NHS Vale of York CCG

Business Case

Scheme/ Programme Title: Medication optimisation for care home residents using the STOPP protocol developed for SystmOne delivered by a GP, a practice based Pharmacist or an Advanced Nurse Practitioner - a health economic evaluation.

Author : Dr Kate Connolly (Y&H Improvement Academy); Dr Lesley Godfrey (Priory Medical Group); Sarah De Biase (Y&H Improvement Academy)

Date: 12th October 2015

  1. Introduction
  • Summarise the proposed scheme
  • Refer to any previous documents/ reports i.e. IVA
  • Benefits – improvements in quality or health outcomes

The aim of this proposal is to improve care of frail and elderly people living in care homes, through improving medication review. In keeping with the National Service Framework for Older People, General Practitioners at Priory Medical Centre (PMC) already undertake regular medication reviews for all patients living in care homes. The practice currently have 491 patients across residential, nursing and EMI homes. Introduction of the STOPP tool will assist GPs to perform medication reviews in this complex patient population.

Undertaking medication reviews with the STOPP tool should lead to improved quality of care around prescribing and provide a more holistic approach, possibly leading to reduction in drug burden and improved quality of life. It will lead to a reduction in potentially inappropriate prescribing, reduction in high risk combination prescribing and reduction in adverse drug events that result in hospital admissions.

In response to the 5 Year Forward View call for alternative workforce options to be explored, a further step in this proposal is to analysis whether alternative practitioners could undertake medication reviews given the complex nature of this patient cohort.

This proposal will adopt a stepwise comparative approach:

Step one would be that GPs from PMC will perform medication reviews for patients who live within one care home – e.g. Connaught House which has a mixture of residential, nursing and patients with dementia. The STOPP protocol will be run for each patient and then medication reviews undertaken with this additional information.

Step two would look at an Advanced Nurse Practitioner using the STOPP tool to use the information generated to undertake medication reviews for patients within one home e.g. Ameila House which is Nursing and Residential care.

Step three would then be a Clinical Pharmacy Practitioner employed by PMC to undertake medication reviews in the same way – e.g. at South Park, a mixture of nursing care and dementia nursing care.

A control group (e.g. Amarna House) will receive medication reviews as they are currently undertaken.

Whilst the aim of this proposal is to improve care for the frail population, is also likely to be financially beneficial. Studies that have examined the use of the STOPP tool have demonstrated it identified potentially inappropriately prescribed medications in between 23.7% and 95.7% of patients included (Chenn et al 2012, Ryan et al 2012 and Grace et al 2014). Therefore use of the STOPP protocol is likely to lead to a reduction in prescribing and therefore a reduction in prescription cost per patient. This may also lead to a reduction in associated costs i.e. blood monitoring for warfarin and anti diabetic medications.

Given that adverse drug events can often lead to hospitalisation, with Pirmohamed et al 2004 demonstrating a prevalence of 6.5% for adverse drug events leading to hospital admissions, reduction in inappropriate prescribing should lead to reduced admissions, therefore adding to the financial benefit.

We recognise that medication reviews could lead to a need for further additional services, and hence additional costs. This might be in the form of altering or additional monitoring of medications right through to the need for specialist advice from secondary care, i.e. memory services and geriatric medicine. However this ultimately will lead to improved care for patients and should be small numbers. This will be evaluated as part of the proposal (see section 5).

To evaluate the potential benefits of this proposal upon whether there is improved patient care and how alternative practitioners can undertake medication reviews we will analyse the following

Aims / Measure:
Improved quality of medication review / Number of inappropriate medications stopped
Severity of risk proposed by those medications stopped
Practitioner surveys
Patient stories
Onward referrals
Improved holistic approach / Number of inappropriate medications stopped
Patient stories
Onward referrals
Practitioner surveys
Reduction in drug burden / Number of inappropriate medications stopped
Patient stories
Onward referrals
Practitioner surveys
Reduction in inappropriate prescribing and high risk prescribing / Number of inappropriate medications stopped
Severity of risk proposed by those medications stopped
Practitioner surveys
Reduction in adverse drug events / Number of inappropriate medications stopped
Severity of risk proposed by those medications stopped
Practitioner surveys
Reduction in admissions – possible use of proxy indicators: / Number of inappropriate medications stopped
Severity of risk proposed by those medications stopped
Improve knowledge and skills of primary care teams / Practitioner surveys

References:

