Transcript Prescribing
What is the Quality Use of Medicines? Andrew McLachlan Professor of Pharmacy (Aged Care) Faculty of Pharmacy [email protected] Medications on admission • • • • • • • • • • • • Aspirin 100 mg daily Methadone 10 mg bd Dothiepin 50 mg nocte Irbesartan/HCT 300/12.5 mg 1 daily Metoprolol 50 mg bd Diazepam 5mg nocte Metoclopramide 10 mg tds Vitamin B12 injection monthly Amlodipine 5 mg mane Liquifilm tears eye drops Fentanyl patch 37.5 mcg/h Sertraline 50 mg daily Drug Allergy: NSAIDs • Carbidopa/levodopa 100/25 mg 2 tds • Panadol Osteo (665 mg) 2 tds • Cholecalciferol 2000IU daily • Multivitamin • Diphenoxylate/atropine 2.5mg/25microgram (Lomotil) 2 tds • Omeprazole 20 mg bd • Gabapentin 300 mg tds • Oxycodone 5 mg PRN • Diazepam 5 mg PRN max 3/day • Temezapam 10 mg PRN nocte • Panadol Osteo 2 PRN nocte 78 year old female RACF resident This talk • What is the quality use of medicines? • Evidence and how we use it • Guiding principles and guidelines • Challenges – Swallowing difficulties • Ethics and QUM My conflicts • Editorial Board member, Australian Medicines Handbook Aged Care Companion • Government committees making recommendations about medicines access and policy • Medication Reference Group, Australian Commission for Quality and Safety in Healthcare • Received research funding from GSK for student scholarships and clinical trial medicines • Collaborate with NPS Medicinewise on education interventions Australia’s National Medicines Policy • Aim: – To meet medication and related service needs, so that both optimal health outcomes and economic objectives are achieved. • Objectives / Policy Arms: – timely, cost effective access to medicines; – quality, safety and efficacy standards; – quality use of medicines (QUM); – responsible and viable medicines industry. http://www.health.gov.au/internet/main/publishing.nsf/content/National+Medicines+Policy-2 Australia's National Medicines Policy Partnership approach “Better health through quality use of medicines” QUALITY USE OF MEDICINES • Quality Use of Medicines is defined as: –selecting management options wisely; –choosing suitable medicines if a medicine is considered necessary; and –using medicines safely and effectively. “Better health through quality use of medicines” QUALITY USE OF MEDICINES • Quality Use of Medicines is defined as: –selecting management options wisely; –choosing suitable medicines if a medicine is considered necessary; and –using medicines safely and effectively. “Better health through quality use of medicines” ….using medicines safely and effectively Limited Relevant Evidence Principles of drug action Optimal drug, dose regimen and dose form http://www.bmj.com/content/319/7211/652.full Concentration-Effect Relationship Probability Benefits Harms Drug Dose ….using medicines safely and effectively “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy” Phillipus Aureolus Theophrastus Bombastas Von Hohenheim Paracelsus (16th Century) Therapeutics Pharmacokinetics Dose Pharmacodynamics Concentration in blood Effect Older people are at greater risk of adverse effects, medication errors and adverse drug reactions Adverse effects in older patients Reduction in organ function Altered pharmacokinetics Altered pharmacodynamic Reduced homeostatic function Adverse effects Multiple diseases Multiple prescribers Multiple medicines Poor adherence “Balanced prescribing is a process that recommends a medicine appropriate to the patient’s condition and, within the limits created by the uncertainty that attends therapeutic decisions, a dosage regimen that optimizes the balance of benefit to harm” http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-resguide-cnt.htm http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-resguide-cnt.htm http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdfresguide-cnt.htm Medicines in people with swallowing difficulties • Not all medications are appropriate to be crushed • Medication omission due to “nil by mouth” • Limited evidence to inform practice Medication Modification: What are the problems • Many tablets may be crushed or capsules opened • Considerations with dose form modification – – – – Efficacy Pharmacokinetics Adverse effects Suitability (e.g IV access) Strachan I, Greener M. Medication-related swallowing difficulties may be more common than we realise. Pharmacy in Practice 2005:411-14. D