Dr Weeliat Chong reviews NICE Guideline 5 on medicines optimisation, outlining the importance of a patient-professional partnership approach
Read this article to learn more about:
- systems for identifying, reporting, and learning from medicines-related patient-safety incidents
- communication of patient information at the point of transfer of care
- patient decision aids and clinical decision support tools.
M edicines are the most common therapeutic interventions in healthcare. In 2014, 1.1 billion prescriptions were dispensed by community pharmacies in England, at a total cost of £8.9 billion.1 The rates of prescribing are expected to rise with the ageing population and the increase in the number of people with long-term conditions and multimorbidity.2,3
A growing body of evidence shows that medicines are often used sub-optimally; up to one half of the medicines prescribed for a long-term condition are not used as intended by the prescriber.4–6 About 159,000 medicine-related patient safety incidents were reported to the National Reporting and Learning System (NRLS) in England between April 2013 and March 2014,7 and 6.5% of hospital admissions are due to adverse drug reactions (ADRs)—over one half of which are preventable.8,9 These avoidable admissions result in nearly 2 million bed days a year with a median length of stay of 8 days and a total cost of £530 million.10 One fifth of re-admissions to hospital within a year of discharge are due to an ADR.11
Moreover, people who may have benefited from prescribed medicines may not always continue to do so, which highlights the importance of a timely review of medicines.3 We need a step change to optimise the use of medicines.
Definition of medicines optimisation
Medicines optimisation is not a new concept. There have been many strategies, models, and concepts with the ultimate aim of optimising the use of medicines over the past two decades. Terms such as 'rational prescribing', 'pharmaceutical care', 'compliance', 'adherence', 'concordance', 'medicines management', 'medicines reconciliation', and 'medication review' have been used to describe various aspects of medicines optimisation.6,12
The Royal Pharmaceutical Society suggests four guiding principles for medicines optimisation:13
- aim to understand the patient's experience
- evidence-based choice of medicines
- ensure medicines use is as safe as possible, and
- make medicines optimisation part of routine practice.
In line with these principles, NICE Guideline (NG5) on Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (see also Box 1, below) defines the term 'medicines optimisation' as:14'A person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.'
|Box 1: NICE Accreditation Mark|
|NICE Guideline 5 on Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes has been awarded the NICE Accreditation Mark.|
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
NICE NG5 outlines how putting patients at the centre of decisions about their care can enable them to use the medicines they are prescribed safely and effectively, and to get the best possible outcomes from medicines.14 NHS England launched an updated Medicines Optimisation Dashboard in May 2015 to help commissioning organisations explore how well placed they are in relation to medicines optimisation across their locality.15 The 48 recommendations in NICE NG5 focus on eight areas that are most likely to deliver positive changes in today's NHS (see Box 2, below).14
Box 2: Eight areas most likely to deliver positive changes in today's NHS14
- Systems for identifying, reporting, and learning from medicines-related patient-safety incidents
- Medicines-related communication systems when patients move from one care setting to another
- Medicines reconciliation
- Medication review
- Self-management plans
- Patient decision aids used in consultations involving medicines
- Clinical decision support
- Medicines-related models of organisational and cross-sector working.
NICE (2015) NG5. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Available at: www.nice.org.uk/guidance/ng5
Reproduced with permission.
Systems for identifying, reporting, and learning from medicines-related patient-safety incidents
Medicines-related patient safety incidents are common and are more likely to occur in people taking multiple medicines (polypharmacy) for long-term conditions.3 These incidents have a wide range of causes, including lack of training, poor communication, failure to adhere to systems and processes, poor documentation, interruptions, and inadequate resources.
It is crucial that patient safety incidents that have or could have led to patient harm (i.e. 'near misses') are reported promptly so that any necessary actions can be taken to prevent similar incidents from occurring in the future. Learning, including feedback on trends or significant incidents, should be shared within the organisation and across the local health economy.14
A robust and transparent system should be established within a 'fair-blame' culture to encourage and support the identification, reporting, prioritisation, investigation, and learning from these safety incidents. Multiple methods should be used, such as the screening tool of older people's potentially inappropriate prescriptions (STOPP) and the screening tool to alert to right treatment (START).16,17 NICE recommends using tools that support the principles of the pharmacist-led information technology intervention for medication errors (PINCER) (see Box 3, below).14,18
Box 3: Pharmacist-led information technology intervention for medication errors (PINCER)14
Organisations and healthcare professionals should consider applying the principles of the PINCER intervention to reduce the number of medicines-related patient safety incidents, taking account of existing systems and resource implications. These principles include:
- using information technology support
- using educational outreach with regular reinforcement of educational messages
- actively involving a multidisciplinary team, including GPs, nurses, and support staff
- having dedicated pharmacist support
- agreeing an action plan with clear objectives
- providing regular feedback on progress
- providing clear, concise, evidence-based information.