  • Grace AR, Briggs R, Keiran RE, Corcoran RM, Romero-Ortuno R, Coughlan TL, O’Neil D, Collins R and Kennelly SP (2014). A comparison of beers and STOPP criteria in assessing potentially inappropriate medications in nursing home residents attending the emergency department. J Am Med Dir Assoc 15(11);830-4
  • Pirmohamed M, James S, Meakin S, Green C, Scott A, Walley TJ, Farrar K, Park K and Breckenridge AM (2004). Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. BMJ 329;15-19
  • Ryan C, O’Mahony D, Kennedy J, Weedle P, Cottrell E, Heffernan M O’Mahony B and Byrne S (2013). Potentially inappropriate prescribing in older residents in Irish nursing homes. Age Ageing 29(6);116-120
  1. Context and impact
  • National and local drivers- political and economic
  • Mandatory/ statutory requirements
  • Best practice, national guidance e.g., NICE
  • Evidence and analysis of need: York JSNA

North Yorkshire JSNA

East Riding JSNA

  • System impact – pressures on the system, providers including voluntary sector, local authorities, or neighbouring CCGs
  • Current performance – baseline data if available/ applicable
  • Benchmarking data if available/ applicable
  • Lessons learned from poor performance (Serious Incidents/ Safeguarding etc.)
  • Risks and any mitigating actions
  • Capacity to deliver

There is an increasing elderly population, with increasing incidence of frailty and multi-morbidity who have complex needs. The 5 year Forward view recognised the need for increasing support for the frail population, whilst recognising the need to deliver care more locally i.e. in primary care.

The British Geriatric Society (BGS) have produced and endorsed several publications around support for patients with frailty. Gold standard assessment is Comprehensive Geriatric Assessment (CGA), however this is lengthy and hence not feasible for everyone who would require it. Medication review is an important part of CGA and Fit for Frailty and The BGS Commissioning Guidance: High Quality Health Care for Older Care Home Residents recognise the need to undertake reviews in patients with frailty. The Quality Care for Older People with Urgent and Emergency Care Needs “Silver book” (2012) recognises the need for primary care lead management of long term conditions to reduce unscheduled care episodes – it discusses how polypharmacy is often one of the main causes of emergency admissions and results in increased hospital length of stay.

Medication review in frailty care is also important as there are higher levels of avoidable harm amongst older people, with medication errors being the second biggest cause of patient safety incidents nationally (NRLS 2011). The Kings Funds document Polypharmacy and medicines optimisation: making it safe and sounds, (2013) also details how patients on multiple medications are at higher risk from adverse drug events and more likely to be admitted to hospital.

Polypharmacy and medicines optimisation (The Kings Fund, 2013) recognises that patients with limited life expectancy are particularly difficult to manage due to their complex needs, this therefore can be said of care home resident as they have a limited life expectancy (Molyan et al 2008). The Kings fund emphasise the importance of reviewing medications with reference to the individual as guidelines and evidence are not as applicable. This transition from disease treating approach to one of palliative care can be challenging with the need for clear and careful communication to ensure that patients and carer’s have a good understanding of the rationale.

The STOPP/START criteria were developed by Gallagher et al (2008), the STOPP arm comprises of contains 65 criteria for potentially inappropriate prescribing in older people, with an explanation attached to each. It was validated by a consensus panel for patients over 65yrs old and Parsons et al, 2012, showed that it was a useful tool to facilitate medication reviews in care home patients. Further more, Silva et al 2015 demonstrated that application of STOPP criteria in care home patients by a pharmacist lead to improvement in medicines safety and cost reduction. Two reviews of STOPP/START tool (Aziz, 2015 and Hill-Taylor et al. 2013) summarises that the criteria are validated and reliable and suggest that they can be used to help medicine optimization.

Ryan et al 2012, amongst other detailed in section 1, demonstrated that a high proportion of care home patients are prescribed at least one potentially inappropriate medication. Fit for Frailty suggests that the STOPP criteria can be used in patients with frailty to conduct evidence-based medication reviews and can lead to discussions around the individual’s ongoing care, with possible referral onward for specialist care, thus leading to a fuller, more comprehensive assessment, including issues around end of life care. Again the Silver book suggests that the STOPP/START criteria may be beneficial in helping to reduce potentially inappropriate prescribing amongst older people.

As the population ages these issues will become an increasing problem and there will be an increasing pressure on healthcare services to insure appropriate prescribing, patient safety and reduction in harm as well as cost efficiency. Therefore, there will be an increasing need for healthcare professionals with the skills to undertake medication and clinical reviews of patients who experience polypharmacy and inappropriate prescribing. This will increasingly fall upon primary care physicians as they take on the care of complex elderly and frail populations - particularly care home residents.

Currently the National Service Framework for older people states that all over 75's should have and annual medication review and that those patients on 4 or more medications should have a medication review 6 monthly. GMS sets targets and QOF requires that medications review are conducted at a "Level 2" - Treatment review: review of medications with patients full notes with or without the patient. This proposal therefore suggests that by applying STOPP criteria to care home residents, the PMC can improve upon their existing care by added in a validated tool with an evidence basis, thus increasing their confidence in decision making around stopping medications.

