Inga Andrew

Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review

Objectives To systematically review the literature to examine the methods used to identify inappropriate prescribing of preventative medication in patients with life-limiting illness and to detail the nature of medications prescribed. Methods A systematic literature search of 4 databases was undertaken (MEDLINE, EMBASE, CINAHL, PsycINFO) from inception to April 2015 to identify peer-reviewed, observational studies assessing inappropriate prescribing of preventative medication in patients with life-limiting illness. Inclusion criteria were: participants had a life-limiting illness; prescribed/dispensed/using preventative medication; medication appropriateness assessed as a specific study aim or outcome. Results We found 19 studies meeting our eligibility criteria. The methods used to assess medication appropriateness included criteria developed for the elderly such as the Beers Criteria, and Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, Delphi consensus and expert clinical opinion. Lipid-regulating drugs (12 studies), antihypertensive (11 studies) and antidiabetic medications (9 studies) were the most common classes of inappropriate medication identified. Conclusions Patients with life-limiting illnesses are prescribed preventative medications considered inappropriate in the context of diminished life expectancy. The way in which preventative medication appropriateness is assessed in patients with life-limiting illness varies considerably—with some methodologies utilising criteria previously developed for elderly populations. Given this lack of standardisation, improving the prescribing in this context requires an approach that is specifically designed and validated for populations with life-limiting illness.

'I don't think I'd be frightened if the statins went': a phenomenological qualitative study exploring medicines use in palliative care patients, carers and healthcare professionals.

BackgroundThere is a growing body of evidence suggesting patients with life-limiting illness use medicines inappropriately and unnecessarily. In this context, the perspective of patients, their carers and the healthcare professionals responsible for prescribing and monitoring their medication is important for developing deprescribing strategies. The aim of this study was to explore the lived experience of patients, carers and healthcare professionals in the context of medication use in life-limiting illness.MethodsIn-depth interviews, using a phenomenological approach: methods of transcendental phenomenology were used for the patient and carer interviews, while hermeneutic phenomenology was used for the healthcare professional interviews.ResultsThe study highlighted that medication formed a significant part of a patient’s day-to-day routine; this was also apparent for their carers who took on an active role-as a gatekeeper of care-in managing medication. Patients described the experience of a point in which, in their disease journey, they placed less importance on taking certain medications; healthcare professionals also recognize this and refer it as a ‘transition’. This point appeared to occur when the patient became accepting of their illness and associated life expectancy. There was also willingness by patients, carers and healthcare professionals to review and alter the medication used by patients in the context of life-limiting illness.ConclusionsThere is a need to develop deprescribing strategies for patients with life-limiting illness. Such strategies should seek to establish patient expectations, consider the timing of the discussion about ceasing treatment and encourage the involvement of other stakeholders in the decision-making progress.

Are we using oxycodone appropriately? A utilisation review in a UK tertiary care centre

Objectives To evaluate the utilisation of oxycodone in a tertiary care centre based in the North of England serving a population of 330 000. Methods A prospective study which gathered data from October 2011 to March 2012. Medical notes were screened to determine the prevalence of oxycodone use during the study period. The medication histories were determined; once the reason for oxycodone initiation was established, it was interpreted and classified as either appropriate or inappropriate. Results During the study period, a total of 51 patients were taking oxycodone; one patient was lost to follow-up. General practitioners were found to be the most common group responsible for initiating oxycodone (22 patients, 44%), followed by specialist palliative care nurses (11 patients, 22%). Other prescribers included palliative care consultants (nine patients, 18%); hospital doctors (seven patients, 14%) and a site-specific specialist nurse (one patient, 2%). Of the 50 patients, 17 (34%) were considered to be using oxycodone inappropriately. The most frequent reason for inappropriate use was initiating oxycodone without initially trying morphine. Conclusions Oxycodone is initiated inappropriately in a significant number of palliative care patients and should only be used as a second-line strong opioid or if morphine is not suitable or cannot be tolerated. The specialist palliative care team should be consulted for advice in cases of complex pain management.

Quantification of drug-related toxicity associated with the prescribing of inappropriate medicines for patients with limited life expectancy.