NICE (2015) NG5. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Available at www.nice.org.uk/guidance/ng5
Reproduced with permission.
An example of implementation is the electronic Clinical Pharmacy Intervention Recording System developed by Humber NHS Foundation Trust. The system enables clinical pharmacy interventions to be recorded at the point of intervention via a touch screen device or laptop. Common omissions, trends of error, and significant events in prescribing and administration are then shared with the clinicians via newsletters and at continuous professional development (CPD) events.
Patients and their family members or carers should be helped to identify and report medicines-related patient safety incidents.14 The MHRA website provides a useful resource for the public on adverse event reporting; materials include information cards and posters.19 Organisations should agree the approach locally and review arrangements regularly to reflect local and national learning.14
Medicines-related communication systems when patients move from one care setting to another
The former National Patient Safety Agency (NPSA) highlighted the risk of poor communication when patients move between care settings;20 this can lead to errors, delays, or omission of medicines.
NICE urges that complete and accurate information about medicines should be shared between healthcare and social care practitioners when a patient moves from one care setting to another, including transfers within an organisation (e.g. between wards), or from one organisation to another (e.g. on admission or discharge). This information should also be shared and discussed with the patient and, where appropriate, their family members or carers. Effective communication should take place within 24 hours of the transfer; see Box 4 (below), for details of what information should be included.14 NICE recommends sending a patient's medicines discharge information to their nominated community pharmacy when possible, with the patient's agreement.14
NICE NG5 adopts the definition of the term 'medicines reconciliation' by the Institute for Healthcare Improvement:14'… the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated.'
Historically, the process of medicines reconciliation has focused on admission to hospital; however, it is widely acknowledged that medicines reconciliation is a wider safety issue rather than just at hospital admission.14 In an acute setting, NICE recommends that medicines reconciliation should be carried out within 24 hours or sooner when a patient moves from one care setting to another. This may happen on more than one occasion during a hospital stay, i.e. on admission, during transfer between wards, and on discharge.14
In primary care on the other hand, medicines reconciliation should be carried out for all patients who have been discharged from hospital or another care setting. This should happen as soon as possible, before a prescription or new supply of medicines is issued, and within 1 week of the GP practice receiving the information.14
Medicines reconciliation should be carried out by a trained and competent healthcare professional, ideally a pharmacist, pharmacy technician, nurse, or doctor with effective communication skills, technical knowledge of processes for managing medicines, and therapeutic knowledge of medicines use. In accordance with the central theme of a person-centred approach, patients, their family members, or carers should be involved in the process.14
Medication review can have several different interpretations with varying quality and effectiveness. In NICE NG5, medication review refers specifically to the following activity:14'A structured, critical examination of a person's medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste.'
This type of medication review is carried out with the patient, with access to clinical notes and laboratory test results. NICE NG5 advises that a structured medication review is carried out for:14
- people who are taking multiple medicines (polypharmacy)
- people with chronic or long-term conditions
- older people.
The medication review may be led by a pharmacist or an appropriate healthcare professional with technical knowledge of managing medicines, therapeutic knowledge on medicines use, and effective communication skills. The review should take into account the patient's and their family members' (or carers') views, understanding, concerns, questions, or problems with the medicines.
The safety and effectiveness of all prescribed, over-the-counter, and complementary medicines currently used by the patient should be reviewed, in line with national guidance. Any risk factors for developing adverse drug reactions and monitoring needs should be identified.14
NICE suggests that a self-management plan is used to support patients with chronic or long-term conditions, who want to be involved in managing their medicines. In NICE NG5, self-management plans are:14'… structured, documented plans that are developed to support a person's self-management of their condition using medicines.'
A self-management plan is part of a person-centred approach. By empowering patients to be confident in managing their symptoms themselves, they can make the most effective use of their medicines and treatments to achieve the best possible outcomes.14 A self-management plan should be in an accessible format, and include the following details:14
- the plan's start and review dates
- the condition(s) being managed
- a description of medicines being taken under the plan (including the timing)
- a list of the medicines that may be self-administered under the plan and their permitted frequency of use, including any strength or dose restrictions and how long a medicine may be taken for
- known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced
- arrangements for the patient to report suspected or known adverse reactions to medicines
- circumstances in which the patient should refer to, or seek advice from, a healthcare professional
- the individual responsibilities of the healthcare professional and the patient
- any other instructions the patient needs to safely and effectively self-manage their medicines.