Wright et al, Consensus guidelines on medication management of adults with swallowing difficulties Medication management of adults with swallowing difficulties 2006 Mendendium Retrospective review of medication management issues in people with swallowing difficulties Most commonly identified problematic medications in dysphagia by class (n= 100) Drug Class Proton Pump Inhibitor Antiplatelet agents Electrolyte Supplement Anticonvulsants Iron Supplements % cases 25 15 9 8 6 Perry et al, 2011 Information, evidence and confusion Combined n= 59 Nurses n= 25 Doctors n= 17* Pharmacists n= 16 % % % % Identified that oxycodone SR cannot be crushed 78 72 65 100 Correctly converted metformin XR dose to standard release 55 36 41 100 Recognised the significance of withholding venlafaxine 52 12 71 94 Clinical question: themed by correct response * n=17 as one respondent did not complete the clinical questions Perry et al, 2011 A guide…… Medication reconciliation • Transitions of care • Accurate medication history – All medicines – Adherence • Discharge medicines Medication Reconciliation • The process of MATCHING UP the medicines that the patient should be prescribed with those that are actually prescribed. • Helps ensure continuity of care and prevent or minimise medication errors. Medication Reconciliation 4 simple steps to improve patient safety 1. Obtain and document best possible medication history • Thorough and structured interview with patient/carer 2. Confirm the accuracy of the medication history • Confirm information with at least second source 3. Reconcile history with inpatient medication chart. Document issues, discrepancies and actions. • Ensure patients are receiving all intended medicines 4. Reconcile on discharge and provide accurate medicines information when care is transferred. • Transfer between wards, hospitals , home, aged care facility provide an accurate and complete list of patient’s medicines Second Source for Medication History • A requirement of National Standard 4 Medication Safety and compliance with action 4.6.1 “a best possible medication history is documented for each patient” • Carer, GP, Community Pharmacy, dispensed packages, personal/patient-controlled electronic health record (PCEHR) • But the 2nd source can also be wrong! Clinical judgement is necessary. Medication reconciliation Helpful link www.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation/ Check this out http://www.youtube.com/watch?v=dc5jFuba6CI Prescribing cascade Rochon and Gurwitz, BMJ 1997 Methadone + fentanyl oxycodone + lomotil + dothiepin Persistent nausea Metoclopramide + dothiepin Dopaminergic side effects / bradykinesia Carbidopa/ levodopa ….choosing suitable medicines if a medicine is considered necessary "Any symptom in an elderly patient should be considered a drug side effect until proven otherwise." J Gurwitz, M Monane, S Monane, J Avorn Brown University Long-term Care Quality Letter 1995 “QUM and The Life Journey” healthy acutely ill chronically unwell severely ill very frail dying Medicines have a role in each stage of the health journey Changing goal of pharmacotherapy Shift in the HarmBenefit balance Weekes L, J Pharm Pract Res Sept 2009 Ethics and Evidence • Autonomy • Beneficence • Non-maleficence • Justice Ethics and QUM • Autonomy Respective a persons choice, effective communication about medicines • Beneficence Evidence of benefit • Non-maleficence Evidence of harm • Justice Equity and access to medicines in a sustainable way Le Couteur DG, Ford GA, McLachlan AJ. Ethics, Evidence and Medication Management in the Elderly. J Pharm Pract Res 2010 QUM and older people • Rationale for commencing a medicine • Individualising therapy (drug, dose regimen, dose form) • Monitoring strategy to assess benefits and harms • Plan to review pharmacotherapy regimen • Rationale for continuing medicines • Rationale for ceasing medicines Acknowledgements NHMRC Project Grant Research Funding NHMRC Centre for Research Excellence – Medicines and Ageing Pharmacy Age Care Research Team • (Dr Sasha Bennett) • Michael Dolton • Shane Eagles • Christina Abdel Shaheed • Atheer Jassim • Daniel Rifkin • Bei Lin Dysphagia Project • Jonathan Perry • Nicole Clayton • Helen Ryan CERA collaborators • A/Prof Vasi Naganathan • Prof David Le Couteur • Dr Robyn McCarthy • Dr Fiona Blyth Also • Angela Wai, Medication Safety & Pharmacy Educator - SLHD