Research poster from Royal Pharmaceutical Society (RPS) Annual Conference 2013, 8-9 September 2013, Birmingham, UKFocal points 1. Polypharmacy is common amongst patients with limited life expectancy; 2. Prescribing of inappropriate medicines for patients with limited life expectancy can lead to multiple drug interactions of varying severity; 3. Patients with limited life expectancy should have their medicines reviewed in line with the original therapeutic goals. Background For patients with limited life expectancy – typically surviving for less than one year from diagnosis – polypharmacy is common as medication is prescribed to manage both life limiting illness and to treat or prevent other long-term conditions. Consequently, there is an increased risk of developing drug-related toxicity resulting from drug-drug or drugdisease interactions. The aim of this work was to assess the prevalence of inappropriate medication and identify any potential theoretical drug-drug interactions in patients attending a specialist palliative care unit. Methods This was a prospective study that examined medication and medical histories for patients attending a specialist palliative care day care centre from November 2012 until March 2013. Medication was assessed for appropriateness using a conceptual framework, which considers remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. 1 Consensus was reached via Delphi methodology using a range of clinical pharmacists and consultants in palliative medicine; to reach consensus agreement was required from all panel members. Drug interactions were identified and assessed according to significance using the drug interaction recognition software, Proscript. Drug interactions identified as significant were further sub-classified as moderate or severe based upon the potential to cause harm or hospitalisation, if they were reversible or irreversible and, if any treatment would be required to manage the outcome. Results A total of 132 patients were assessed during the study period, 108 (82%) had cancer, 8 (6%) congestive heart failure, 11 (8%) severe chronic obstructive pulmonary disease and 5 (4%) Parkinson’s disease. In total, the number of medications taken was 1532 (mean per patient, 12; range 1 to 21). Of the 1532 medicines assessed, 238 (16%) were considered to be inappropriate given the patients limited life expectancy. Out of the 132 patients assessed, 92 (70%) were taking at least one inappropriate medication. The most common therapeutic group considered inappropriate were the statins, which were prescribed in 35 patients (27%). The drug interaction recognition software identified a total of 267 potential drug interactions: 155 were considered non-significant, while 112 were classified as significant. Among those identified as significant, 92 were considered moderate while 20 were considered severe. In our study, discontinuing inappropriate medicine would prevent 57 non-significant, 23 moderate and 8 severe potential drug interactions. The most frequent major potential drug interaction that could be prevented by discontinuing inappropriate medication was between simvastatin (> 20 mg daily) and amlodipine, a well-defined drug interaction, which increases the risk of myopathy; this was identified in 4 patients. Discussion Our results show that the majority of people accessing the day care centre in a specialist palliative care unit are being prescribed many inappropriate medications in view of their life limiting illness. These inappropriate medications contribute to potential drug interactions and thereby increase the risk of patients developing drug-related toxicty. Our findings are consistent with the literature and build upon our previous work that showed patients with advanced lung cancer take many inappropriate medications, some of which can potentially interact with chemotherapy and contribute to negative outcomes for patients. 2 In conclusion, these findings demonstrate there is potential for pharmacists to become involved in medication review for patients with limited life expectancy in order to faciliate discontinuation of inappropriate medication in the context of the origninal therapeutic goals. References 1. Holmes HM, Hayley DC, Alexander GC et al. Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine. 2006, 166, 605-9. 2. Todd A, Williamson S, Husband A, et al. Patients with advanced lung cancer: is there scope to discontinue inappropriate medication? International Journal of Clinical Pharmacy. 2013, 35, 181-4The End of Life Care Strategy published by the Department of Health in 2008, describes the role healthcare and non-healthcare professionals, including pharmacists, can play in the delivery of care to people at the end of life. The minimum level of skills and knowledge described for the effective provision of healthcare within various sectors highlights the need for the highest level of communication skills and collaborative working within healthcare teams1. Pharmacy education has responded to develop curricula that incorporate experience-based learning that involves ‘participation in practice’ evolving along a spectrum from passive observation to performance. This study reports students’ qualitative evaluation of a placement in practice with respect to outcomes achieved from the experience.• This study aimed to explore the views of the senior learning and development managers (SLDMs) at large multiple community pharmacies (LMCPs) on pharmacist professional development. • Participants recognised that community pharmacists cannot fulfil their roles without further development. • Employer support for postgraduate qualifications as a means to address these development needs has been limited and opportunities have tended to be restricted to community pharmacists performing successfully in their role.

A palliative care (PC) hospice placement : students' qualitative evaluation of experience-based learning.

