Medicines Optimisation Polypharmacy Prescribing Comparators, a presention by Clare Howard FFRPS FRPharmS Clinical Lead. Wessex AHSN and SPS

1. Wessex AHSN and SPS
5th July 2017
Clare Howard FFRPS
FRPharmS Clinical Lead
Medicines Optimisation
Polypharmacy Prescribing Comparators

2. • In 2002, there were 617 million items dispensed, in 2012, there
were 1,000.5 million (an increase of 62%)
1
• In 2015, 1,083.6 million prescription items were dispensed
overall, a 1.8 per cent increase (19.1 million items) from 2014.
This is an increase of 50.4 per cent (363.4 million) on the
number dispensed in 2005; 720.3 million items
2
• The average number of prescription items per head of the
population in 2015 was 19.8, compared to 19.6 items in the
previous year and 14.3 in 2005 and 13 in 2003 2
• One third of over 75’s now take at least six medicines 3
IS IT HAPPENING IN ENGLAND?

3. POLYPHARMACY
So what?
• A person taking ten or more meds is 300% more likely
to be admitted to hospital (4)
• 6.5% of hospital admissions are for adverse effects of
medicines this rises to 17% in the over 65 age group.
• 30 – 50% of people do not take their medicine as
intended by the prescriber.
• Over 70% of hospital admissions for adverse reactions
to medicines could be avoided.

4. MEDICATION SAFETY
We aren’t getting it right…
Evidence from primary care shows:
• 1 in 20 prescription items has an error and 1 in 550 is serious
5
• Prescription errors had been made for one in eight patients
overall, and four in ten patients over 75 years of age. In all, 1 in
20 prescriptions written featured an error. Of the errors, 42%
were judged to be minor, 54% moderate and 4% severe.
• In 2013, there were over 1 billion items dispensed in England
therefore this equates to 1.8 million serious errors 3
• Adverse drug reactions account for 6.5% of hospital admissions
and over 70% of the ADRs are avoidable.
• Over 50% of errors were in 4 disease classes, antiplatelets,
NSAIDs, diuretics and anticoagulants5

5. POLYPHARMACY PRESCRIBING
COMPARATORS - THE STORY SO FAR….
Wessex AHSN workshop November 2015.
“Metrics” identified as a key starting point.
There seemed little point developing just for one
locality?
Why not engage NHS BSA and NHS Digital and
develop some national measures?
So we held a small workshop. GPs, Pharmacists,
BSA, RPS, NHS Digital and others. RCGP also aware
and engaged.

6. FOR EACH INDICATOR WE ASKED..
• Is it useful?
• Is it valid? (are there any health warnings)
• How would you use it?
• What other data sources might make it more
meaningful?
• In or out? i.e should it be included in the final
polypharmacy measures?
• Any other measures that the group could
suggest?

7. INITIAL SUGGESTIONS FOR POLYPHARMACY
PRESCRIBING INDICATORS
1. Average number of items per patient by CCG/ Practice
2. Average number of items per ASTRO PU by CCG/ Practice
3. Can you do average number of items in patients over 75?
4. Can you do average number of items in patient over 65
5. Number of patients on 10 or more meds over 65
6. Number of patients on 10 or more meds over 65
7. Number of patients on 4 or more meds over 65
8. Number of patients on 4 or more meds over 65
9. Number of patients on 20 or more meds over 65 and 75
10. Spend on top 10 drugs in STOPP part of STOPP start tool by
CCG in the over 75’s (controversial but this is a workshop)
11. Anticholinergic burden score in over 75s by CCG/ Practice
Have changed a bit since this first list…..

8. BSA AND HSCIC WORKED THEIR MAGIC….

9. LIMITATIONS:
• Historically, prescribing information was derived from the reimbursement
processes for dispensed medicines. However, the BSA is now able to
capture extra information that undoubtedly adds value to prescribing
measures.
• The NHS number can now be linked to prescription items. In this way, we
are able to demonstrate much better the quality of prescribing in key
areas.
• The polypharmacy prescribing comparators are the first suite of measures
to take advantage of this development. Currently, 92% of all prescription
items can be linked to an NHS number with an accuracy of 99%. Age and
date of birth can be linked to 73% of items with an accuracy of 99%. As the
utilisation of electronic prescribing (EPS) increases, the coverage and
accuracy of this data will increase.
• Therefore, CCGs are encouraged to drive up the uptake of EPS. To support
this improvement, EPS levels have been included at the start of these
comparators.

