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- Drugs associated with preventable hospital admissions include: warfarin, insulin, non-steroidal anti-inflammatory drugs, digoxin, antihypertensives, benzodiazepines, oral hypoglycaemics, opiates, methotrexate, injectable or enteral medicines and drugs requiring therapeutic drug monitoring.
- Conditions associated with preventable admissions include: chronic obstructive pulmonary disease, asthma, heart failure, Parkinson’s disease and diabetes.
- Pharmacists should also look out for adherence issues, a new request for compliance support, physical or cognitive impairment and social issues.
Medication contributes to between 5 and 20 per cent of hospital admissions and readmissions. Almost half are preventable.Admissions relating to adverse drug reactions cost the NHS up to £466m annually.
In 2004, A North West London Hospitals Trust (NWLHT) based retrospective study found that 15 per cent of general medicine cases (23/154) related to an “adverse event” (eg, a fall), of which 72 per cent were preventable. Of these events 35 per cent were related to medication.
Scullin et al investigated methods of reducing medicines related readmissions. They provided an integrated medicines management service to hospital inpatients on at least four regular medicines, who were taking a high-risk medicine, who were over 65 years and had a hospital admission in the previous six months. Interventions included medicines reconciliation, patient counselling and improved discharge communication. For every 12 patients receiving the service, one readmission to hospital was prevented. They calculated the potential saving for the service as £424 per patient. Garcia-Caballos et al reviewed the management of drug-related problems in older people after hospital discharge and found that the most effective interventions in reducing these should focus on a combination of discharge planning and home follow up.
The Harrow Integrated Medicines Management Service (HIMMS) was established in 2008 as a collaboration between Harrow Primary Care Trust and NWLHT to reduce preventable medicines-related problems and readmissions. As part of this service, we developed the PREVENT tool to help identify patients at risk.
Development of the PREVENT tool
The PREVENT case finding tool was developed using an iterative process.Published tools, including the Fleetwood model, the Combined Predictive Model (including the Castlefield model andSherbrooke questionnaire), and STOPP-START, evidence from literature, action research and expert opinion were used. The tool was refined through reflective practice, root cause analysis and patient feedback.
We identified specific factors relevant to medicines-related risks in older people from our practice, supported by the evidence. Our pharmacists use the tool when visiting patients on admission to a ward, as part of the consultation around medicines reconciliation (see Panel 1). The tool is not prescriptive; it is a guide used in conjunction with pharmacists’ clinical judgement to prioritise patients’ risks. People will refer patients with one or more unresolved issues. For example, warfarin prescribed to a housebound patient who is visually impaired will indicate increased risk only if the patient has no medicines specific support system in place.
PANEL 1: PREVENT TOOL PATIENT REFERRAL CRITERIA
Physical impairment (including difficulty with swallowing, poor manual dexterity, vision, hearing or mobility [eg, patients with arthritis or stroke])
Risk from specific medicine (including anticoagulants, insulin, non-steroidal anti-inflammatory drugs, digoxin, antihypertensives, benzodiazepines, oral hypoglycaemics, opiates, methotrexate, injectable or enteral medicines and drugs requiring therapeutic drug monitoring), with no monitoring or where the medicine has caused the admission
AdhErence issues (Assessors can look out for various dispensing dates on medicines, patients with new medicines or who cannot give names of medicines they are taking. Language issues may be a barrier to communication of all medicines issues.)
CognitiVe impairment (eg, patient is acutely or chronically confused. Assessors refer for mini mental state examination or relevant capacity assessment.)
Exacerbation of or a new diagnosis of a chronic illness causing recurrent admissions (eg, chronic obstructive pulmonary disease, asthma, heart failure, Parkinson’s disease, diabetes), or admission or attending casualty in the previous 30 days
New request for compliance support
SocieTal issues (eg, patient cannot manage daily activities independently or has carers to help with daily activities but not medicines. Assessors can look out for social isolation, financial problems, self neglect, unknown GP, and those who are housebound or who have no fixed abode.)
The HIMMS team receive referrals from both health and social care professionals, but most are from pharmacists. In order to increase referral rates, we have recently adapted the tool for use by nursing staff. Patients referred get a personalised clinical pharmacy service from admission to discharge, which includes:
- Medicines reconciliation (if not previously carried out) and use of patients’ own drugs where appropriate
- Medicines review of all medicines taken (prescribed and non-prescribed)
- Counselling (for patients and carers) on all medicines prescribed and other medicines taken, including a specific adherence assessment
- Documentation of medicines changes and monitoring requirements for specific medicines within the discharge letter to GPs
- Discharge planning, which may include compliance support
- Communication with the health and social care across the secondary and primary care interface regarding pharmaceutical management requirements (including secure fax or email of the discharge information to the relevant primary care professional [eg, community pharmacist] and discussion of a follow-up medicines use review.)
