Polypharmacy — the use of multiple medications by a patient — generally occurs in older adults aged 65 years and over. The increasing number of treatment options and an ageing population mean that, anecdotally, we are seeing more patients with co-morbidities. The multiple specialisms involved in various aspects of cancer patient care can lead to no one taking responsibility for the patient as a whole, which may result in poorer therapeutic outcomes and inappropriate polypharmacy[1]
,[2]
.
Prostate cancer is prevalent in older men and therefore we developed a pharmacist-led optimisation service for this cohort of patients.
Our aim for the service was to understand the value of a secondary care-led medicines use review (MUR) in prostate cancer patients. The objectives were:
- To evaluate changes in medicines usage and adherence of patients with prostate cancer;
- To evaluate change in quality of life and wellbeing of patients with prostate cancer;
- To understand service implications and time taken to conduct the MUR.
A medicines optimisation framework was developed (and validated by the project board); this included an adaptation of a validated patient adherence tool and EQ5D’s Health Thermometer to measure adherence and health state.
The framework also included deprescribing criteria, which were outlined in the STOPP/START toolkit. All patients with prostate cancer were eligible to access the service. Patients were identified to attend through a questionnaire that was sent to all prostate cancer patients in December 2015, and also through direct referral from specialist nurses, doctors and pharmacists[3]
.
The baseline consultation was completed by a trained oncology pharmacist who would review and make recommendations to the patient; this was followed up with a letter to the GP. A minimum of one month after the original review, patients were asked to complete a questionnaire re-assessing their medicine adherence and health state. Changes in adherence and health state were recorded and outcomes were categorised into three areas: clinical, economical and general advice.
Between August 2016 and June 2017, 23 patients were seen in the polypharmacy clinic. Each consultation lasted approximately 20 minutes, either in person or over the telephone (telephone consultation was equally effective). At follow-up, 23/23 patients (100%) found the clinic beneficial, 11/23 patients (48%) had an improvement in health state (average improvement in patients’ health state was 16%) and 7/23 (30%) had an improvement in their adherence (15/23, 65% had no change in their adherence). Of the interventions made (total of 20) by the oncology pharmacist at the time of consultation, 80% were clinical, 25% were economic and 20% were general advice [some interventions were both clinical and economic].
In summary, the clinic’s outcomes have highlighted the importance of long-term pharmacy in ensuring access to lifelong personalised care, managing chronic diseases and reducing inappropriate polypharmacy among cancer patients despite no direct savings on wasted medications[4]
. Further work is planned to move the service to the community.
Joseph Williams and Pinkie Chambers,
University College of London Hospitals (UCLH), London, and Cancer CMORE (The Cancer Centre for Medicines Optimisation, Research and Evaluation), London
Mark Prentice, Reena Davda, Laura E Sellers, Heather Payne,
UCLH, London
References
[1] Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as a cause of admission to hospital: prospective analysis of 18,820 patients BMJ 2004;329:15–19. doi: 10.1136/bmj.329.7456.15
[2] The King’s Fund. Polypharmacy and medicines optimisation: making it safe and sound. Available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf (accessed January 2018)
[3] Sellers L, Williams J et al. Prevalence of polypharmacy in the prostate cancer clinic and patient interest in a medicine review service. J Oncol Pharm Pract 2017;23(4 Suppl). doi: 10.1177/1078155217691227
[4] Guy GP Jr, Yabroff KR, Ekwueme DU et al. Economic burden of chronic conditions among survivors of cancer in the United States. J Clin Oncol 35(18): 2053–61. doi: 10.1200/JCO.2016.71.9716
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