Risks of this proposal:

Risks / Mitigation actions
Increased GP time to undertake medication reviews as stopping medications may lead to requirements to allocate time for discussions with patients and families / But will enable more holistic approach and can incorporate patients reviews with medication review to increase sustainability
Patients and/or families attitudes towards stopping medications / Need to ensure clear communication
Increased onward referrals / Could source a secondary care advise link
Unable to appoint clinical pharmacists
Reviews by pharmacist/ANP may also use GP time / Regardless there would still be an overall reduction in their time
Attitude of patients/family towards reviews by ANP/pharmacists / Need to ensure clear communication

References:

  • Aziz V. 2015. RCPsych in Wales eNewsletter - Winter/Spring 2015. Can be found at: Accessed October 2015
  • Fit for Frailty. British Geriatric Society 2014
  • Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D (2008). ‘STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation’. International Journal of Clinical Pharmacology and Therapeutics, vol 46:72–83.
  • Hill-Taylor B, Sketris I, Hayden J, Byrne S, O'Sullivan D and Christie R (2013). Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. Journal of Clinical Pharmacy and Therapeutics, vol 38 (5); 360–372.
  • Molyan T, Roberts M and Murray S. Medical needs and survival of NHS continuing care residents. Scottish medical Journal, vol 53; 21-23
  • NRLS 2011: National Learning and Reporting Service
  • Parsons C, Johnson S, Mathie E, Baron N, Machen I, Amador S and Goodman C (2012). Potentially inappropriate prescribing in older people with dementia in care homes: a retrospective analysis. Drugs Ageing vol 29 (2);143-55
  • Polypharmacy and medicines optimization: making it safe and sound. The Kings Fund 2013
  • Ryan C, O’Mahony D, Kennedy J, Weedle P, Cottrell E, Heffernan M O’Mahony B and Byrne S (2013). Potentially in appropriate prescribing in older residents in Irish nursing homes. Age Ageing 29(6);116-120
  • The Quality Care for Older People with Urgent and Emergency Care Needs “Silver book” (2012)
  • The BGS Commissioning Guidance: High Quality Health Care for Older Care Home Residents
  1. Strategic Initiatives

Select the Strategic Initiative this project is contributing to – seeIntegrated Operational plan
Y/N
Integration of Care / Y
Person Centred Care / Y
Primary Care Reform / Y
Urgent Care Reform
Planned Care / Y
Transforming mental health and learning disability services
Children and maternity
Cancer, palliative and end of life care / Y
System Resilience – impact on unplanned care resilience plan (see Andrew Phillips*) / Y
System resilience – impact on planned care resilience plan (see Caroline Alexander*)

4. Engagement

Please consult with Kevin Aston, Engagement Lead

  • You said, we did – provide a summary of any engagement with patients, public, carers, partners, local clinicians, providers or partnership work to date.
  • Outline how you will engage with stakeholders as this scheme develops.

This proposal aims to improve care around medications for frail and elderly people but there is also evidence that undertaking medication reviews with the use of STOPP and reducing potentially inappropriate prescribing, hence reducing adverse drug events and potential hospital admissions will lead to this being a cost neutral or may lead to cost savings. This could therefore lead to an "Invest and reward" type scheme for the future which would improve engagement from other practises.

  1. Financial Analysis

Please complete this section in partnership with Finance and Contracting – contact Gordon Masson

  1. Activity and Cost Assumptions
  • Provide a summary of financial and activity implications of the proposed scheme
  • Attach or embed a detailed analysis of these assumptions, include, for example:
  • Point of delivery i.e. elective care, unplanned care
  • Type of activity i.e. acute, community, diagnostics
  • Activity information at the lowest detail available i.e. HRG level
  • Timescales e.g. phasing in times and time to become fully effective
  • Levels of activity – activity in and taken out
  • Impacts of finance and activity i.e. on providers, point of delivery
  • Reference the methodology used for these assumptions, the source and its reliability

Cost for time taken for reviews: / GP (control verses intervention) / Components to consider / Admin/preparation
ANP / Face to face time
Pharmacists / GP time if ANP/pharmacy performing
Additional employment cost
Prescription cost analysis considerations: / Reduction in medications prescribed
Increase/reduction in monitoring/reviewing
Change to alternative medications
Increase/reduction in additional support - ie onward referals
Reduction in admissions / Proxy indicator of risk stratification of potential severity of medication stopped?
  1. Others cost consideration:
  • Employment costs
  • Training of use of STOPP