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Section 5: Putting Medication Review into Practice

Establishing a Medication Review Process

Defining Your Strategy
 
A medication review strategy can be most useful if it is seen in the wider context of the overall goals for health and well being of the community, and developed collaboratively by health professionals involved in patient care and operational managers, with input from patients.
 
It will be less useful if it is seen as a corporate initiative developed in isolation by PCT staff responsible for prescribing, and designed to meet an externally imposed target. Local stakeholders who could usefully be involved in the development of the strategy and subsequently the guidelines could include:
  • The Professional Executive Committee of the PCT
  • The Patient Forum
  • Individual practices and practice staff
  • Local groups representing pharmacy
  • The Local Authority, particularly in relation to the Single Assessment Process for Older People.
 
To begin with, it is useful to establish your own levels of baseline activity and to determine your own goal, based on local priorities and available resources. What you do next will depend on what you want to achieve. Earlier in this guide we proposed a framework for classifying medication reviews and some PCTs have chosen to prioritise reviews of one particular type. It is entirely possible to implement elements from more than one type simultaneously based on this framework.
 
Identifying which patients to prioritise for review can be an important element of the strategy. It may be useful to consider two categories of people: those who could be at particular risk of medicationrelated problems, and those who have more broadly defined special needs. Trigger questions about medicines use in the Single Assessment Process for Older People could be a key route for identifying people who might benefit from review. Encouraging community pharmacists to ask a few simple questions when dispensing regular medicines may also help pick up patients in need of full review.
 
POTENTIAL TARGET PATIENT GROUPS
 
At risk of medicines-related problems
  • Taking four or more medicines every day
  • Recently discharged from hospital with complex medicines
  • Receiving medicines from more than one source (eg hospital specialist and GP)
  • Significant changes to the medication regimen in the past 3 months
  • Taking medicines requiring special monitoring (eg lithium), with a wide range of side effects (eg NSAIDs) or a narrow therapeutic range (eg digoxin)
  • Symptoms suggestive of an adverse drug reaction
  • Where non-compliance is suspected or known to be a problem.
 
Special needs
  • Older people
  • Residents in care homes
  • Learning difficulties
  • Sensory impairment such as poor sight or hearing difficulties
  • Physical problems eg arthritis, inability to swallow
  • Mental states such as confusion, depression, anxiety, serious mental illness
  • Communication difficulties
  • Literacy or language difficulties
  • Minority ethnic groups
  • Refugees and asylum seekers.
 
Opportunities to improve care
  • Patients in disease areas where new evidence on treatments or guidelines have become available.
 
A number of Primary Care Organisations participating in the National Collaborative Medicines Management Services Programme have chosen to focus initially on sub-sets of patients such as those taking a particular drug or with a particular medical problem such as diabetes or hypertension. This approach seems to be successful in testing out ideas, which can then be implemented more widely. It also makes the workload and resource implications more manageable.
 
In setting objectives for medication review at a strategic level it is important to think about how you will track your progress. Finding useful indicators for medication review is not necessarily straightforward but will be highly worthwhile. For example, evidence on health improvement or cost effectiveness could make significant contributions to taking practice forward.
 
ILLUSTRATIVE MARKERS FOR TRACKING PROGRESS IN MEDICATION REVIEW
 
  • Existence of agreed local guidance for medication review
  • Number of practices that have adopted the guidance
  • % of patients 75 years and over whose notes contain documented evidence of a medication review in the last 12 months
  • % of patients 75 years and over taking 4 or more medicines whose notes contain documented evidence of a medication review in the last 6 months, and a clinical medication review in the last year
  • % of vulnerable patients discharged from hospital on repeat medication whose notes contain evidence of a clinical medication review within 8 weeks of discharge
  • % of medication reviews that led to a recommended change in treatment
  • Number of reviews of each level carried out
  • Estimated cost savings/increases from medication review
  • Cost of implementing the medication review guideline
  • Patient satisfaction with medication review process andoutcome (sample basis).

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