Meeting notes, Contributory Measures Workshop, 3 March 2015
Healthy Aging: Polypharmacy
General points
The group:
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Noted the importance of being able to stratify measures by ethnicity and other high
need populations;
Also noted the importance of being able to stratify measures by residential care
status, where that is reasonable. It was pointed out that dispensing claims are
differentiated on the basis of residential care status, and may be a basis for such a
stratification;
While the discussion was largely based upon knowledge of the pharmhouse dataset,
it was noted the electronic prescribing dataset was now used in nearly all
pharmacies, and includes non subsidised medicines. This resource should be
explored for future definitions of polypharmacy measures.
The measures identified here are intended to be meaningful contributory measures which
can inform education and quality improvement programmes for prescribers and pharmacists
across a number of different care settings. They should serve as a basis for feeding
information back to prescribes and pharmacists, reducing variation in practice, and overall
reducing the number of patients who are inappropriately receiving 11 or more long term
medications.
Potential measures
Transfer of care
This is about Identify where transfers of care, particularly between community and hospital
settings, increase the number of different prescribers and inappropriately increase the
number of medicines a patient receives. It is based upon comparing the Long Term
Medications (LTMs) for patients in the six months prior to a hospital admission, and the six
months after discharge.
There could be two complementary measures: a) one based upon patients receiving 11+
(LTMs) in the six months prior to a hospital admissions (and then looking to see how many
were on more medications after discharge), and b) one based upon patients who received
11+ LTM post discharge, and looking to see what was added or changed around the time of
admission.
Because of the need to wait six months post discharge, this measure would lend itself to an
annual or six monthly snapshot, rather than to continuous reporting. But it has much
potential for richness in exploring the kinds of medicines which contribute to polypharmacy,
and the prescribers who are involved in adding and subtracting medicines. It would provide
rich contributory information to quality improvement programmes involving hospital and
community prescribers and pharmacists.
Number of prescribers
The denominator for the measure is the number of people receiving 11+ LTM in the last two
quarters. The numerator is the number of people who have had 4 or more different
prescribers for those LTMs. The criterion of four should be investigated, and explored
further.
The rationale for this measure is that it indicates how fragmented prescribing is across
different care settings. It is a tin opener to use to examine different clinical roles.
Medicine combinations
This explore particular classes of medication which may be included within 11+ LTMs, and
which have particular risks for patients. It support quality improvement in prescribing more
generally, but also a critical approach to reviewing medicines for patients with 11+ LTMs.
The denominator is the number of people receiving 11+ LTM in the last two quarters.
Suggested combinations of medicines of interest for numerators are:
Numerator 1: 2+ sedatives
Numerator 2: ACE/NSAIDS/frusemide
Numerator 3: (to explore: diuretics and CCBs)
Numerator 4: Opiates and lactulose
Numerator 5: (to explore: Anticoagulants. People on multiple anticoagulants?).
Numerator 6: 4+ medicines with antihypertensive effect
Multiple pharmacies
The intent of this measure is to indicate fragmentation of care, particularly for patients who
are not picked up by the pre and post hospital discharge measure above.
The denominator is: Patients with 11+ LTMs in the previous two quarters, who have not
been in hospital for 1 year. The numerator is the subset of those patients who have been
dispensed medicines from 2 or more pharmacies within the same DHB (some exploration
will be needed to decide whether some DHBs might need to be combined for the purpose of
this definition, eg. Hutt and Capital and Coast).
Patient information on discharge
While not applicable in every district, where yellow cards (or some other equivalent
mechanism) are used to provide patients with a record of their medications, a measure of
quality is the proportion of patients with 11+ LTMs in the last two quarters who were
discharged from hospital with a yellow card. This speaks to patient experience and health
literacy aspects of care.
This measure cannot be monitored from routine datasets, but could be the subject of
periodic clinical audit.
Find my patients
Clinical audit at practice level using the Find my patients tool from the Atlas. A practice level
contributory audit and quality improvement exercise which can identify patients who have
received multiple medicines prescribed within the same practice.
Medicines therapy assessment
Denominator: patients receiving 11+ LTMs in previous two quarters. Numerator: of these,
which patients have received a medicines therapy assessment in the previous twelve
months. This contributory measure reflects a specific process of patient care which has
been found to reduce medications, and to reduce acute hospital admissions for patients who
received MTA, particularly patients in aged residential care.