NHS Doncaster Community Pharmacy Falls Prevention

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Evaluation of a Community
Pharmacy Falls Prevention
Service
A Report for NHS Doncaster Clinical
Commissioning Group (CCG)
May 2014
1
Evaluation of a Community Pharmacy Falls Prevention Service
A Report for NHS Doncaster Clinical Commissioning Group (CCG)
May 2014
Abstract
Aim and Objectives: To evaluate a community pharmacy falls prevention service. To
identify the number of patients using the service, the types of risk factors being identified and
the interventions being provided by community pharmacists, exploring patient satisfaction
with the service and ideas for service development/improvement.
Setting: Twenty-three community pharmacies across Doncaster.
Methods: A mixture of research methods were used for data collection: audit of 414
consultations, analysis of 353 patient satisfaction questionnaires and a face-to-face meeting
with a Falls Co-ordinator. Audit and questionnaire results were analysed using descriptive
statistics, qualitative comments using a thematic approach.
Key Findings: Ninety-five percent of patients reviewed were taking one/more ‘high-risk’
medicine, 32% were experiencing fall-inducing side effects, 22% had fallen in the past year
23% had balance/gait problems, 22% vision or continence problems and 17% were afraid of
falling. Of those patients who reported experiencing side effects 31% had fallen in the last
year, which was statistically significant (p<0.001). Forty-three per-cent of patients with
balance/gait problems had fallen in the last year, which was also statistically significant
(P<0.001). Over 50% of patients who had suffered a previous fragility fracture were not
currently prescribed bone-sparing medication. Thirty-seven per-cent of patients prescribed
bone-sparing medication had compliance problems. The majority of interventions involved
the pharmacist alone. Ten percent of patients were referred to the specialist falls clinic.
Patients expressed a high level of satisfaction with the service.
Conclusion: There is a role for community pharmacists in falls and fracture prevention.
This service should be continued and developed further to work more closely with other
health professionals, include service provision for housebound patients and reduce the
number of prescribed medicines to tackle the increasing problem of falls in Doncaster.
2
Acknowledgements
The author of this report would like to acknowledge and thank all those who
participated in and assisted with this service evaluation. Firstly I would like to thank the
patients who took the time to complete feedback questionnaires during the course of the
evaluation. I would like to thank Steven Hague and Michelle Morgan for their help and
support in implementing community pharmacist referrals to the Specialist Falls Clinic, and
Steven for giving up his time to provide valuable feedback for the evaluation.
I would like to acknowledge all the community pharmacists and their support staff
who engaged with and delivered this service, and submitted data for evaluation. In particular
I would like to thank Laura Sharp for her feedback regarding service delivery and the data
collection tools.
I would like to thank Richard Harris and Alison Howard for their help and input into
developing the pilot Community Falls and Fracture Prevention Service from which this
service has been adapted. I would also like to thank all the patients and staff at Weldricks
Pharmacy East Laith Gate and the GPs at Francis Street Medical centre who were involved
in the pilot service and evaluation.
I would like to acknowledge the contributions made by NHS Doncaster Clinical
Commissioning Group in implementation and evaluation of the service, especially Jonathan
Briggs, Ian Carpenter, Martha Coulman, Dr Andrew Oakford and Emma Smith.
Finally I would like to thank fellow members of Doncaster Local Pharmaceutical
Committee and colleagues at H. I. Weldrick Ltd for their help and support in implementing
and evaluating the service; Paul Chatterton, Michelle Foley, Richard Harris, Nick Hunter,
Darren Powell, Richard Wells and especially Alison Ellis for her hours spent data inputting.
This service evaluation was commissioned by NHS Doncaster Clinical Commissioning
Group.
3
Contents
Page
Introduction
5
