Prescribing and medication management

Introduction: Best practice tariff for Neck of Femur Fractures (NOFF) includes establishing a bone protection plan (BPP). Optimal management is often delayed due to insufficient vitamin D levels. Here we reviewed the administration of anti-resorptive (AR) therapies when giving vitamin D loading doses over 7 weeks compared to stat high dosing followed by maintenance therapy.

Method: Pre-intervention, we reviewed vitamin D levels, treatment given and bone protection therapy administered in all new NOFF admissions over 3 months. We introduced once-only high dose vitamin D therapy in deplete individuals over subsequent 3 months; deplete (Vit D <50) patients received 140,000 units stat colecalciferol, patients with insufficient levels(Vit D 50-70) received 60,000 units stat colecalciferol and replete individuals received adcal maintenance. Patients were given in-patient AR therapy or referred to fracture liaison service (FLS).

Results: Pre-intervention included 64 patients, of which 61% (N=39) had low vitamin D levels. These patients were loaded with once weekly 40,000 units of colecalciferol for 7 weeks and referred to FLS; 51% (N=24) received an appointment within 4 months. Only 14% (N=9) received in-patient AR treatment. Post intervention, 84 patients were reviewed. Vitamin D replacement was required in 69% (N=59) of patients, of which 83%(N=49) received the new loading regimen. This allowed 53% (N=20) of eligible patients to receive in-patient AR therapy.

Conclusion: Administrating high dose vitamin D to NOFF patients allowed us to increase in-patient AR therapy treatment 3.7 times. This simple intervention results in less out-patient appointments and treatment is given before opportunity to re-fracture.

Introduction

The concept of “polypharmacy” is a well recognised phenomenon, forming a keystone of any comprehensive geriatric assessment. We considered whether a similar concept could be applied to the number of outpatient clinics that patients may attend - a concept we have coined “polyclinic”. We recognise that older populations may have a greater number of comorbidities and, as a result, have more healthcare professionals inputting into their care. Similar to the potential detrimental effects of multiple medications, we were interested to explore if a similar detrimental effect may apply to patients attending multiple clinics. We also attempted to consider environmental impacts. We approached this in both a quantitative and qualitative manner.

Method

A cohort was selected from all admissions to a subacute Geriatrics ward at University Hospital of Wales during the month of April 2023. National records were used to review the last decade of clinic attendances. For interviews every 4th patient was contacted

Results

66 patients (75% female) were identified with 3 exclusions. The average number of clinics attended was 18.4 with 0.36 new diagnoses being made per clinic and 0.69 interventions per attendance. Geriatric clinic attendance yielded both a higher average number of diagnoses and interventions (0.93 and 1.4 respectively). Patient feedback was limited to 8 patients and 7 next of kin. Feedback regarding ‘worthwhileness’ was very positive with ratings >8/10. Feelings about possible cutting back on clinics or virtual clinic attendance were mixed with concerns regarding suitability and access to technology

Conclusions 

We identified several limitations to this pilot project,  however, overall feedback gained from patients and next of kin regarding clinic attendance was positive.

This study does not have the scope to suggest that attending multiple clinics are detrimental but aims to raise the concept of “polyclinics” that may be overlooked, particularly in a co-morbid population. We have also considered potential patient impact to multiple attendance and concerns regarding possible changes to traditional face to face clinics. With a climate crisis upon us we also draw attention to environmental impacts for consideration.

Promoting Bone Health by ensuring in-patient Ortho-geriatrician Bone Health plan in patient notes following Neck of Femur Fracture (NOF).

1. Introduction & Aims

Osteoporosis affects 3 million people in the UK with more than 500,000 hospital presentations annually due to fragility fractures costing in excess of £4.4 billion to the NHS. Bone protective medications are a cost-effective way of reducing fracture and admission following a fall.

The Royal College of Physicians National Hip Fracture Database targets that patients are: “given suitable bone strengthening treatment and followed up to ensure that they are still receiving this protection 120 days after fracture”. Lewisham Hospital achieves this in only 22% of suitable patients against a national average of 35%.

This project aimed to increase the number of eligible NOF patients on bone protective medication.

2. Method

Data was collected for patients over the age of 65 admitted with NOF. 22 eligible patients were admitted from 01/01/23 to 28/02/23 and 16 from 01/03/23 to 31/05/23. It was identified whether an appropriate bone health plan, including FRAX and calcium/vitamin D supplementation, was recorded in the medical notes and electronic departure note (EDN). Interventions included an advice sheet for rotating doctors, additional education at induction and a bone health proforma for medical notes and EDNs.

3. Results

86% of patients in cohort one had bone health plans in their notes and 59% in their EDN.  64% commenced on bisphosphonates with 1 eligible patient (4.5%) not receiving medication. After the interventions 100% patients had a bone health plan in their notes and 80% on their EDN. 46.7% of this cohort commenced bisphosphonates which equated to 100% of patients appropriate for bone protective medication.

