Medicines review care planning

what are the problems with medicines use

• adverse drug reactions cause hospital admissions

• adverse drug reactions during hospital admissions are due to new treatments started

• prescribing errors

• increasing antimicrobial resistance

• some medicines aren’t taken as prescribed → avoidable waste in primary care estimated at £150m/year

what are never events 

largely preventable patient safety incidents that should never occur in healthcare if established national guidance and safety procedures are followed

what is the NHS England never events list

five relate to medication 

• mis-selection of strong potassium 

• wrong route of administration

• overdose of insulin due to abbreviations or incorrect device 

• overdose of methotrexate 

• mis-selection of high strength midazolam for conscious sedation 

what are the cost effects of medicine use

• In 2022 /23

  • the total cost to NHS commissioners for medicines, appliances and medical devices was £18.5 billion (7.6% increase compared to previous year)

  • almost 50:50 split between primary and secondary care

• In 2023 / 24

  • 1.21 billion items dispensed in community pharmacy (3% increase
    from previous year)

  • Cost = £10.9billion (5% increase from previous year)

what is a medication review

• a structured critical examination of a person’s medicines

• the objective are to:

  • reach an agreement with the person about treatment

  • optimise the impact of medicines

  • minimise the number of medication-related problems

  • reduce waste

what is room for review

defines the different levels of reviewing a patient’s medicines

• Level 0 → unstructured, opportunistic review

  • looking at an FP10 prescription and want to know what else they’re on 

• Level 1 → prescription review

  • technical review of patient’s full medicines list

  • doesn’t require access to patient’s notes

• Level 2 → treatment review

  • uses patient’s full notes

  • requires access to patient’s notes so you get information about all the co-morbidities that need to be treated, up to date blood test results etc

• Level 3 → clinical medication review

  • face to face review of medicines and conditions

  • patient is present

what do you need to consider during a medicines review

• current status of the patient 

• person’s / family’s views, understandings and concerns 

• problems and conditions the patient has, or is at risk of 

• are treatment goals being achieved?

• adverse drug reactions → evident or at risk of 

• potential medication changes 

why would there be potential medication changes 

• the safety and efficacy of the medicines

• monitoring requirements 

• patient preference 

• cost 

who needs a medication review 

• patients starting a new medicine 

• patient request

• patients transferred between settings 

• hospital ward rounds 

• higher risk groups identified through screening tools 

• follow up from previous review

what tools support medication reviews

• STOPP screening tool

• STOPPFrail tool  

• Beers criteria 

• Anticholinergic burden scales 

• Medication Appropriateness Index (MAI)

• STOMP

STOPP screening tool

• identifies potentially inappropriate prescriptions in people above 65 years 

• considers several BNF categories, drugs that affect people with falls etc

STOPPFrail tool  

• 27 medicines criteria that identifies inappropriate medicines for people with poor prognosis (shortened life expectancy)

• example: lipid-lowering therapy, antiplatelets, osteoporosis treatments, oral anti-diabetic agents, multivitamins 

Beers criteria 

• identifies inappropriate medications for the elderly 

• examples: anticholinergics, nitrofurantoin, alpha blockers for hypertension, long-acting sulphonylureas

Anticholinergic burden scales 

identifies medicines that have a negative effect on cognitive function 

Medication Appropriateness Index (MAI)

looks at ten questions considering the drug’s efficacy, dosage, administration practicality etc 

STOMP

• stops over-medication of people with a learning disability, autism or both

• these patients are more likely to be given medicines for psychosis, depression, anxiety, sleep disorders and epilepsy 

what is the approach to medication review 

• prepare for the encounter with the patient

  • is the person carrying out the review properly trained 

  • consider the environment of where review will take place e.g. face to face and in a clinic room, or online 

  • do we have up to date information about the patient: blood tests, medication list etc 

• conduct the review 

  • introduce yourself 

  • explain the purpose of the review

  • ask for patient’s consent to go ahead with the review 

  • document what was discussed and what the planned actions would be 

• after the review 

  • consider how long records will be kept for, in line with clinical governance requirements

  • do we need to let other HCPs know about the outcome of the review

  • do we need to meet the patient again

what is pharmaceutical care

• the responsible service of drug therapy for the purpose of achieving specific outcomes that improve a patient’s quality of life

• practitioner takes responsibility for a patient’s drug-related needs and is held accountable for this practice

what is the pharmaceutical care model

1. identify problems

2. aims of treatment

3. assessment of problem

4. proposed actions → treatment options and how they would be implemented 

5. monitoring 

pharmaceutical care model: identify problems

• can be a medical, pharmaceutical or social problem

• is it actual or potential?