- Post-discharge referral to primary care health and social care professionals, as well as carers where necessary, to ensure continuity of pharmaceutical care
- Post discharge telephone follow-up for patients or carers where required
Results so far
Over the past year PREVENT has helped to identify 147 patients considered to be at increased risk of a medicines-related readmission.
We found that there are three domains of risk associated with preventable medicines-related readmissions: medicine-specific, clinical and social risks (see Panel 2). These are similar to findings in the literature. The most frequent reasons for referral to our service were:
- Adherence issues (102 patients, 69 per cent)
- Compliance support requests (43 patients, 29 per cent)
- Patients with cognitive impairment requiring help (43 patients, 29 per cent)
- Patients taking high risk medicines without appropriate monitoring or review in place (29 patients, 20 per cent).
Some patients were referred for more than one reason.
Of the 147 high risk patients identified, 17 patients were readmitted within 30 days of discharge. The most common reasons included exacerbation of a pre-existing clinical condition (four cases), unresolved existing condition (four) and a new diagnosis (five). Readmissions were usually due to complex clinical issues, and usually involved more than one risk domain. No patients were readmitted with a preventable medicines-related problem.
PANEL 2: RISK DOMAINS
Medicines-related risks Medicines-related factors, such as inadequate monitoring of medication, drug-drug interactions and adverse drug reactions have been identified. Certain medicines account for most of the adverse drug reactions leading to hospital admissions (eg, warfarin, anti-platelet agents, non-steroidal anti-inflammatory drugs and diuretics). Other medicines with increased risk of readmission include insulin, oral hypoglycaemics, antihypertensives, benzodiazepines, opiates, methotrexate, injectable or enteral medicines, and some medicines with a narrow therapeutic range.Studies have shown that communication failures, knowledge gaps about medicines and about medical history between care interfaces can adversely affect admission rate. Intentional and unintentional non-adherence are both reasons for referral to ourservice.
Clinical risks Patients with chronic obstructive pulmonary disease, asthma, heart failure, Parkinson’s disease or diabetes are all at increased risk of readmission, as are those who have recurrent falls or issues with alcohol. Cognitive and physical impairments resulting from illness can also affect a patient’s ability to use their medicines safely.
Social risks Patients with social risks include those who are not fully independent, who may rely on a formal or informal care package to support daily living activities. It is worth noting that not all carers are able to provide medicines management support.
Even when medicines support is provided by carers, patients might need medicines more frequently than the carer visits. Other risk factors include social isolation, being housebound, self neglect, homelessness, having no GP or refusing to visit a GP, financial problems, self neglect, having no fixed abode and alcohol issues.
The HIMMs team recognises that causes of preventable readmission are multifactorial and working within the multidisciplinary team to identify and minimise the preventable medicines-related risks is critical. We are mindful that some patients have broader needs that make medicines management risks a lower priority. For example, for patients who are housebound or who cannot safely manage daily living activities independently, discharge planning will need to take wider issues, such as shopping and cooking into account, as well as medicines issues.
Opportunities for pharmacists
We hope that other pharmacists will find the PREVENT tool useful to support patient identification and workload management, targeting pharmaceutical resource towards patients who will most benefit from interventions. For those working in hospital, we suggest that the first step is to establish a relationship with all health and social care professionals and teams involved in discharge planning for complex patients (eg, discharge co-ordinator, rehabilitation teams, occupational therapists and social workers).
Community pharmacists can use PREVENT to identify and prioritise patients who may benefit from MURs, smoking cessation, repeat dispensing, collection and delivery services, and compliance support assessments. There may be value in developing links with GP practices, district nurses, community matrons, specialist nurses, social workers and care agencies to manage risk factors identified. This will support increased referral or signposting of these patients to services they require. Further developments could include safety MURs for high risk drugs and support identification of patients eligible for the recently announced new medicine service and for targeted MURs.
In the emerging NHS landscape that includes shared responsibility across the care interfaces, GP commissioning and integrated care; pharmacists in all sectors need to be proactive in case finding and case management of patients at risk of preventable medicines-related admissions.
GPs are familiar with the nursing model (Combined Predictive Model), which supports community matrons in identifying patients at risk of readmission and this is an opportunity to extend identification to medicines-related risk. Health and social care commissioners may be interested in integrated medicines management services as a method of reducing preventable admissions and readmissions.
We are investigating ways to validate PREVENT in a range of settings. We hope that validation will provide pharmacists with a robust method of targeting their medicines management services towards patients who need support the most, working towards improved patient outcomes.
We gratefully acknowledge Anna Jenkins, formerly ChiefPharmacist, Harrow PCT and Christine Ward,Chief Pharmacist, NWLH for their dedicated and continued support of this work and Meena Sethi for her primary care input.