Type 3 reviews in Brighton and Hove: a service in development
Helena Stimpson, a pharmacist in East Sussex, describes her work developing and providing a type 3 clinical medication review service
It aims to identify medication issues that could result in unplanned hospital admissions (the prevalence of preventable medicines-related hospital admissions is estimated at between 4 and 5 per cent of all admissions),1 to reduce prescribing costs and to provide education and support to patients and carers in order to help them with taking their medicines.
The service was commissioned and is funded by the local primary care trust as part of its unscheduled care strategy and I am part of the community matron team. This team case manages patients identified as being “very high intensity users” of primary and secondary care services, who typically have several long-term conditions and complex care needs.
I provide type 3 medication reviews (ie, face-to-face with the patient, with access to the medical history and laboratory results) for patients in the community. This format is based on guidance in the national medication review document “Room for review” (which was released in 2004 and was recently revised as “A guide to medication reviews”) and the primary care trust has set performance criteria against which the role is assessed and evaluated.
When the service was started, information on the operation and outcomes of similar services was collected through a literature search and by talking to service managers and staff at other PCTs.
How the service works
GPs at 16 surgeries, community matrons, the community respiratory team, heart failure nurses and the intermediate care team refer patients to the service. Referral criteria, based on information from trials and national guidance that describe the most common causes of medication-related admissions to hospital,2–5 were developed and have been amended as necessary since the service started, in order to maximise the number of appropriate referrals. The current referral criteria are shown in the Panel.
Referral criteria for clinical medication review
I visit patients at home and, if required, I make a follow-up appointment after two or three months. Before a review, I collect information on the patient from the GP surgery or community matron’s notes, such as prescribed medicines, allergies, medical history and blood results.
A preliminary office-based assessment is then carried out, based on this information. Each drug is considered to determine the indication, dose, efficacy, possible adverse effects, interactions, contraindications, whether it is evidence-based therapy and what monitoring is required.
At the patient’s home, I compile a full drug history, including prescribed and non-prescribed medicines, and identify if what the patient takes differs from what has been prescribed, and any problems the patient might have in taking his or her medicines.
Any recommendations for a medicine change or otherwise (eg, the use of blister packs or ongoing monitoring) I identify are discussed with the patient. A report is then sent to the patients’ GP, community pharmacy and the referrer, whom I might telephone to reinforce or discuss recommendations further.
I also liaise with other primary and secondary care health providers, such as hospital pharmacists and carers, where necessary.
Since the service started, I have revised the format of this report several times in response to feedback from GPs and according to my own judgement. Where possible, it is kept to one-page long, and includes information on all medicines taken by the patient and how he or she manages them.
A table is used to highlight any actions that need to be taken. It identifies the issue, the recommended action and the person responsible for this action.
There is also a column for the GP to record his or her response to any proposals, making it easier for me to check whether a recommendation has been agreed and, if so, whether it has been followed.
I discharge patients once I consider the intervention to be complete, but they can be re-referred to the service if necessary.
I collect data in a spreadsheet following each review. These are then collated and presented to the PCT by the information management service at the NHS trust. Data collected include the number of regular medicines taken by the patient, any prescribing savings, the risk of hospital admission, cost saving due to prevention of hospital admission (as a result of medication issues identified at the review) and the number of recommendations made.
Initially, it was difficult to decide whether or not a hospital admission had been prevented. There were no suitable tools to use so one was developed, based on the National Patient Safety Agency risk matrix.
Medication issues identified at the review are assessed as putting the patient at very low through to high risk. Those at moderate or high risk are considered as potential hospital admissions that have been prevented.
It is hoped that the PCT will audit the patients reviewed to determine if unplanned hospital admissions have actually reduced.
Prescribing costs are determined using the Drug Tariff and are calculated per 28 days of treatment. Hospital admission costs are based on the cost of an average elderly care admission (ie, £1,900 in 2007 and £2,700 for 2008, based on information from the PCT).