Methodology and Methods
11
Results
14
Discussion
24
Conclusions
34
References
36
Appendices
40
For further information regarding this evaluation please contact:
[email protected]
This report was written by Claire Thomas MPharm, MSc, MRPharmS, GPhC, Doncaster
LPC Member on behalf of NHS Doncaster Clinical Commissioning Group.
4
1. Introduction
Falls and falls-related injuries are common in older people having an impact on
quality of life, health and healthcare costs.1,2 People aged 65 years and older have the
highest risk of falling, with 30% of people older than 65 and 50% of people older than 80
falling at least once a year.1 Consequences of falling include; fractures, head injuries,
psychological problems i.e. social isolation/depression, disability, loss of independence,
need for long term residential/nursing home care and mortality.1-5 It is estimated that falls
cost the National Health Service (NHS) more than £2.3 billion a year.1
Risk factors include; falls history, balance and/or gait deficit, mobility impairment, fear
of falling, visual impairment, cognitive impairment, urinary incontinence and home hazards.
The most significant risk factor is a previous fall.3 Psychotropic drugs including neuroleptics,
sedatives/hypnotics, antidepressants and benzodiazepines increase the risk of falling as
does the use of multiple (>3 or 4) medicines.3 Other medication associated with falls
includes cardiovascular medication, opiate analgesics, urological agents, antihistamines and
medication for Parkinson’s disease, epilepsy and diabetes.6 Anti-hypertensives have also
been associated with falls via postural hypotension.7
Osteoporosis increases susceptibility to fracture and affects 1 in 3 women and 1 in
12 men over the age of 50 resulting in over 200,000 fractures annually.8,9 Fractures most
commonly occur in the spine, wrist and hip, 86,000 hip fractures occur annually, 95% of
which are the result of a fall. Following a hip fracture 20% of patients die within 12 months,
up to 75% do not regain their prior level of function and 50% can no longer live
independently.1,4,8,10 Risk factors include; smoking, excessive alcohol consumption, low body
mass and low calcium and vitamin D intake.2,3,8,10-12 Certain medicines have been associated
with osteoporosis in particular oral glucocorticoids and anticonvulsants.12,13 Poor patient
compliance with osteoporosis treatment is common.11
Falls and fracture risk increases with age therefore falls and osteoporosis feature
predominantly in the National Service Framework for Older People which recommends staff
5
in community health care settings should be trained to identify people at risk of falling and
refer them to falls services for assessment.4,5,6,8 Falls prevention guidelines have been
produced by the National Institute of Health and Care Excellence (NICE) and jointly by the
American Geriatrics Society (AGS) and the British Geriatrics Society (BGS). NICE
recommends: “older people in contact with healthcare professionals should be asked
routinely whether they have fallen in the past year…” and people at risk and their carers
should be offered information orally and in writing about what measures they can take to
prevent falls.1 The AGS/BGS guideline highlights the importance of rationalising use of
medications to reduce the risk of falling; medication reduction/withdrawal is stressed for all
older people.14,15
Many of the risk factors for falls and osteoporosis are potentially modifiable and there
is growing evidence of cost effective interventions to prevent falls and fractures.2 In 20122013 in England 914.3 million prescription items were dispensed in community
pharmacies.16 People aged over 65 receive about half of all prescriptions, 80% being repeat
prescriptions visiting the pharmacy on a regular basis.17 Community pharmacies are easily
accessible, open at convenient times and have private consultation areas.18 Community
pharmacists are therefore ideally placed and with their knowledge of pharmacotherapy could
be effectively utilised to provide falls and fracture prevention services. 19 Falls prevention is
included in ‘Healthy Lives, Healthy People’ and the potential role of pharmacy is highlighted
in ‘Pharmacy in England’ where the Government recommends pharmacy can contribute to
the challenges associated with an ageing population by providing focused medication