10. SO, THE FINAL DATA SET
These comparators will be available at GP Practice, and CCG level
and will include measure such as…
• The average number of unique medicines prescribed per patient
• Percentage of patients prescribed 8 or more unique medicines,
10 or more unique medicines, 15 or more unique medicines, 20
or more unique medicines
• Percentage of patients with an anticholinergic burden score of 6
or greater, 9 or greater, 12 or greater
• Percentage of patients prescribed multiple anticoagulant regimes
• Percentage of older patients prescribed medicines likely to cause
Acute Kidney Injury (DAMN Drugs)
• Percentage of patients prescribed a NSAID and one or more other
unique medicines likely to cause kidney injury (DAMN medicines)

11. PORTSMOUTH CCG PERCENTAGE OF
PATIENT WITH ACB SCORE OF 9 OR MORE

12. PORTSMOUTH CCG PERCENTAGE OF PATIENTS
ON 15 OR MORE UNIQUE MEDICINES

13. ePACT2 is now live and the roll out to users has begun.
Initially, only 2 users per CCG will be given access with further
users being added in a phased approach. Over the next few weeks
and months we will also be writing out to existing ePACT Users in
order to transfer them onto our new improved system. The plan is
to complete roll-out by Autumn 17.
If you would like to request access to ePACT 2 please drop the
NHS BSA an email nhsbsa.informationsystems@nhs.net
Further information regarding ePACT 2, including the benefits can
be found on NHS BSA’s
website (https://www.nhsbsa.nhs.uk/epact/epact2)

14. CORE PATIENT MESSAGES….
• Polypharmacy is not about reducing medicines costs – it is
about making sure you are only on the medicines you need,
to live well and avoid unnecessary or unplanned visits to
hospital.
• As you get older, medicines may no longer be appropriate for
you as your body changes. It may be time for a medication
review.
• Taking too many medicines increases your risk of going into
hospital.
• So – you should know your medicines. If not, speak to your
Pharmacist or GP.
• Don’t stop taking medicines without a review. Your local
Community Pharmacist can review how you use your
medicines and make recommendations to your GP. Ask them
today.

15. RESOURCES
http://www.sign.ac.uk/pdf/p
olypharmacy_guidance.pdf
See http://wessexahsn.org.uk/programmes/
11/medicines-optimisation
https://www.cppe.ac.uk
http://www.kingsfund.org.uk

16. Name Role/Organisation
Clare Howard Clinical Lead, Medicines Optimisation, Wessex Academic Health Science Network (Chair)
Graham Mitchell Information Services Manager, NHS Business Service Authority
Paul Brown Senior Pharmaceutical Adviser, NHS Digital
Neil Watson Clinical Director of Pharmacy and Medicines Management, Newcastle Hospitals NHS Foundation Trust
Vicki Rowse Programme Lead, Medicines Optimisation, Wessex Academic Health Science Network
Julia Blagburn Senior Lead Clinical Pharmacist for Older People's Medicine and Community Health, Newcastle Hospitals NHS Foundation
Trust.
Michelle Trevett Senior Pharmacist ,NHS Dorset Clinical Commissioning Group
Dr Paul Mason GP and Prescribing Lead ,NHS Dorset Clinical Commissioning Group
Dr Lawrence Brad GP and RCGP Polypharmacy Lead
Dr Simon Flack GP and Locality Lead ,NHS Dorset Clinical Commissioning Group
Simon Cooper Head of Prescribing Support, Portsmouth Clinical Commissioning Group
Katie Griffiths Medicines Safety Officer, Dorset University Healthcare NHS FT
Catherine Armstrong Lead Pharmacist – Pharmicus, English Pharmacy Board, Royal Pharmaceutical Society
Helen Kennedy Prescribing Analyst, NHS Dorset Clinical Commissioning Group
HUGE THANKS TO THE WORKING GROUP

18. WHERE NEXT???
EVALUATION: Does this
data truly identify those
most at risk from harm?
How do we join up with
secondary care??
Let’s not get to
10 medicines in
the first place! Research to
help us to stop
medicines
safely!
Trigger tool to
ensure a review
when patient is
about to go from
9-10 medicines
Tools that helps
the practice to
identify and
prioritise the
patients most in
need of review.

19. Health Warning:
‘indicators only indicate’