For the first six months of the service, a feedback form was sent to the GPs with each medication review report, asking them to answer questions on their satisfaction with the service and the report. This information was then collated and analysed by the pharmacist, and has been used to improve the service.
From April 2007 to March 2008,193 medications reviews were carried out, including initial (117) and follow-up (76) reviews. The mean age of patients reviewed was 79 years old, the range being 37 to 96 years. I believe that 23 hospital admissions were prevented, although there is no admission data.
Of the 450 recommendations made to GPs, 296 (66 per cent) were accepted and 249 (84 per cent) of these were subsequently actioned. From January to March 2008, the mean number of repeat medicines per patient was nine and the range was three to 18.
Prescribing costs increased by a total of £15 per 28 days for the total number of reviews done but savings (hospital admissions and prescribing costs per 28 days) were £49, 285. Prescribing costs can also be offset by the expected benefits of treatment (eg, starting a statin in a patient after a heart attack to prevent a further heart attack).
There are other benefits from the service that cannot be measured easily, for example, education on medicines to improve compliance and reduce morbidity or mortality.
These medication reviews can be read-coded by GP surgeries as part of the Quality and Outcomes Framework, which awards a GP surgery with achievement points for several areas of patient care, including the management of chronic diseases, such as asthma and diabetes.
It also includes an indicator that every patient should have a medication review at least every 15 months. Therefore, this service also helps GPs meet their QOF targets by making sure that prescribing is reviewed and optimised for patients to ensure they are able to meet clinical targets, such as HbA1c results.
It also helps GPs meet the National Standard Framework standard for older people — that everyone over 75 years old has an annual medication review, and those on four or more regular medicines receive a six-monthly review.
Some trials have shown that medication review by pharmacists can prevent hospital admissions,6–8 while others have shown no effect, or increased admission.9–12
This service has been effective, but needs to develop further and I still spend a lot of time on developmental issues, including looking at ways to expand and deliver an effective service.
One such development has included setting up a clinic to review follow-up patients, rather than seeing them at home for the second review. It is hoped that this will save travelling time and enable more patients to be reviewed.
However, it has proved a challenge to recruit suitable patients for the clinic because many patients are housebound or are not keen to attend another clinic in addition to GP and hospital appointments.
It can be difficult to balance the requirements of the PCT commissioners with the demands of providing and developing the service as a single pharmacist.
Future developments for the service could include:
- Expanding the referral pathway to include referrals from community pharmacists, community nurses, the falls prevention service
- Expanding the patient group to include hospital discharge patients and getting more GP surgeries to make referrals
- Surveying patients and referrers to assess satisfaction with the service
- Auditing patients who have been reviewed to track if they have been admitted to hospital
It is important that any developments take into account the national agenda of moving care closer to home, where the benefit of a full clinical pharmacy review, together with other community services, can help to support patients at home.
I hope, in the future, that it will be possible for data collected by medication review services across the UK to be collated and presented, so that it is shown as a positive initiative that requires more investment and support at a national level.
It would be ideal to think that there could be a national network of medication review pharmacists that supports the qualification and continuing professional development needs of other pharmacists who are carrying out a role that is still uncommon in the pharmacy world.
This could be based on the home medicines review (HMR) scheme in Australia, where HMR facilitators provide support, advice, education and information to pharmacists and GPs in their local area about home medicines reviews.13
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10. Holland R, Brooksby I, Lenaghan E, Ashton K, Hay L, Smith R et al. Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial. BMJ 2007;334:1098.
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12. Nazareth I, Burton A, Shulman S, Smith P, Haines A, Tomberall H. A pharmacy discharge plan for hospitalised elderly patients-a randomised controlled trial. Age and Ageing 2001;30:33–40
13. Pharmacy guild of Australia. Home medication review. Available at www.guild.org.au/mmr (Accessed 31st May 2008).
Citation: The Pharmaceutical Journal URI: 10046928
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