None listed
Conditions
Brief summary
Australia has an ageing population with an associated increase in people living with multiple chronic diseases. There has been a major increase in polypharmacy (multiple medicines use) in Australia over the past decade and the prevalence continues to rise, especially in older adults. Polypharmacy can lead to medication errors, adverse drug reactions, falls, confusion, frailty, loss of independence, hospitalisation and mortality. Evidence is emerging that supervised withdrawal of harmful or unnecessary medicines (deprescribing) is safe and may improve quality of life in older people. Over 90% of older adults surveyed in a range of settings, including Royal North Shore Hospital inpatients stated they would like to stop one of their medicines if their doctor said it was possible. An acute hospital stay represents a missed opportunity to review a patient’s medicines and reduce polypharmacy. In the Royal North Shore Hospital (RNSH) inpatient aged care service, the prevalence of hyperpolypharmacy increases from 45.8% on admission to 60.4% on discharge. Involvement of clinical pharmacists has been shown to improve care of hospitalised patients. The main barriers to optimising medicines during admission are a focus on the acute presenting problem; inadequate information on the patient’s comorbidities and medications prior to admission; difficulties reaching consensus between the patient, multiple specialists and general practitioner; inadequate time with short length of stay; and lack of expertise by junior medical officers, who do most of the prescribing. Failure to address polypharmacy in hospital results in longer lengths of stay due to adverse drug events, and a higher likelihood of readmission. We propose testing a new service at RNSH to improve Quality Use of Medicines by older patients across the continuum of care. Quality Use of Medicines, which is a pillar of Australia’s National Medicines Policy, is best achieved through partnership between consumers, clinicians, academics and policy makers. Such partnership is central to the Multidisciplinary Multiple Medicines Management Service (4MS) that will be tested in this proposal.
Interventions
Cycles of usual care period (~4 weeks) followed by intervention period (~4 weeks) will be conducted on 3-5 medical units including general medicine, cardiology and respiratory medicine.Depending on when the patient is recruited, patient will be assigned to usual care (period 1) or intervention (period 2).
Screen all patients aged over 65 years admitted to medical service at Royal North Shore Hospital. Obtain informed consent from participant or person responsible. Obtain baseline data for all
Cycles of usual care period (~4 weeks) followed by intervention period (~4 weeks) will be conducted on 3-5 medical units including general medicine, cardiology and respiratory medicine.Depending on when the patient is recruited, patient will be assigned to usual care (period 1) or intervention (period 2). Screen all patients aged over 65 years admitted to medical service at Royal North Shore Hospital. Obtain informed consent from participant or person responsible. Obtain baseline data for all participants on sociodemographics, reason for admission, medications, comorbidities, falls, probable one year survival and cognition. Administer a frailty questionnaire (Reported Edmonton Frail Scale). Intervention: After consent is obtained, study pharmacist obtains best possible medication history and documents on standard hospital medication history form (medication management plan; MMP). Study pharmacist will also generate a medication optimisation plan as documented on the MMP. Ideally, this should be completed within 48 hours of the patient's admission but may be delayed. A copy of this plan is to be provided in the medical notes. If the patient is taking a medication that contributes to the drug burden index (DBI), that is, taking a medication with sedative and/or anticholinergic effects, the DBI will be calculated online using a DBI calculator, which has been shown to be a reliable and validated computerised clinical decision support system to report DBI of older patients taking multiple medications. The plan is discussed with the patient/carer, General Practitioner (GP) and the patient's treating team (registrar +/- consultant). The patient's team will decide whether to make any changes to medicines, at their own discretion, They can decide to agree or disagree with the recommendations outlined in the plan by the pharmacist. The intervention will run over a period of approximately 4 weeks, The study pharmacist will also record the time taken by staff involved to review medicines (pharmacist, admitting team, consults, case conferences etc). Where possible, the study pharmacist will prompt the patient's usual team pharmacist to document any changes made to medicines and reasons for changes that are not already documented through routine care. Where possible and clinically appropriate, the study pharmacist will call the patient's GP to explain changes made on discharge. The patient will be followed up at 1 and 6 months from their discharge date by phone call to patient/carer and/or GP and/or facility manager and medical records. The patient may choose to receive an email or postal mail containing the follow-up questions. Questions will be on their medicines, falls, readmission, institutionalisation and mortality (which can be confirmed with Births, Deaths and Marriages when necessary).
Sponsors
Royal North Shore Hospital
Study design
Allocation
Non-randomised trial
Intervention model
Other
Primary purpose
Prevention
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
• Male and female patients aged 65 years or older • Admitted to a service within the division of medicine • Expected to remain in hospital for at least 72 hours after recruitment • Expected to survive the acute admission • Informed consent can be obtained from patient or a person responsible • Taking 10 or more medications on admission • Able to communicate in English (or a translator is available)
Exclusion criteria
• Patients in terminal phase of illness who are expected to die during current admission (as documented in the medical notes available on the ward). • Inability of patient or a person responsible to give consent and participate in an interview in English • Predicted hospital stay <72 hours • During admission to high dependency units e.g. Intensive Care Unit, Coronary Care Unit or Respiratory Care Unit
Outcome results
None listed