Graham North – CCA Rep Alliance Boots

1. Graham North – CCA Rep Alliance Boots

2. Aims • What is a MUR – What it is not • Why are they important – who wins ? • Addressing GP concerns • Breaking barriers to success • Practical tips • Quick wins and areas to develop • Action plans • The need for Quality, Simplicity and Relevance

3. What is a Medicines Use Review ? Concordance based approach between the patient and pharmacist and prescriber – two objective zones Patient Prescriber Pharmacist MUR

4. Establish actual patient usage/understanding their experience of taking meds and their beliefs (listening-prompting) Identifying side effects/drug interactions other concerns that may affect compliance Discuss and resolve poor or ineffective use of meds inappropriate/misplaced beliefs Agree way forward Patient Prescriber Pharmacist Review benefits (1) – Patient centred

5. Improve the cost effectiveness of prescribed therapy Identifying prescribing issues and suggest improvements Encourage best practice and reduce wastage Patient Prescriber Pharmacist Review benefits (2)– Prescriber Centredin mutually agreed areas

6. What is a MUR – NOT !! • A full clinical review • An agreement about changes to medication • A discussion about the medical condition beyond that which is needed to conduct a usage review • A discussion on the effectiveness of treatment based on test results

7. Why are MURs important?

8. Prescribed medication is everywhere! • 60% of the UK population are taking medicines to treat or prevent ill-health or to enhance well-being • 3 out of 4 people over 75 are taking prescribed medicines • 40% of older people take 4 or more different medications on a regular basis • Majority of long term illnesses are managed by means of prescribed drugs Source: Medicines Partnership: www.medicines-partnership.org

9. How many of the following patients do you see every week ?? • Patients on 4 or more meds ? • Elderly patients ? • Patients recently discharged from hospital

10. Why do we need MURs?Public, PCT and GP dimensions • What percentage of medication is not being taken as prescribed ??

11. Why do we need MURs?Public, PCT and GP dimensions • 50% of medication not taken as prescribed1 • No matter how good clinical prescribing is, if patients don’t take their meds, the benefits and health goals are not realised • £100 Million drugs are returned to pharmacies • What percentage does this rise to in the elderly?

12. Why do we need MURs?Public, PCT and GP dimensions • 50% of medication not taken as prescribed1 • This rises to 75% in the elderly1 • What percentage of prescribed medication is wasted ?

13. Why do we need MURs?Public, PCT and GP dimensions • 50% of medication not taken as prescribed1 • This rises to 75% in the elderly1 • 10-20% of prescribed medication is wasted2 • What percentage of hospital admissions are due to adverse drug reactions3

14. Why do we need MURs?Public, PCT and GP dimensions • 50% of medication not taken as prescribed1 • This rises to 75% in the elderly1 • 10-20% of prescribed medication is wasted2 • Up to 17% of hospital admissions are due to adverse drug reactions3 • What percentage of hospital re-admissions in the elderly are due to poor compliance3

15. Why do we need MURs?Public, PCT and GP dimensions • 50% of medication not taken as prescribed1 • This rises to 75% in the elderly1 • 10-20% of prescribed medication is wasted2 • Up to 17% of hospital admissions are due to adverse drug reactions3 • >50% of hospital re-admissions in the elderly are due to poor compliance3 • 1. Dunbar-Jacob J, Schlenk E (2001): Patient adherence to treatment regimens. • 2. Pharmaceutical Journal, vol 267, November 24, 2001 • 3. Medicines and Older People (supplement to the NSF for Older People).2001. Department of Health, London

16. Deliberate Unintentional Beliefs Ability Causes of poor compliance Non-compliance A conscious decision Forgetful or lack of understanding Motivation/perceptions Practicalities

17. ICEBERGS !!50% of all LTC meds are not taken correctlymostly undisclosed – increase in the elderly BUT WHICH 50% IS YOUR NEXT PATIENT IN – HOW DO YOU KNOW ?

18. Why do we need MURs ? • The fees are quite important too • 400 x £27 = £ 10,800 • Offset for Cat M and reduced item fees

19. Old Contract Dispensing Fees Professional Services LPS 2004 - 2006 Fees & Essential Advanced Enhanced Services LPS After 2007? Advanced Services Essential/ Enhanced Services & PBC LPS/ PMS Payment: Why we have to do it differently.