reviews to prevent falls and that further research should be conducted relating to a role in
osteoporosis risk assessment.18,20
Doncaster has a population of around 302,402 people with 51,141 people aged over
65.21,22 This age group has been increasing and will by 2020 have reached 60,800.26 The
number of people falling in Doncaster has been increasing year on year. Between April 2013
and February 2014 there were 2409 emergency admissions to Doncaster Royal Infirmary
6
due to all injuries caused by falls, 1093 due to fractures caused by falls and 399 due to hip
fractures caused by falls.23 The inpatient cost of treating patients following a fall totalled
£6,463,415 over this 11 month period. The inpatient cost of admissions due to fractures
caused by falls totalled £4,507,485, with hip fractures alone costing £2,570,278.23 The
average spend per patient admitted with an injury following a fall was £2683 and the average
spend per patient admitted with hip fracture during this period was £6442. With the ageing
population the number of falls, fractures and associated costs will increase dramatically
unless something is done to address the problem in Doncaster.
Doncaster does not have a multi-disciplinary falls service and there are no clear
pathways in place for healthcare professionals to refer patients identified as at risk for help
with falls prevention. A newly formed Falls Alliance involving health and social care workers
from both primary and secondary care are currently working on the development of a falls
pathway for Doncaster. There is a specialist falls clinic at Tickhill Road Hospital where
patients who have fallen in the last 12 months can be assessed and be seen by an
appropriate member of their team (nurse, physiotherapist, occupational therapist or
consultant) depending on the problems identified. The majority of patients seen are frail
elderly frequent fallers referred by GPs. This service does not address the issue of primary
prevention: identifying patients at risk and preventing the first fall/fracture.
A Falls and Fracture Prevention Medicine Use Review (MUR) Service was developed
by a member of Doncaster Local Pharmaceutical Committee (LPC) to try and address this
issue, to identify patients at risk of falls/fractures at the same time improving the quality of
MURs being provided. The service was piloted at Weldricks Pharmacy East Laith Gate in
Doncaster town centre in conjunction with The Medical Centre adjacent to the pharmacy.
The service was a standard MUR with additional falls and osteoporosis risk assessment and
prevention elements. Patients aged 65 years and over taking three or more medicines,
patients prescribed ‘high-risk’ medication (appendix 1a), osteoporosis medication, or
corticosteroids/other medication known to reduce bone mineral density (BMD) were targeted
for a consultation with the pharmacist.24
7
Evaluation of this pilot service found: Ninety-six percent of patients reviewed were
taking one/more ‘culprit/high-risk’ medicine, 44% were experiencing fall-inducing side
effects, 46% had fallen in the past year and 75% were identified as at risk of falls. Thirty-one
percent of patients referred to the GP had their medication changed, 12.5% were referred to
secondary care and 6% were referred to the falls clinic. Patients expressed a high level of
satisfaction with the service and the skills of the pharmacist. Themes emerged from
interview results including; a role for community pharmacists, benefits of the service and
interprofessional working. The evaluation concluded that there was a role for community
pharmacists in falls and fracture prevention.24
Based on this previous work Doncaster LPC developed and launched a new
Community Pharmacy Falls Prevention Service funded by NHS Doncaster using Winter
Pressures money released by NHS England. This report is the findings of evaluation of this
new service.
1.1 Description of Service
This new community pharmacy service aims to address the issue of primary
prevention of falls and fractures (identifying patients at risk and preventing the first
fall/fracture). It also aims to identify patients who have fallen in the last 12 months.
Patients aged 65 years and over taking three or more medicines or patients