Conclusion(s)

Providing guidance and education to rotating doctors to ensure Geriatrician-led bone health planning resulted in all eligible patients commencing bone protective medication and total numbers above the national average.

Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Introduction

Reduction in outpatient appointments during the COVID-19 pandemic and patient concern surrounding risk of contracting COVID-19 by attending day-case settings, resulted in delayed or cancelled medical treatments including Zoledronic Acid infusions as management for Osteoporosis. This, alongside recent research concluding that these treatments can be given safely as early as 1-2 weeks post-fracture, lead to the adaptation of protocol at Hull University Teaching Hospitals Trust in 2021, to provide rapid loading of Cholecalciferol over 6 days, prior to administration of Zoledronic Acid on day 7. However, some concerns remain surrounding the potential interference with bone remodelling and healing. This completed audit cycle evaluates the logistics and safety of this new protocol.

Methods

All patients over 60, admitted with neck of femur fracture who received Zoledronic Acid infusion as inpatient or outpatient in 2019 and 2021 were included in the initial and repeat audit respectively. Electronic records for the following 12 months were analysed evaluating for further fragility fracture and mortality rate.

Results

There was an increase in patients receiving Zoledronic Acid as an inpatient treatment from 21% in the initial audit to 97% in the repeat audit. There was a slight increase in mortality rate at one year from 14% to 19%. The percentage of a further fragility fracture within one year, remained stable at 7%.

Conclusion

The increase in inpatient infusions suggests more patients with significant frailty who would otherwise not have been able to attend outpatient settings, have been able to receive treatment. The mortality results reflect this frailer audit population. The absence of a substantial increase in the rate of further fragility fracture at one year; supports the earlier administration of Zoledronic Acid as a management protocol.

Introduction:
The number of older adults has been constantly growing around the world. Chronic disease occurrence and concurrency increase with age, and medication use rises correspondingly. The World Health Organisation (WHO) defines multi-morbidity as the “ co-occurrence of two or more chronic medical conditions in one patient.” The most commonly used definition of Polypharmacy is “taking co-currently five or more medications daily by an individual.” Polypharmacy is associated with increased mortality, falls, adverse drug reactions, hospital stay, readmission, and medication costs. STOPP (Screening Tool for Older Person’s Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria can be used for medication reconciliation in elderly patients. According to experts, STOPP/START criteria improves clinical outcome in multi-morbid elderly patients.  

Methods:
A clinical audit was conducted among patients admitted to the elderly care ward over one month. The prescription at admission was reviewed with their medical history as part of medication reconciliation. STOPP/START criteria were applied manually for reviewing prescriptions.

Results:
Out of 60 patients, 23 were female, and 37 were male. The mean age of the population was 85 years. The prevalence of multi-morbidity was 88.3%. The prevalence of Polypharmacy is 90%. The number of Potential Inappropriate Medication prescriptions (PIM) was 52, and the Number of Potential Prescription Omissions (PPO) was 18.

Conclusions:   
Prevalence of multi-morbidity and Polypharmacy is very high in our population. By applying STOPP/START criteria, PIMs and PPO can be identified and reduced. STOPP/START criteria can be used as a tool to reduce Polypharmacy in elderly people.

Introduction 

Older people living with frailty are often prescribed many medications exposing them to potential medicine-related harm. Pharmacists are a new addition to the East Kent Community Frailty Team, which otherwise consists of doctors and advanced clinical practitioners at various levels of training. Pharmacists are ideally placed to develop medication review processes and support fellow clinicians with deprescribing efforts in frailty. This audit set out to determine current levels of medication review and associated cost-savings through deprescribing. 

Method 

All patients admitted to the frailty team caseloads in the month of May 2023 had their notes manually reviewed for evidence of medication reconciliation, review, and deprescribing. Medicines were assigned a cost price based on the NHSBSA Drug Tariff (May 2023). 

Results 

192 patients were seen in total, 170 of whom were acutely unwell. 62% of patients had their medication documented, taking an average of 8.2 medicines. The majority of omissions were patients with a zero length-of-stay, which include advice calls. 29% of patients had at least one medication stopped, representing an average 0.7 medicines stopped per patient seen. The monthly cost of medications stopped was £690. There were greater levels of deprescribing in the caseloads with MDT board rounds. 

Conclusion 

Rates of deprescribing are low compared to published studies (Ibrahim et al, BMC Geriatr 21, 258 (2021)), although still represent a rolling saving of approximately £8,000 per month on cost of medicines alone, assuming a twelve-month average life expectancy. Lack of standardisation of clinical notes and documentation made data collection difficult and has the potential to lead to transfer-of-care errors. Further work needs to be undertaken to optimise the medication review process and address inappropriate polypharmacy and will be the focus of efforts over the coming year. 

Background:

Patients not yet receiving medication provide insight to drug-naïve early physiology of Parkinson's Disease (PD). Decisions to start medication and assessment of response to its initiation can be challenging for physicians and patients alike.