The patient should be advised on how the plan is used, as well as the risks and benefits of using the plan. Their values, preferences, knowledge, and skills in using the plan should be considered. The plan should be reviewed regularly.14
Patient decision aids used in consultation involving medicines
Shared decision-making is an essential component of evidence-based medicine. All patients should be offered the opportunity to be involved in making decisions about their medicines.14 When there is more than one reasonable option with potential benefits and harms, NICE recommends the use of a high-quality patient decision aid to facilitate patient engagement. These aids should not advise the patients to choose one option over another, nor are they meant to replace the discussion in a consultation. The aids should make the decision explicit, describe the options available, and help patients to understand these options in order to make informed, value-based, preference-sensitive decisions with the professional. Patient decision aids should give patients more realistic expectations.14,21
Patient decision aids may be paper-based or electronic, e.g. pamphlets, videos or web-based tools. These aids should be in line with the criteria set by the International Patient Decision Aid Standards (IPDAS) Collaboration (for the full list of criteria, see here).22
Professionals should read and understand the contents of a patient decision aid before using it in a consultation. They should understand its limitations and adjust discussions according to the patient's baseline risk. Professionals should be able to explain the tradeoffs between particular benefits and harms. NICE highlights the importance of training and education to help professionals use patient decision aids effectively.14
Clinical decision support
In NICE NG5, clinical decision support software relates to active or interactive computerised clinical decision support systems, at the point of prescribing medicines.14 These systems should identify important safety issues and reflect the best available evidence. They should contain relevant information in order to reduce 'alert fatigue'. Alerts relating to 'never events' should not be customisable.14,23
'Never events' are defined by NHS England as:24'… serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.' Professionals using a clinical decision support system should understand its limitations; clinical decision support systems should not replace clinical judgement.14
Medicines-related models of organisational and cross-sector working
Cross-organisational and cross-sector working is essential in the provision of seamless care. NICE recommends a multidisciplinary team approach to improve outcomes for people who have long-term conditions and those who take multiple medicines.14
When making strategic decisions about medicines use or when developing care pathways that involve medicines, NICE recommends that a pharmacist with relevant clinical knowledge and skills should be involved.14
Optimising the use of medicines has been a longstanding challenge. Getting the best possible outcomes from medicines can only be achieved by putting patients at the centre of decision about their care. Shared decision-making should be based on the best available evidence and the patient's individual needs, preferences, and values.
Lessons should be learned from past patient-safety incidents to prevent similar incidents from occurring in the future. There is a greater risk of medicines-related incidents and poor communication when patients move between care settings. It is crucial to ensure that complete and accurate information about medicines is shared between healthcare and social care practitioners, and that medicines are reconciled in a timely and appropriate manner.
It is clinically and cost effective to carry out structured medication review with people who are taking multiple medicines, people with chronic or long-term conditions, and older people.
NICE NG5 on medicines optimisation provides evidence-based recommendations that, if implemented and embraced by all healthcare and social care practitioners and care organisations, will help to change practice, allowing people the opportunity to make their own informed decisions about the medicines they are taking to obtain the best possible outcomes from them.
- A robust and transparent system should be established within a 'fair-blame' culture to encourage and support the identification, reporting, prioritisation, investigation, and learning from medicines-related patient safety incidents. Multiple methods should be used
- Complete and accurate information about medicines should be shared between healthcare and social care practitioners when a patient moves from one care setting to another, including transfers within an organisation, or from one organisation to another
- Consider sending a patient's medicines discharge information to their nominated community pharmacy where possible, with the patient's agreement
- In an acute setting, medicines reconciliation should be carried out within 24 hours or sooner when a patient moves from one care setting to another. This may happen on more than one occasion during a hospital stay, such as on admission, during transfer between wards, and on discharge
- In primary care, medicines reconciliation should be carried out for all patients who have been discharged from hospital or another care setting. This should happen as soon as possible, before a prescription or new supply of medicines is issued, and within 1 week of the GP practice receiving the information
- A structured medication review should be carried out for people who are taking multiple medicines, people with chronic or long-term conditions, and older people
- Consider using a self-management plan to support patients with chronic or long-term conditions. The patient should be advised on the appropriate use of the plan, as well as the risks and benefits of using the plan. Their values, preferences, knowledge, and skills should be considered
- All patients should be offered the opportunity to be involved in making decisions about their medicines. Use a high quality patient decision aid to help patients make a preference-sensitive decision that involves trade-offs between benefits and harms
- Computerised clinical decision support systems should contain information that is relevant in order to reduce 'alert fatigue'. Alerts relating to 'never events' should not be customisable
- Involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.