• can be cured, improved or prevented by

  • drug therapy

  • application of clinical knowledge/skills

• may also be caused/worsened by drug therapy 

how are problems identified in a pharmaceutical care plan

• patient interviews involving medication history 

• clerking by Dr 

• referral letter to hospital 

• lab results and other observation charts 

• observation of patient 

• liaison with other HCPs

• pharmacist’s intuition 

what is on a typical patient’s problem list

• co-morbidities 

• deranged blood tests that aren’t part of other diagnoses

• adherence issues 

• lifestyle issues e.g. smoking 

• risk of complications e.g. risk of osteoporosis if being treated with a repeat course of steroids 

• reason for admission/consultation 

• complications that developed during admission 

pharmaceutical care model: aims of treatment

• aims may be

  • qualitative 

  • quantitative 

  • evidence-based

  • targets set by guidelines 

• use a patient-centred approach → what are their expectations and concerns 

pharmaceutical care model: assessment of problem 

• assessment determines whether any action is necessary 

• need to separate ‘acute’ (e.e.g reasons for admission) from ‘chronic’ problems 

• acute problems:

  • always highest priority 

  • use established severity/prognostic tools where appropriate e.g. pain scores 

  • are there any contributing factors e..g ADR, other relevant co-morbidities, social influences 

what needs to be considered to chronic problems

• consider whether aims of treatment are being met

• reasons for aims not being met:

  • patient needs additional therapy 

  • drug given without an indication

  • dose too high/low 

  • patient receiving wrong drug 

  • patient experiencing ADR

  • patient not taking/receiving prescribed therapy 

pharmaceutical care model: proposed actions, treatment options and how they would be implemented 

what needs to be done:

• wait for effect

• adding or switching to a different drug 

• stopping of therapy altogether 

• dose change 

• different route or formulation 

• patient counselling/education (including lifestyle factors)

• nothing 

what factors are considered when deciding on new medicines or dose adjustments 

• age of patient 

• co-morbidities 

• other medicines

• pregnancy and breast-feeding

• licensing of the product

• ease of administration

• ease of monitoring

• side effects

• evidence

• cost

all this is irrelevant if patient doesn’t want to take the treatment anyway → patient preference needs to be considered

START criteria 

a screening tool to alert prescribers to right treatments for patients older than 65, where no contraindications exist 

• this tools helps address patients where under prescribing may have occurred 

• covers several BNF classes

  • cardiovascular → anticoagulation in presence of chronic AF, ACEI in chronic heart failure 

  • musculoskeletal → biphosphonates in patients taking maintenance corticosteroids

  • endocrine → metformin in type 2 diabetes

what is polypharmacy

use of multiple medicines by a person

• the evidence available for combinations of medicines in multiple conditions in an individual patient is limited 

• two categories of polypharmacy 

  • appropriate polypharmacy → prescribing for an individual  with complex conditions or  multiple conditions, in circumstances where medicines use has been optimised and where medicines are prescribed according to best advice 

  • problematic polypharmacy → prescribing multiple medicines inappropriately, or where the intended benefit of the medicines aren’t realised

pharmaceutical care model: three Ws of monitoring and follow-up

three Ws

• WHY are we doing it?

  • so safety and efficacy of treatments are considered 

• WHAT parameters are being monitored?

  • qualitative or quantitative measures

  • need to be specific e.g. potassium rather than U&Es

  • link to the problem and the medicine 

• WHEN 

  • how long will it take for treatments to have an effect 

  • what is the national guidance on how long we should be monitoring patients for 

pharmaceutical care model: monitoring and follow-up

• focus on what is relevant and important to the patient 

• does cost money to the NHS and has a carbon footprint 

• differentiate between what needs to be done during admission and in the future 

• monitoring results could identify new problems 

• communicating with other relevant personnel 

  • changes made to medication and why

  • follow-up monitoring required

  • concerns about patient

what is the importance of transfer of care

• there is potential for miscommunication and unintentional changes to their medicines 

• recommended core content of records for medicines upon transfer 

  • patient and GP details 

  • allergies (and description of reaction)

  • details of current medicines and medication changes

  • medication recommendations

  • monitoring requirements

  • information that needs to be given to patient or representative