To assess the impact of a clinical pharmacy medication review service in improving patient safety via optimising medication use in polypharmacy patients.
Caring for an aging population with multi-morbidities is the single greatest challenge facing healthcare to date. An increasingly older and frail population with complex medical needs has shifted the delivery of care from the acute setting into the community.
It is estimated that 11% of unplanned hospital attendances are attributed to medication related harm1. The majority of these consist of elderly patients prescribed multiple medications which include high risk therapies. By proactively identifying and rationalising inappropriate polypharmacy in patients at high risk of medication harm, there are significant opportunities for reducing unplanned hospital admissions.
The team consists of six whole-time equivalent pharmacists based across 40 GP (general practitioner) practices. The service provides structured medication reviews focusing on assessing adherence, rationalising drug therapy and reducing inappropriate polypharmacy in compliance with medicines optimisation principles. Reviews are conducted either at patient residences or their surgery. The target patient cohort of frail or older persons prescribed polypharmacy was identified from searches within GP clinical systems and through referrals from clinical practitioners, voluntary and social care services. Patients reviewed between April 2017 and March 2018 were included in the study. For each patient reviewed a score was attributed based on the RiO scoring system. This study did not require ethics approval.
Patients, carers and relatives, GP practice staff, thee local CCG and the national NHS budget.
To optimise and or rationalise medication use in frailty elderly patients.
A total of 1,300 patients were referred into the service and reviewed. Of these, 43% (n=559) originated from GPs and 24% (n=306) were classified as moderate to severely frail by the Electronic Frailty Index (eFI)1. 12% of reviews involved initiating medication to manage previously unmet health needs. 11% of reviews resulted in onward referral to other primary care services and 9% of patients were deprescribed high risk medicines1. 4.5% (n=58) of patients reviewed were ascribed as high risk of readmission. Over the 12-month period a total of 3,680 interventions were recorded, a mean of 2.8 interventions per patient. 91% (n=3342) of interventions were agreed and actioned by the relevant clinician.
Targeted medication reviews of patients at risk of hospital admission demonstrated a number of benefits. Domiciliary visits offered patients improved access to specialist medicines advice and reduced inappropriate polypharmacy. The main limitation of this study was the quality of data collected was not sufficiently robust to draw a causative link between pharmacist interventions and admissions avoidance. The utilisation of more sophisticated information technology solutions in the future will improve data collection and analysis. Additionally, an admissions avoidance peer review panel has been established to review scoring system. Moreover, a retrospective audit of patients is planned to ascertain if reduced polypharmacy as a result of pharmacist review, reduced hospital admissions.