Research poster from Royal Pharmaceutical Society (RPS) Annual Conference 2013, 8-9 September 2013, Birmingham, UKFocal points 1. Polypharmacy is common amongst patients with limited life expectancy; 2. Prescribing of inappropriate medicines for patients with limited life expectancy can lead to multiple drug interactions of varying severity; 3. Patients with limited life expectancy should have their medicines reviewed in line with the original therapeutic goals. Background For patients with limited life expectancy – typically surviving for less than one year from diagnosis – polypharmacy is common as medication is prescribed to manage both life limiting illness and to treat or prevent other long-term conditions. Consequently, there is an increased risk of developing drug-related toxicity resulting from drug-drug or drugdisease interactions. The aim of this work was to assess the prevalence of inappropriate medication and identify any potential theoretical drug-drug interactions in patients attending a specialist palliative care unit. Methods This was a prospective study that examined medication and medical histories for patients attending a specialist palliative care day care centre from November 2012 until March 2013. Medication was assessed for appropriateness using a conceptual framework, which considers remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. 1 Consensus was reached via Delphi methodology using a range of clinical pharmacists and consultants in palliative medicine; to reach consensus agreement was required from all panel members. Drug interactions were identified and assessed according to significance using the drug interaction recognition software, Proscript. Drug interactions identified as significant were further sub-classified as moderate or severe based upon the potential to cause harm or hospitalisation, if they were reversible or irreversible and, if any treatment would be required to manage the outcome. Results A total of 132 patients were assessed during the study period, 108 (82%) had cancer, 8 (6%) congestive heart failure, 11 (8%) severe chronic obstructive pulmonary disease and 5 (4%) Parkinson’s disease. In total, the number of medications taken was 1532 (mean per patient, 12; range 1 to 21). Of the 1532 medicines assessed, 238 (16%) were considered to be inappropriate given the patients limited life expectancy. Out of the 132 patients assessed, 92 (70%) were taking at least one inappropriate medication. The most common therapeutic group considered inappropriate were the statins, which were prescribed in 35 patients (27%). The drug interaction recognition software identified a total of 267 potential drug interactions: 155 were considered non-significant, while 112 were classified as significant. Among those identified as significant, 92 were considered moderate while 20 were considered severe. In our study, discontinuing inappropriate medicine would prevent 57 non-significant, 23 moderate and 8 severe potential drug interactions. The most frequent major potential drug interaction that could be prevented by discontinuing inappropriate medication was between simvastatin (> 20 mg daily) and amlodipine, a well-defined drug interaction, which increases the risk of myopathy; this was identified in 4 patients. Discussion Our results show that the majority of people accessing the day care centre in a specialist palliative care unit are being prescribed many inappropriate medications in view of their life limiting illness. These inappropriate medications contribute to potential drug interactions and thereby increase the risk of patients developing drug-related toxicty. Our findings are consistent with the literature and build upon our previous work that showed patients with advanced lung cancer take many inappropriate medications, some of which can potentially interact with chemotherapy and contribute to negative outcomes for patients. 2 In conclusion, these findings demonstrate there is potential for pharmacists to become involved in medication review for patients with limited life expectancy in order to faciliate discontinuation of inappropriate medication in the context of the origninal therapeutic goals. References 1. Holmes HM, Hayley DC, Alexander GC et al. Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine. 2006, 166, 605-9. 2. Todd A, Williamson S, Husband A, et al. Patients with advanced lung cancer: is there scope to discontinue inappropriate medication? International Journal of Clinical Pharmacy. 2013, 35, 181-4The End of Life Care Strategy published by the Department of Health in 2008, describes the role healthcare and non-healthcare professionals, including pharmacists, can play in the delivery of care to people at the end of life. The minimum level of skills and knowledge described for the effective provision of healthcare within various sectors highlights the need for the highest level of communication skills and collaborative working within healthcare teams1. Pharmacy education has responded to develop curricula that incorporate experience-based learning that involves ‘participation in practice’ evolving along a spectrum from passive observation to performance. This study reports students’ qualitative evaluation of a placement in practice with respect to outcomes achieved from the experience.• This study aimed to explore the views of the senior learning and development managers (SLDMs) at large multiple community pharmacies (LMCPs) on pharmacist professional development. • Participants recognised that community pharmacists cannot fulfil their roles without further development. • Employer support for postgraduate qualifications as a means to address these development needs has been limited and opportunities have tended to be restricted to community pharmacists performing successfully in their role.

A solution to the problem of clinical supervision for lone allied health professionals within a hospice setting

Background Clinical supervision has long been an integral part of practise within the nursing profession, and more recently with allied health professions, the benefits of which have been demonstrated in the literature. Within the Hospice setting, allied health professionals (AHPs) often work alone within their professional group. During informal discussions, AHPs at St. Benedicts Hospice found they were experiencing similar challenges and changes to their clinical practise. Aims To establish a peer-led, AHPs, clinical supervision group. Method: All AHPs working for the Hospice, were invited to attend; chaplain, occupational therapist, physiotherapist (community), physiotherapist (Hospice), lecturer/practitioner, pharmacist, social worker. The social worker declined to participate due to different management structures. Monthly, hour long meetings were planned, with each member agreeing to facilitate sessions on a rota for a year. A basic structure was established, including that brief notes would be taken on the following; What were the issues/problems? Analyse the event Proposed actions following the event What is the main learning taken away from the event? Outcomes Over the first year the mean number of participants per meeting was 4 (66%). The percentage of meetings participants attended ranged from 100 to 38%. The brief notes demonstrated participants sent apologies if unable to attend. After a year, participants all gave positive feedback, particularly about the benefits of supporting one another through times of great change within the NHS. The group was keen to continue and formally agreed an ‘AHPs clinical supervision contract’ including details of; ground rules, structure, documentation and evaluation. The success of the group continues, the mean percentage of AHPs at meetings this year is 75%. Conclusion This well attended model of multidisciplinary clinical supervision could prove to be a solution to the problem of supervision for lone allied health professionals within a Hospice setting.

Implementing a system for tackling under‐eporting of adverse drug reactions within a district general hospital

□ The aim of the project was to produce a sustainable, stimulating ongoing programme to improve adverse drug reaction (ADR) reporting rates