prescribed ‘high-risk/culprit’ medication (appendix 1a) are targeted for a face-to-face
consultation with a pharmacist who has undertaken targeted falls prevention training. During
the consultation the pharmacist enquires about falls history, identifies any culprit/high-risk
medicines, side effects which may contribute to falls, performs an assessment of
gait/balance using the ‘Turn 180° test’ (appendix 1b) and asks the patient if they have any
problems with vision or continence. Smoking status and alcohol consumption are also
obtained. All patients are provided with oral falls and fracture prevention advice (appendix
1c) and given a leaflet to take home (appendix 1d). A checklist was devised for the
8
pharmacist to use during the consultation to ensure a high quality review is conducted
(appendix 1e).
The service can be used as an extension of the existing Medicine Use Review (MUR)
service or as a stand alone service. Patients who have fallen in the past year can be referred
directly to the Specialist Falls Clinic at Tickhill Road Hospital. A GP notification form is
completed for patients identified as having falls risk factors that the GP may not be aware of.
Any adherence issues identified to bone protection medication that cannot be resolved by
the community pharmacist are also highlighted to the GP. (A copy of the service
specification can be found in appendix 1).
Evaluation of this service is important to evaluate whether the service can
successfully identify people at risk of falls/fractures and make referrals for interventions
which may prevent falls. The number of falls and associated costs in Doncaster are high and
with the aging population the number of people falling will increase impacting on individuals’
quality of life and independence and on the NHS and Local Authority due to the increasing
costs of increased hospital admissions, fractures and residential/nursing care. Positive
evaluation results could lead to service continuation and/or development which could fill a
much needed gap in the primary prevention of falls in Doncaster.
Several falls and/or osteoporosis projects have been developed in other pharmacies.
In Medway, patients aged 65 and over and taking four or more medicines are targeted for a
MUR which includes use of a falls assessment tool to direct referrals to a falls service.25 In
Barnet, patients on medicines for osteoporosis are recruited for a MUR which covers
compliance with bisphosphonates and calcium and colecalciferol and lifestyle advice. In
Southampton, patients on osteoporosis treatment are given adherence support and those at
risk of falls/osteoporosis are referred.25 Hampshire and the Isle of Wight LPC developed a
Community Pharmacy Osteoporosis and Falls MUR Plus Service to target patients with
osteoporosis to improve compliance and identify culprit medications that may contribute to
falls to reduce future fractures.26 No studies could be found that have evaluated any of these
projects.
9
These projects were more focussed on assessing osteoporosis risk than falls risk.
Although osteoporosis does increase fracture risk fracture is not the only consequence of
falling. This current service focuses primarily on falls prevention but does have elements to
improve bone health and help reduce fracture risk.
In Glasgow there is a multi-agency falls prevention service with involvement of
Specialist falls/osteoporosis, General Practice based and Community pharmacists providing
medication reviews to patients aged 65 and over living in the community who have had a fall
in the past year.27 Early evaluation found that a total of 1426 recommendations to change
treatment/order tests directly related to falls/osteoporosis were made by pharmacists to GPs
(1.63 per patient) and 1223 (86%) were accepted and implemented demonstrating that the
service is successful in identifying and implementing prescribing changes that are likely to
have a positive effect on fall rates.27 The Glasgow service is multi-disciplinary and involves
pharmacists from all branches of the profession, however the medication review element of
the service is very similar to the one being evaluated in this project, with the exception that
pharmacists can refer patients directly to other health professionals.
1.2 Aim:
To evaluate a Community Pharmacy Falls Prevention Service in Doncaster.
1.3 Objectives:

