70% of hospital admissions for adverse reactions to medicines could be avoided.

MEDICATION SAFETY We aren’t getting it right…

Evidence from primary care shows:

• 1 in 20 prescription items has an error and 1 in 550 is serious 5

• Prescription errors had been made for one in eight patients overall, and four in ten patients over 75 years of age. In all, 1 in 20 prescriptions written featured an error. Of the errors, 42% were judged to be minor, 54% moderate and 4% severe.

• In 2013, there were over 1 billion items dispensed in England therefore this equates to 1.8 million serious errors 3

• Adverse drug reactions account for 6.5% of hospital admissions and over 70% of the ADRs are avoidable.

• Over 50% of errors were in 4 disease classes, antiplatelets, NSAIDs, diuretics and anticoagulants5

POLYPHARMACY PRESCRIBING COMPARATORS - THE STORY SO FAR….

Wessex AHSN workshop November 2015. “Metrics” identified as a key starting point. There seemed little point developing just for one locality? Why not engage NHS BSA and NHS Digital and develop some national measures?

So we held a small workshop. GPs, Pharmacists, BSA, RPS, NHS Digital and others. RCGP also aware and engaged.

FOR EACH INDICATOR WE ASKED..

• Is it useful? • Is it valid? (are there any health warnings) • How would you use it? • What other data sources might make it more

meaningful? • In or out? i.e should it be included in the final

polypharmacy measures? • Any other measures that the group could

suggest?

INITIAL SUGGESTIONS FOR POLYPHARMACY PRESCRIBING INDICATORS

1. Average number of items per patient by CCG/ Practice 2. Average number of items per ASTRO PU by CCG/ Practice 3. Can you do average number of items in patients over 75? 4. Can you do average number of items in patient over 65 5. Number of patients on 10 or more meds over 65 6. Number of patients on 10 or more meds over 65 7. Number of patients on 4 or more meds over 65 8. Number of patients on 4 or more meds over 65 9. Number of patients on 20 or more meds over 65 and 75 10. Spend on top 10 drugs in STOPP part of STOPP start tool by

CCG in the over 75’s (controversial but this is a workshop) 11. Anticholinergic burden score in over 75s by CCG/ Practice

Have changed a bit since this first list…..

BSA AND HSCIC WORKED THEIR MAGIC….

LIMITATIONS: • Historically, prescribing information was derived from the reimbursement

processes for dispensed medicines. However, the BSA is now able to capture extra information that undoubtedly adds value to prescribing measures.

• The NHS number can now be linked to prescription items. In this way, we are able to demonstrate much better the quality of prescribing in key areas.

• The polypharmacy prescribing comparators are the first suite of measures to take advantage of this development. Currently, 92% of all prescription items can be linked to an NHS number with an accuracy of 99%. Age and date of birth can be linked to 73% of items with an accuracy of 99%. As the utilisation of electronic prescribing (EPS) increases, the coverage and accuracy of this data will increase.

• Therefore, CCGs are encouraged to drive up the uptake of EPS. To support this improvement, EPS levels have been included at the start of these comparators.

SO, THE FINAL DATA SET

These comparators will be available at GP Practice, and CCG level and will include measure such as… • The average number of unique medicines prescribed per patient • Percentage of patients prescribed 8 or more unique medicines,

10 or more unique medicines, 15 or more unique medicines, 20 or more unique medicines

• Percentage of patients with an anticholinergic burden score of 6 or greater, 9 or greater, 12 or greater

• Percentage of patients prescribed multiple anticoagulant regimes • Percentage of older patients prescribed medicines likely to cause

Acute Kidney Injury (DAMN Drugs) • Percentage of patients prescribed a NSAID and one or more other

unique medicines likely to cause kidney injury (DAMN medicines)

PORTSMOUTH CCG PERCENTAGE OF PATIENT WITH ACB SCORE OF 9 OR MORE

PORTSMOUTH CCG PERCENTAGE OF PATIENTS ON 15 OR MORE UNIQUE MEDICINES

ePACT2 is now live and the roll out to users has begun. Initially, only 2 users per CCG will be given access with further users being added in a phased approach. Over the next few weeks and months we will also be writing out to existing ePACT Users in order to transfer them onto our new improved system. The plan is to complete roll-out by Autumn 17. If you would like to request access to ePACT 2 please drop the NHS BSA an email nhsbsa.informationsystems@nhs.net Further information regarding ePACT 2, including the benefits can be found on NHS BSA’s website (https://www.nhsbsa.nhs.uk/epact/epact2)

CORE PATIENT MESSAGES…. • Polypharmacy is not about reducing medicines costs – it is

about making sure you are only on the medicines you need, to live well and avoid unnecessary or unplanned visits to hospital.

• As you get older, medicines may no longer be appropriate for you as your body changes. It may be time for a medication review.

• Taking too many medicines increases your risk of going into hospital.

• So – you should know your medicines. If not, speak to your Pharmacist or GP.

• Don’t stop taking medicines without a review. Your local Community Pharmacist can review how you use your medicines and make recommendations to your GP. Ask them today.

RESOURCES

http://www.sign.ac.uk/pdf/polypharmacy_guidance.pdf

See http://wessexahsn.org.uk/programmes/ 11/medicines-optimisation

https://www.cppe.ac.uk http://www.kingsfund.org.uk

Name Role/Organisation

Clare Howard Clinical Lead, Medicines Optimisation, Wessex Academic Health Science Network (Chair)

Graham Mitchell Information Services Manager, NHS Business Service Authority

Paul Brown Senior Pharmaceutical Adviser, NHS Digital

Neil Watson Clinical Director of Pharmacy and Medicines Management, Newcastle Hospitals NHS Foundation Trust

Vicki Rowse Programme Lead, Medicines Optimisation, Wessex Academic Health Science Network

Julia Blagburn Senior Lead Clinical Pharmacist for Older People's Medicine and Community Health, Newcastle Hospitals NHS Foundation

Trust.

Michelle Trevett Senior Pharmacist ,NHS Dorset Clinical Commissioning Group

Dr Paul Mason GP and Prescribing Lead ,NHS Dorset Clinical Commissioning Group

Dr Lawrence Brad GP and RCGP Polypharmacy Lead

Dr Simon Flack GP and Locality Lead ,NHS Dorset Clinical Commissioning Group

Simon Cooper Head of Prescribing Support, Portsmouth Clinical Commissioning Group

Katie Griffiths Medicines Safety Officer, Dorset University Healthcare NHS FT

Catherine Armstrong Lead Pharmacist – Pharmicus, English Pharmacy Board, Royal Pharmaceutical Society

Helen Kennedy Prescribing Analyst, NHS Dorset Clinical Commissioning Group

HUGE THANKS TO THE WORKING GROUP

WHERE NEXT???

EVALUATION: Does this data truly identify those most at risk from harm? How do we join up with

secondary care??

Let’s not get to 10 medicines in the first place! Research to

help us to stop medicines

safely!

Trigger tool to ensure a review when patient is

about to go from 9-10 medicines

Tools that helps the practice to

identify and prioritise the

patients most in need of review.

Health Warning:

‘indicators only indicate’