GP commissioning messages
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- NICE NG5 outlines the importance of appropriate medicines management and where it is cost effective
- CCGs should:
- review current systems and look to target interventions where they are most likely to be cost effective, e.g. on hospital discharge
- work with NHS England to help target national initiatives, such as MURs for pharmacies or DRUMs for dispensing practices, to those who are most likely to gain from the intervention
- National policy is soon likely to encourage employment of pharmacists in practices who could then assume major roles implementing the best practice outlined in this guidance
- Although the workload identified in this guidance may appear excessive to GPs, pharmacists are one of the only professional groups in the NHS where there is likely to be ample workforce supply
- CCGs could look to take on greater roles in commissioning community pharmacy and integrating this with other primary care suppliers as suggested in the NHS Five year forward view through co-commissioning arrangements.
CCGs=clinical commissioning groups; MURs=Medicines Use Reviews; DRUMs=Dispensing Review of Use of Medicines.
- Health and Social Care Information Centre. Prescription cost analysis England 2014. HSCIC, 2014. Available at: www.hscic.gov.uk/ catalogue/PUB17274/pres-cost-anal-eng-2014-rep.pdf (accessed 24 June 2015).
- Department of Health.Long Term Conditions Compendium of Information. DH, 3rd ed, May 2012. Available at: www.gov.uk/government/ uploads/system/uploads/attachment_data/ file/216528/dh_134486.pdf (accessed 24 June 2015).
- Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: making it safe and sound. The King's Fund, 2013. Available at: www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf (accessed 2 July 2015).
- Dias A, Pereira C, Monteiro M, Santos C. Patients' beliefs about medicines and adherence to medication in ischemic heart disease. Aten Primaria 2014; 46 Suppl 5:101–106.
- Morrison V, Holmes E, Parveen S et al. Predictors of self-reported adherence to antihypertensive medicines: a multinational, cross-sectional survey. Value Health 2015; 18 (2): 206–216.
- NICE. Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence. Clinical Guideline 76. NICE, 2009. Available at: www.nice.org.uk/guidance/cg76
- National Reporting and Learning Service. NRLS Quarterly Data Workbook. NHS England, 2014. Available at: www.nrls.npsa. nhs.uk/resources/type/data-reports (accessed 2 July 2015).
- Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329 (7456): 15–19.
- Howard R, Avery A, Howard P, et al. Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study. Qual Saf Health Care 2003; 12 (4): 280–285.
- NICE. Costing statement: Medicines Optimisation. NICE, 2015. Available at: www.nice.org.uk/guidance/ng5/resources/costing-statement-6916717 (accessed 2 July 2015).
- Davies E, Green C, Mottram D, et al. Emergency re-admissions to hospital due to adverse drug reactions within 1 year of the index admission. Br J Clin Pharmacol 2010; 70 (5): 749–755.
- Editorial. Optimising medicines management? Drug Ther Bull 2013; 51 (4): 37.
- Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines. London: Royal Pharmaceutical Society; 2013. Available at: www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf (accessed 8 July 2015).
- NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guideline 5. NICE, 2015. Available at: www.nice.org.uk/guidance/ng5
- NHS England. Medicines Optmisation Dashboard 2015. NHS England, 2015. Available at: www.england.nhs.uk/ourwork/pe/mo-dash/#mo-dash (accessed 2 July 2015).
- Lang P, Hasso Y, Belmin J et al. STOPPSTART: adaptation of a French language screening tool for detecting inappropriate prescriptions in older people. Can J Public Health 2009; 100 (6): 426–431.
- O'Mahony D, O'Sullivan D, Byrne S et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44 (2):213–218.
- Avery A, Rodgers S, Cantrill J et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012; 379 (9823): 1310–1319.
- MHRA. Yellow Card Scheme. MHRA, 2015. Available at: yellowcard.mhra.gov.uk (accessed 2 July 2015) .
- NPSA. Safety in Doses—Improving the use of medicines in the NHS London. National Patient Safety Agency, 2007. Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=61625 (accessed 2 July 2015).
- Stacey D, Legare F, Col N et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014; 1: CD001431.
- IPDAS Collaboration. International Patient Decision Aid Standards (IPDAS) Collaboration 2013. IPDAS, 2013. Available at: ipdas.ohri.ca (accessed 2 July 2015).
- NHS England. Revised Never Events Policy and Framework. NHS England, 2015. Available at: www.england.nhs.uk/wp-content/ uploads/2015/04/never-evnts-pol-framwrk-apr.pdf (accessed 2 July 2015).
- NHS England. Never events. Available at: www.england.nhs.uk/ourwork/patientsafety/neverevents (accessed 2 July 2015).