To identify whether community pharmacists can identify patients at risk of falls,
provide face-to-face consultations to assess falls risk and provide interventions to
reduce risk of falling.

Identify the number of patients using the service, the types of risk factors being
identified and the interventions being provided by community pharmacists.

Identify whether community pharmacists can provide patient education to reduce
patients’ risk of future falls and fractures.
10

Explore patient satisfaction with the service.

To explore feasibility of re-commissioning of the service and identify future service
development/improvements.
2. Methodology and Methods
Formative evaluation of the service using mixed methods was conducted to gather
information regarding the structure, processes and outcomes of the service and identify any
benefits.28,29 This was necessary to take account of stakeholder perspectives and evaluate
how the service could be developed/improved.
Quantitative methods were employed to conduct analysis of data collection records
made by pharmacists during consultations and a patient satisfaction survey/questionnaire.
28,30
A questionnaire/survey method was chosen to explore patient experience rather than
interviews/focus groups because it was felt more honest/open responses would be obtained
using an anonymous questionnaire. There were also other disadvantages of focus groups to
consider; finding a suitable/accessible venue, resources e.g. refreshments, travel for
participants and the associated costs.31 A qualitative approach to explore patient experience
was incorporated in to the patient questionnaire by asking patients to write additional
comments. A face-to-face meeting was held with the Falls Co-ordinator at Tickhill Road
hospital to find out whether referrals from community pharmacists had been appropriate and
explore his views of the new service.
The audit and patient questionnaire methods were based on positivism and provided
quantitative data for analysis. The additional comment section of the patient questionnaire
provided qualitative data for analysis. 28,32
2.1. Ethical considerations
This project falls within the remit of service evaluation therefore ethical committee
approval was not required.
11
2.2 Audit
A data collection tool was designed (appendix 1f) and piloted on four consultations
before data collection commenced. Data was collected for consultations conducted between
January and March 2014. Information regarding risk factors identified and
interventions/outcomes were inputted into an electronic dataset. Data collected was
anonymous.
2.3 Patient Questionnaire
A structured questionnaire was designed (appendix 1g) including a mixture of closed
questions with pre-coded response choices to enable collection of unambiguous and easy to
count answers providing quantitative data for analysis. Leading questions were avoided
reducing interviewer bias. A mixture of dichotomous and Likert scaled response formats
were used. The Likert scale was chosen because it is easily understood and analysed.28
Questionnaires were given to patients in person at the end of their consultation and
asked to complete it either in the pharmacy or at home. This was an
opportunistic/convenience sampling method. The questionnaire explored the patients’
experience and satisfaction of using the service.28,33
2.4 Limitations
The methods used may have been limited by investigator bias. The investigator
developed and implemented the service and was one of the community pharmacists
providing the service; this may have influenced the results obtained.
2.4.1. Audit:
The audit results may have been limited by information bias and poor piloting of the
data collection tool.28 Due to time pressures to implement the service as soon as possible to
make use of Winter Pressures funding the data collection tool and other paper based
aspects of the service were not thoroughly piloted. A consultation checklist had been
designed to help the pharmacists perform the falls assessment and a separate data
12
collection form created for evaluation purposes. There were also other components of the
service that required paperwork completing, for example, if a patient required referral to the
falls clinic or the GP needed notifying. It could therefore be very time consuming for
pharmacists to complete all the paperwork which may have affected the accuracy and
completeness of the data collection record sheet. A paper based method of data collection
resulted in some information being left blank.
2.4.2 Patient questionnaire:
Questionnaire design, question wording and scale construction may have influenced
the results. Patients are more likely to report being satisfied in response to a general
satisfaction question using the Likert scale than they are to more open-ended, direct
questions and simple ‘yes/no’ dichotomised pre-coded response choices. Codes ranging
from ‘strongly agree’ to ‘strongly disagree’ have the potential of leading to a set response.28
Using pre-coded response choices may not have been sufficiently comprehensive therefore
some respondents may have been ‘forced’ to choose inappropriate pre-coded answers.
Despite these limitations the Likert scale is the most commonly used scale in health
research. The results may have also been affected by recall bias and it was a disadvantage
that the interviewer wasn’t present to clarify/probe and some respondents may not have
understood all questions.28
Asking patients to complete the questionnaire in the pharmacy may have introduced
interviewer bias and non-response bias. Patients may not have been as open and honest
with their responses or may have declined to complete the questionnaire if they thought the
pharmacist would see their responses.
2.4.3 Meeting with Falls Co-ordinator:
This was a brief informal meeting in which notes were made. A more formal interview
with use of a structured/semi-structured interview schedule would have provided more indepth qualitative information for analysis.
2.5 Data Analysis
13
The data from all pharmacies was inputted into an Excel spreadsheet. The data was
then imported into IBM SPSS statistical software (version 21). This facilitated descriptive and
comparative statistical exploration of the dataset, where this was possible and valid.
3. Results
3.1 Service Activity

Data was provided for analysis for a total of 414 Falls Prevention Service
consultations conducted between January and March 2014.
Chart 1: Number of Consultations
Conducted per Month (n=400)
Number of consultations conducted
149
127
124
January