Aim:

To identify objective, sensor-derived features of upper limb bradykinesia, postural stability, and gait that can inform decision-making in a movement disorder clinic. Methods: We used a single finger sensor to identify upper limb features and an array of six body-worn sensors to measure postural stability and gait. Patients were tested over nine visits, at three-monthly intervals, as part of a standard neurological examination.

Results:

Three upper limb bradykinetic features (finger tapping speed, pronation supination speed, and pronation supination amplitude) and three gait features (gait speed, arm range of motion, duration of stance phase) were found to progress in unmedicated early-stage PD patients. In all features, progression was masked after the start of medication.

Conclusion:

Commencing antiparkinsonian medication is known to lead to masking of progression signals in clinical measures in de novo PD patients. In this study, we show how this effect can be measured using digital devices. The testing kit can be used in movement disorder clinics to inform decision-making and progression monitoring in early PD.

Introduction

AFU aims to provide Comprehensive Geriatric Assessment to frail, older service users.  A key component is Medication Review.

Patients living with frailty are more susceptible to medication side-effects and are often on Falls Risk Increasing Drugs (FRIDs¹) and medications with Anticholinergic Burden (ACB²) effects, which can cause falls/confusion/delirium/hallucinations. Aiming to reduce inappropriate polypharmacy, ACB and FRIDs scores, and optimise bone health is therefore essential.

Data highlighted only 17% of patients received Medication Review by a Pharmacist, which needed addressed without additional resources.

Method 

Medication Review usually involves a Pharmacist working alone and can be a lengthy process. We suggested a team approach with preparation and clinical details brought to a focused meeting with decisions made collectively.

After identifying key stakeholders, we introduced a focused Medication Review meeting twice weekly. 

Aims of review: reduce ACB and FRIDs scores, discontinue medications no longer indicated, improve bone health with a patient-centred approach throughout.

We produced a data collection form for audit purposes, and agreed how to communicate suggested changes to patients and other staff. 

Results

109 patients audited from October 2022-March 2023.

Medication Reviews increased from 17%-69%.

Improvements noted: average number of medications reduced from 9.5-9.0 (reduction diminished by addition of bone optimising medications³), number of patients with ACB ≥3 reduced from 32-11, average ACB score reduced from 1.9-0.9 and FRIDs score from 5.5-3.4.

ScHARR⁴ potential cost avoidance for 557 interventions was £37,501 - £86,218 with an average of 5 interventions/patient.

Conclusion 

A focused multidisciplinary Medication Review led to a reduced ACB and FRIDs score, with a potential saving from interventions. It also increased the number of patients receiving a Medication Review.

This innovative way of providing Medication Review makes best use of our time and skills, encourages education, and promotes conversations with patients/families about medications to see what matters to them.

References

1.  FRIDs (Falls Risk Increasing Drugs)

Northern Ireland Medicines Optimisation in Older People (MOOP)

2.  ACB Calculator

Available at: https://www.acbcalc.com/

3.  FRAX® Fracture Risk Assessment Tool

Available at: Frax.shef.ac.uk. (2023)

4.  ScHARR Potential Cost Avoidance

Karnon, J.; McIntosh, A.; Dean, J. et al. Modelling the expected net benefits of interventions to reduce the burden of medication errors. J. Health Serv. Res. Policy 2008, 13, 85–91.

Introduction

The World Health organisation states that polypharmacy is a major global challenge. Older people in care homes are at risk of harm with 91% taking 5 or more medications. Pharmacists play an essential role in conducting medication reviews, identifying potential drug related problems, and implementing appropriate interventions to optimise treatment.

Method

As part of a pilot project for The Welsh Government Six Goals For Urgent and Emergency Care Pharmacists in Swansea Bay University Health Board’s Medicines Management team worked in collaboration with Consultant Geriatricians at Morriston hospital to review and optimise care home residents medication. Polypharmacy reviews were conducted assessing falls risk medication, anticholinergic burden and appropriateness of medication. Pharmacists engaged with the care homes to complete holistic clinical reviews and collaborated with consultant geriatricians to review recommendations. Pharmacists then actioned interventions and supported ongoing monitoring, working closely with the care homes. A total of five care homes have been chosen for the project with an estimated 200 residents. The team are still undertaking these reviews and conducting education.

Results

Thus far 79 residents totalling 855 medications have been reviewed. 288 interventions have been identified averaging 3.6 interventions per resident. Of the 288 interventions 132 (15.4%) medications have been stopped that were identified as inappropriate or no longer required, 16.7% of the medication stopped were classed as medications that may increase the risk of falls. In addition to safety measures results from medication reviews have shown financial benefit through cost savings.

Conclusion

Problematic polypharmacy continues to be a challenge that needs to be addressed and with nearly a quarter of medications prescribed in this cohort being stopped the benefit of specialist older people polypharmacy review for care home residents is apparent.