20. What are the barriers outside pharmacy ? • Variable awareness in GP population • 50% received 10 or more forms • 33% fewer than 10 • Format of documentation (new form at DoH) • GP perception of commercial vs. patient centred • GP uncertainty of value to patient care • Marketing to patients & GPs • Patient perception that MUR encroaches on GP responsibility From Wilcox & Hardy study Cornwall & IOS PCT 60% GPs had good relationship with pharmacist

21. What GPs would NOT like to see • Pages of information to hunt through • Asking GP to check BPs etc when these have been done • Patients who have had same meds for years and GP knows they are compliant (or are they?) • When the practice has done a medication review • (perhaps the Medicines Usage Review should precede that ?) • Highlighting known problem that the GP is already working on • Discussing adverse effects that are inevitable • but take care to note concordance challenge

22. What GPs would like to see • Simplified paperwork – Try RAG system ? • Succinct action points – more later • Ensure patient is clear about purpose • Comments on compliance issues • Comment on patients’ understanding of meds and problems handling/taking medicines • More collaborative working • Avoid negative remarks about surgery ! • Targeting mutually agreed specific patient groups

23. Breaking BarriersDeveloping Relationships with GPs & others • Meetings with GPs are essential – use PSNC factsheet • Balance on roles/responsibilities and patient relationship • Establish what a MUR iswhat it is not • Sharing information – how was it for you ? What should change (this is two –way!!) • Content of Action Plans • Agree what not to say – when to phone • Agree the Go and No Go areas • How to say it without compromising the “triangle” • Red/Amber/Green flagging for action plans

24. Breaking BarriersDeveloping Relationships with GPs & others • Establish and share benefits with all stakeholders • Help with their agenda – encourage the referrals • RDS recruitment/explanation of process • Identify and agree some “quick win” mutual benefits • QoF objectives – See notes

25. Breaking BarriersDeveloping Relationships with GPs & others • Establish and share benefits with all stakeholders • Help with their agenda – encourage the referrals • RDS recruitment/explanation of process • Identify and agree some “quick win” mutual benefits • QoF objectives – See notes

26. Quick wins and mutual benefits • Referrals prior to Annual Medical Reviews for elderly • Referral from “Fallers” units in hospitals • Community matrons and district nursing teams Vulnerable patients at home • Patients recently discharged from hospital – what was that % ?? • Biphosphonate patients – see Lancet 2006; 368:973-4 • Compliance and persistence falls below 50% in year 1 • Increases to 80% in 3 years • Problems tend to occur within 3 months of start of tmt

27. Quick wins and mutual benefits • New & existing CDS patients – perform DDA and MUR to confirm best solution • Dose optimisation and Generic Prescribing reminders • Unsynchronised repeats and appropriate pack sizes (Adcal 100 to 112) • Recurrent request for emergency supply • Care home and housebound patients – enabling access to services

28. Breaking BarriersDeveloping Relationships with GPs & others • Establish and share benefits with all stakeholders • Help with their agenda – encourage the referrals • RDS recruitment/explanation of process • Identify and agree some “quick win” mutual benefits • QoF objectives – See notes

29. Quality and Outcomes Framework (QOF) • Relies on good collaboration between GP and Pharmacist • GMS contract includes med reviews • Simple review without patient present • 4 domains in GMS contract – pharmacist could contribute info from MUR? • Epilepsy 4 points • Mental Health 23 points • Medicines Management 15 points • Review of 80% of patients on 4+ meds or repeats • Asthma and COPD • Pathways into or out of disease clinics or reviews • See sheet

30. Example QOF points

31. Asthma & COPD MURs • Over 5 million people treated for asthma in the UK

32. Asthma & COPD MURs • Over 5 million people treated for asthma in the UK • There are approx. 500 asthma/COPD patients on average per pharmacy • What percentage do not use their inhalers correctly ??

33. Asthma & COPD MURs • Over 5 million people treated for asthma in the UK • There are approx. 500 asthma/COPD patients on average per pharmacy • 30% do not use their inhaler medication properly • Rate of inspiration needs to match inhaler type • Only 5.3% are correctly/fully controlled • This means there are nearly 428 patients who could have better control over their asthma

34. Asthma – COPD check points • Usage of Relievers and Preventers • Explain what each inhaler does • Can the patient actuate the inhalers effectively ? • Dexterity • Synchronisation • Can the patient inspire the drug at the correct rate (In Check) • Learning by doing • What to do in an exacerbation ? • Side effects and other drugs to review