February
March
Activity levels were similar for each month.
There were slightly more consultations provided in February. This could be due to the
fact that pharmacist training for the service was not provided until the middle of
January delaying start up of the service. Some pharmacists may have been providing
the service as an adjunct to a Medicine Use Review (MUR), reaching the 400 MUR
target in February or early March resulting in a drop in service provision.
Actual activity was only 26.13% of predicted activity.
The vast majority of service delivery was provided by Association of Independent
Multiple Pharmacies (AIMp) and independent pharmacies.
23 pharmacies submitted data for evaluation. The number of consultations provided
by these pharmacies ranged from 1-70 over the 3 month period with an average of 6
consultations per pharmacy per month. One pharmacy provided an average of 23
consultations per month.
14
3.2 Costs





Figures obtained from NHS Doncaster relating to payments made to pharmacies for
providing the service between January and March 2014 totalled £4850.
Average monthly spend: £1617.
Initial set up costs/training plus service evaluation: £1880.
Overall spend on the service: £6730.
Estimated cost for the year if the service was to continue and activity levels are
maintained: £19,400.
3.3 Patient Demographics
3.3.1 Patient Age:
Chart 2: Ages of Patients Assessed
(n=341)
Number of Patients
94
79
65
53
46
4
0-64


65-69
70-74
75-79
Patient Age (Years)
80-84
85+
Mean patient age was 75 years
Ages ranged from 54-92 years.
3.3.2 Patient Sex:

Almost equal split between males (49.5%) and females (50.5%) (n=333)
15
3.3.3 Number of Regular Medicines being taken:
Chart 3: Number of Medicines being
taken by Patients Assessed (n=308)
Number of Patients
158
93
35
0 to 3



18
4 to 7
8 to 11
Number of Medicines
12 to 15
88.6% of patients were taking 4 or more regular medicines.
Mean number of medicines being taken was 6.
Number of medicines being taken ranged from 1 to 22 medicines.
3.4 Audit Results
Number of falls and fracture prevention MUR consultations audited: 414
16
4
16 plus
3.4.1 Falls Risk Factors Identified
Chart 4: Risk Factors for Falling
Percentage of Patients
94.9
31.5
17.4
High Risk
Medicine
(n=414)




Side Effects
(n=413)
Afraid of
Falling
(n=413)
22.6
22
22.1
21.8
Balance/gait
Problem
(n=411)
Vision
Problem
(n=413)
Urinary
Continence
Problem
(n=412)
Fall in last 12
months
(n=412)
The most frequently identified risk factor for falling was ‘high-risk/culprit’ medication
with 94.9% of patients prescribed one or more ‘high-risk/culprit’ medicine.
Nearly a third (31.5%) of patients were experiencing potentially fall inducing side
effects.
A similar number of patients were experiencing problems with their balance/gait,
vision or continence.
90 patients (21.8%) were found to have fallen in the last 12 months.
17
3.4.2 Patient Age and Number of Falls Reported:
Chart 5: Number of Patients in each Age
Group who have Fallen in the Last Year
Number of Falls Reported
22
18
14
13
8
3
0-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85 + years

There appears to be a statistically significant relationship between age and the
number of patients reporting having fallen in the last year (chi-square test, p=0.027).

The majority of patients reporting haven fallen were in the 75-79 year age group.
3.4.3 Patient Age and Fall-inducing Side Effects Reported:

Fall-inducing side effects were most commonly being experienced by patients in the
75-79 year age group.

There was no significant relationship between age and fall inducing side effects (Chisquare test, p<0.05).
3.4.4 High-risk Medicines Prescribed and Fall-inducing Side Effects:

32.6% of patients prescribed high-risk medicines (n=393) reported experiencing
potentially fall-inducing side effects.

