Susan Patterson*, Chris Cardwell†, Grainne Crealey ¶ and Carmel Hughes*

1. Susan Patterson*, Chris Cardwell†, Grainne Crealey¶ and Carmel Hughes* *School of Pharmacy, †Dept. of Epidemiology, Queen’s University Belfast. ¶ Clinical Research Support Centre 30th October 2008 How much does it cost to care? Optimising the safety of medicines for older people in nursing homes

2. People >65yrs with long-term conditions (England) 15 million, 2008 18 million, 2025

3. Ageing and illness • The over 80s are the fastest growing age group in the UK • ¼ of UK population is over 60 years • Compression of morbidity? Expected time lived in poor health: • 1981: 6.5 yrs (men) 10.1 yrs (women) • 2001: 8.7 yrs (men) 11.6 yrs (women) • Variety of drugs • Multiple medical conditions

4. Older people and medicines • 81% men and 86% women over 75 take one or more medicines • 36% of over-75s take four or more medicines • Polypharmacy • Appropriate • Inappropriate • Increased risk of drug interactions • Increased risk of Adverse Drug Events related to number of drugs taken • Number of drugs prescribed is a significant predictor of mortality (Dale et al., 2001) Dale et al. Int J Geriatr Psychiatry. 2001;16:70-6

5. Age-related physical changes • Changes in composition in the ageing body • Water and fat balance altered • Decline in physiological functions • By age 75, 50% decline in renal function • Hepatic blood flow reduced and cytochrome p450 enzyme less active • Gastric emptying slow and reduced blood flow to gut • Decreased cardiac output

6. Prescribing for older people • Most frequent medical intervention experienced • Complex due to multiple morbidities • Limited evidence from studies – usually carried out in the under 65s • Prescribing cascade: • Add-on treatment for side effects • Diagnosis important before prescribing • Repeat prescriptions are common • Convenient for patients but……… • Less opportunity for prescriber to monitor therapy and intervene

7. Inappropriate medication • Unnecessary medicines or • Lack of treatment • Studies indicate a prevalence of inappropriate prescribing, a modifiable risk factor for adverse drug events in older people, in nursing homes of up to 55% (Rancourt et al. 2004) • Inappropriate medication results in an increased number of falls, adverse drug events and costly hospital admissions Rancourt C et al. BMC Geriatr 2004; 4: 9-19

8. Prescribing of Hypnotics and Anxiolytics in General Practice in N. Ireland

9. Prescribing of Antimanic drugs and Antipsychotics in General Practice in NI

10. Making drug therapy safer • Manage the risk of medication-related problems by: • Reducing the number of drugs (polypharmacy) • Reducing inappropriate drugs • Increasing appropriate drugs • Monitoring • Therapeutic effects • Safety: side effects, laboratory tests • Regular review of medicines – “brown bag” approach

11. Pharmaceutical care: the Fleetwood NI project Ensuring that patients get the best drug treatment “responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” (Hepler & Strand, 1990)

12. Development of the Fleetwood US model of pharmaceutical care • Developed by the American Society of Consultant Pharmacists. • Moving beyond US regulations: • Reduction in the use of inappropriate medication • Tackles under treatment of medical conditions • Seeks to reduce adverse drug events • Promotion of evidence-based practice Cameron K et al. Consultant Pharm 2002; 17: 181-194

13. Components of the Fleetwood model • Screening for high-risk patients • Prospective medication review • Resident assessment by the consultant pharmacist – pharmaceutical care needs • Pharmacist intervention and direct communication with the prescriber • Formalised pharmaceutical care planning

14. Fleetwood NI Project • Adapt the US model for use in NI – phase 1 study • Test the adapted model in NI nursing homes • Focus of analysis on psychoactive drugs • Primary outcomes • No. residents taking one or more inappropriate psychoactive drugs • No. residents who fall • Secondary outcomes • Changes in healthcare resource use over time • Professional satisfaction

15. Fleetwood NI project: design • 22 nursing homes across NI participated: • 11 matched pairs randomly assigned as intervention or usual care • 15 residents per home recruited, total=334 • Pharmaceutical care plan designed to encourage standardised approach: • stepwise design based on elements of model • 9 prescribing support pharmacists delivered intervention to 11 homes • Training provided on intervention and medicines for older people