35. In Check Dial for different inhalers

36. Asthma – COPD check points • Usage of Relievers and Preventers • Explain what each inhaler does • Can the patient actuate the inhalers effectively ? • Dexterity • Synchronisation • Can the patient inspire the drug at the correct rate (In Check) • Learning by doing • What to do in an exacerbation ? • Side effects and other drugs to review

37. MEDICINES USE REVIEW – OTHER THERAPEUTIC AREAS What therapeutic areas ?

38. Patient examples – What are your competency areas ? • Elderly on 3/4+ medicines • Diuretics compliance • Emollient and steroid use in Eczema - • Diabetic test strip usage for Type II diabetics • SSRI compliance/concerns about stepping down • Drug toxicity risks – check for toxicity and understanding • Digoxin/ Warfarin/ Methotrexate/ Amiodarone • PPIs – asymptomatic patients on high dosage for extended periods • Clarify or specify more effective directions • Methotrexate specify day • Isosorbide Mononitrate

39. Eczema – Worrying facts • What % of patients are shown how to use creams effectively? 20% • What % are applying the emollient in the same way as steroid 25% • What % believed they would become dependant on treatment 50% • What % saw a reduction in symptoms after brief intervention? 89%

40. Emollients – Things to know ? • How long should 500gm of emollient last with an adult ? 1 week • How to apply emollients ? Light downward strokes – no rubbing • How much and how often ? Min 2-3 x day – up to hourly in flares • What about sensitivities to contents of sun creams – is there a list – where? YES – www.eczema.org

41. Eczema and steroids creamsFinger tip Units - FTUs

42. Eczema and steroids creamsFinger tip Units - FTUs

43. Patient examples – What are your competency areas ? • Elderly on 3/4+ medicines • Diuretics compliance • Emollient and steroid use in Eczema - • Diabetic test strip usage for Type II diabetics • SSRI compliance/concerns about stepping down • Drug toxicity risks – check for toxicity and understanding • Digoxin/ Warfarin/ Methotrexate/ Amiodarone • PPIs – asymptomatic patients on high dosagefor extended periods • Clarify or specify more effective directions • Methotrexate specify day • Isosorbide Mononitrate

44. ANTICOAGULANT CHECK LIST 12 POINT PLAN • 0NE Ensure patient has received appropriate written and verbal information • TWO Find Out what patient already understands and remembers • THREE Explain in clear and simple terms what the medicines are for and when the patient should take them. • FOUR Inform the patient of the side effects or symptoms the drugs may produce, how common or rare these are, how to recognise them • FIVE Explain any lifestyle changes that will be needed in order to ensure good anticoagulant control • SIX Accurately answer any questions relating to a patient therapy • SEVEN Encourage patients to avoid halving tablets as this can be difficult and inaccurate. Recommend alternative strengths to Gps as required • EIGHT Before dispensing a repeat Rx, check the INR is being monitored an that it is at a safe level for a repeat. Rx to be dispensed. • NINE Check for clinically significant interacting medicines • TEN Ensure doses are expressed in milligrams and not number of tablets • ELEVEN Ensure patient is aware of potential interactions with OTC • TWELVE Ensure risk assessment is carried out on the use of MDS with anticoagulation patients.

45. Patient examples – What are your competency areas ? • Elderly on 3/4+ medicines • Diuretics compliance • Emollient and steroid use in Eczema - • Diabetic test strip usage for Type II diabetics • SSRI compliance/concerns about stepping down • Drug toxicity risks – check for toxicity and understanding • Digoxin/ Warfarin/ Methotrexate/ Amiodarone • PPIs – asymptomatic patients on high dosagefor extended periods • Clarify or specify more effective directions • Methotrexate specify day • Isosorbide Mononitrate 1BD

46. Nitrates and tolerance • Tolerance effects can be reduced through reduction of blood-nitrate concentrations to low levels for 4-8 hours /day • Give the second of the two daily doses 8 hrs after the first dose rather than 12hours • Morning and mid afternoon • What are the labelling implications ?

47. Comfort Zones A LIMITED SET OF BEHAVIOURS THAT A PERSON WILL ENGAGE IN WITHOUT FEELING ANXIOUS

48. Comfort Zones A LIMITED SET OF BEHAVIOURS THAT A PERSON WILL ENGAGE IN WITHOUT FEELING ANXIOUS

49. Comfort Zones A LIMITED SET OF BEHAVIOURS THAT A PERSON WILL ENGAGE IN WITHOUT FEELING ANXIOUS

50. MEDICINES USE REVIEW – OTHER THERAPEUTIC AREAS What therapeutic areas do you like to explore ? EXAMPLES PLEASE