There appears to be a statistically significant relationship between being prescribed a
high risk medicine and experiencing potentially fall inducing side effects, (Chi-square
test, p=0.034).
18
3.4.5 Patients with Risk Factors who have Fallen in the Last Year:
Chart 6: Risk Factors and Falls in the
Last Year
Percentage of patients who have fallen in the last 12 months
65.3
42.9
31
27.8
22.3
High-risk
medicine
Side effects
Afraid of
falling
27.6
Balance/gait Vision problem Continence
problem
problem
High-risk medicines
 22.3% of patients taking one or more ‘high-risk’ medicine (n=393) reported falling in
the last year.
 There was no significant relationship between taking a ‘high-risk’ medicine and falling
in the last year (Chi-square test, p<0.05)
Side Effects
 31% of patients who reported experiencing potentially fall inducing side effects
(n=129) reported having fallen in the last year.
 There appears to be a statistically significant relationship between patients reporting
side effects and having fallen in the last year (Chi-square test, p=0.002)
Afraid of falling
 65.3% of patients afraid of falling had fallen in the last 12 months (n=72).
 There appears to be a statistically significant relationship between patients who are
afraid of falling and having fallen in the last year (Chi-square test, p=0.000)
Balance problems
 42.9% of patients with balance/gait problems had fallen in the last 12 months (n=91).
 There appears to be a statistically significant relationship between patients with
balance/gait problems and falling in the last year (Chi-square test, p=0.000)
Vision problems
 27.8% of patients reporting problems with their vision not corrected by glasses had
fallen in the last year (n=90). This was not statistically significant (Chi-square test,
p<0.05).
19
Continence problems
 28.6% of patients reporting problems with continence had fallen in the last year
(n=91). This was not statistically significant (Chi-square test, p<0.05).
3.4.6 Bone Health
Chart 7: Patients Prescribed Bone
Protection who have previously had a
Fragility Fracture
Number of Patients
23
19
Prescribed Bone Protection



Not Prescribed Bone Protection
Less than half of patients who have suffered a fragility fracture are currently
prescribed bone protective medication.
54.8% are not currently prescribed bone protection increasing risk of further
fractures.
Overall 12.9% (n=371) of patients were recorded as being prescribed bone
protection of those patients 37% were identified has having compliance issues with
their prescribed bone protective medication.
20
3.4.7 Outcomes Following the Consultations
Chart 8: Interventions following Falls
Prevention Service Consultations
Percentage of Patients
98.3
94.3
81.2
28.5
10.2
Patient Referred to GP Notified (n=410)
Pharmacist
Oral Advice
Falls Clinic (n=371)
Intervention Alone Provided (n=410)
(n=405)



Leaflet Given
(n=403)
The vast majority of the interventions provided involved the pharmacist alone for
example giving advice to minimise side effects and help with compliance.
Nearly all patients were given falls and fracture prevention advice.
28.5% of patient’s GPs were notified of risk factors identified/referrals made
indicating a relatively low impact on GP workload.
3.4.8 Falls Service Referrals




10.2% of all patients assessed (n=371) were referred to the specialist falls service at
Tickhill Road Hospital
90 patients were identified as having fallen in the last year 41.2% of whom were
referred to the falls service.
9 patients who had fallen in the last year had previously been seen at Tickhill Road.
Additional comments added to some of the datasets indicated why a patient hadn’t
been referred e.g. “patient did not want to be referred” or “one off accidental trip”
however for the majority the reason for not referring was not recorded.
21
3.5 Patient Questionnaire Results
353 questionnaires were returned for analysis. Response rate: 85.3%
Questions 1-3 provided information on patient demographics (see 3.3)
Question 4: Knew the Service Existed

89.4% (n=320) of patients who responded to this question did not know that the
service existed before being offered the service.
Questions 5-11: Explored patient satisfaction and thoughts regarding the service:
Chart 9: Patient Evaluation of the Service
Recommend Service to Others (n=308)
Will make Lifestyle Changes (n=302)
Increased Knowledge of Falls Prevention (n=306)
Advice Given was Useful (n=304)
Understand more about my Medicines (n=308)
Pharmacist Spoke Clearly (n=313)
Pharmacist Explained Purpose of Service (n=312)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of Patients
Strongly Agree