16. Adapted from Oborne et al., 2002

17. Baseline resident characteristics

18. Baselineresident diagnoses

19. FleetwoodNI: Baseline data • Total number of medicines per resident = 10.8 7.6 regular+3.0 prn+0.2 acute • 155 GPs cared for 334 residents • 0.38 medication reviews per resident (intervention homes) during pre-study year Number of residents receiving one or more CNS (BNF Chapter 4) medicines at baseline

20. Types of pharmacists’ interventions

21. Fleetwood NI Project: Results • 2.8±3.3 clinical interventions per resident at first visit • 72.4% interventions accepted by prescribers • Increase in medication reviews to 1.50 per resident during study year in intervention homes • Reduction in the numbers of inappropriate psychoactive and all CNS drugs over time Numbers of residents receiving one or more CNS medicines after 12 months

22. Number of CNS prescriptions in intervention homes over time

23. Significant reduction in residents prescribed inappropriate psychoactives: After one year the odds of a resident receiving an inappropriate psychoactive drug in an intervention home = 0.26 (95% CI: 0.14, 0.49) compared to a resident in the control group of homes

24. Fleetwood NI Project: Falls • No change in the numbers of nursing home residents having one or more falls in the control and intervention groups during the pre-study year and the study years • No change in falls risk score after one year

25. Professional Satisfaction

26. Conclusions • An adapted US model of holistic pharmaceutical care was successfully implemented in a cluster RCT in nursing homes in Northern Ireland • A need for regular review of nursing home residents’ medication was demonstrated • There was a significant decrease in the rate of inappropriate psychoactive prescribing in the intervention group of nursing homes • No changes were detected in the number of home residents who fell

27. Health economics How much does it cost to care? Clinical benefit of pharmaceutical care is proven But………

28. What is economic evaluation? • The comparative analysis of alternative courses of action in terms of both their costs and consequences • Costs on one side of the equation • Outcomes on other side of equation

29. Outcome side of the equation: • Outcome in terms of ‘patient benefit’ (e.g. change in prevalence of inappropriate psychoactive drugs) • Another potential outcome: • Changes in resource usage generated as a result of the new intervention (as compared to current resource usage) • Hence we need to quantify such changes (for example, increased patient mobility could increase or decrease usage of nursing resources)

30. Prescribed medicines Total healthcareresources (NHS costs) GP services Healthcareprofessionalvisits Hospitalcosts Laboratorytests Data collection Quantity x unit costs (PSSRU data)

31. Economic evaluation:methods & results • Unit costs NHS services (PSSRU) • Frequency of each cost element calculated for pre-study year and study year • Intervention and control groups compared • Increase in total costs in both groups of homes after one year • No difference between intervention and control homes

32. Costs per resident of primary and secondary care resources

33. Economic modelling • Pharmaceutical care service costs unknown • Service analysed and measured during study year using • Multidimensional work sampling (MDWS) • Pharmacists’ payment claims • Economic modelling undertaken • Scenarios compared: • Reference case • Optimistic case • Pessimistic case

34. MDWS: Pharmaceutical care activities Proportion of professional, semi-professional and non-professional time spent by pharmacists providing a pharmaceutical care service to nursing home residents

35. Other Car 8% 2% GP practice Nursing home 29% 48% Workplace 13% MDWS: pharmacists’ time, location & contact with others Time spent on different types of activities Location of pharmacist Contact with others

36. Building an economic model • Service profile • Three scenarios • Targeting those at highest risk through screening • Staffing • Skill mix • Grading & salary • Overheads • Premises • Travelling

37. Reference case scenario Cycles of pharmaceutical care as they occurred in the Fleetwood NI study Risk screening by community pharmacist to identify residents at highest risk of adverse drug events

38. Outcomes of economic model Output of the economic model: Cost estimates in the reference scenario Comparison of three modelled scenarios:

39. Sensitivity analysis Sensitivityanalysis: Variations in cost parameters in the reference case

40. Why is this important? • Already interesting findings from the study • breakdown between professional and non-professional activities • Analysis of data enables ‘profiling’ of activities and identification of efficiencies • Allows a service delivery ‘costing & feasibility’ model to be developed • Can provide accurate financial projections address planning issues relating to the service • Aids decision-making (reduces uncertainty)

41. Conclusions • Benefits of pharmacist input were demonstrated in nursing homes – reduction in inappropriate psychoactive prescribing • Can calculate how much it costs to care through the use of economic modelling techniques • This approach can assist decision-makers by providing evidence-based cost estimates of proposed new services

42. Thank you for listening……… Any questions? Contact : spatterson20@qub.ac.uk