Agree
Uncertain
Disagree
Strongly Disagree
99.7% of patients agreed/strongly agreed the pharmacist explained the purpose of
the service.
100% of patients felt the pharmacist spoke clearly
98.4% of patients agreed/strongly agreed that they understood more about their
medicines after their consultation with the pharmacist.
99.3% of patients agreed/strongly agreed that the advice they were given was useful.
97.4% of patients agreed/strongly agreed that their knowledge of falls and fracture
prevention had increased following the consultation.
85.4% of patients said they would make lifestyle changes.
98.7% of patients would recommend the service to others.
22
Free Text Comments from Patients
Patients were encouraged to contribute their own comments about the service at the end of
the patient survey. Only 50 additional comments were documented. Thematic analysis of
these comments resulted in some interesting categories, as shown in the table below:
Theme
“Revelation” comments
Examples of Patient Comments
“Support was amazing after poor service
from DRI A&E. The pharmacy has done
more to support my falls and reduce
readmission to A&E which is for me a step in
the right direction”
“Pleased to be referred into falls clinic, lives
alone and has just broken her wrist following
a fall”
“Very useful and grateful for time and advice.
recently had ? fitted and feels reassured we
are trying to preserve him”
Useful and Excellent Service
“Very useful and will share with elderly
mother being her sole carer”
“Useful way to save NHS money”
“Very useful and will make think in the future”
“Excellent”
“Very useful, used to be a nurse and thinks
this could help people”
“I found if very helpful”
“Very good”
“Enjoyable, informative”
“Very useful to know these things”
Would recommend the service
“Would recommend to sister in law”
“Excellent service and will send her
husband”
Bone Protection
“Pharmacist picked up on compliance issue grateful for advice on calcium supplement”
“Will make GP appointment to discuss
calcium / vit D”
Negative comments
(NB the majority of these comments were
received from the same pharmacy and
appear to have been written by the
pharmacist)
“Excellent service although was bemused at
being targeted”
“Thought it was strange to be targeted as he
doesn’t feel old or unsteady. Most advice is
common sense”
“Common sense but thought was useful”
“More appropriate to an older age group but
said I have made her think”
“Was reluctant at first but has now consented
23
to falls clinic referral. Fiercely independent
and wants to maintain this. Found
paperwork from clinic very patronising”
“A lot of this is common sense but hopefully
added some value”
“Good idea but more suited to slightly older
age group”
Patient actions/changes
“Going to look at home trip hazards”
“Patient promised to take bone protection
regularly”
“Will make GP appointment regarding
dizziness, good advice”
General comments about the Pharmacist
“Reassuring to know somebody takes the
time to explain things”
“The pharmacist explained things clearly
and was kind and understanding”
“Pharmacist was very helpful”

The majority of recurring comments added by patients related to the service being
“very good”, “excellent” or “very useful”.
3.6 Meeting with Falls Co-ordinator at Tickhill Road Hospital





Feedback provided by the falls co-ordinator was positive: “the service is beneficial, it
is accessing a group of patients that might not be accessing other services”.
Majority of referrals in to the falls clinic have been appropriate.
On the whole patients referred by community pharmacists are younger and more
able then those normally seen at the clinic.
Some patients have declined to attend the clinic following referral. This may be for a
variety of reasons e.g. they do not feel they need further assessment. There may
also be stigma associated with the past history of Tickhill Road hospital used to treat
Tuberculosis suffers and people with mental health problems.
Currently no funding for primary prevention work at Tickhill Road Falls Clinic. The
Falls Co-ordinator felt that primary prevention of falls and fractures was important.
24
4. Discussion
The aim of this project was to evaluate a community pharmacy falls prevention
service. Although the data collection period was relatively short the use of mixed methods
increased the validity of the results. The aim and objectives were met.
Service Activity
Actual activity was less than the predicted activity. As this was a brand new service it
was difficult to accurately predict the number of patients likely to be recruited. The majority of
service delivery was provided by Association of Independent Multiple Pharmacies (AIMp)
and independent pharmacies. It was disappointing that service delivery from the larger
Company Chemist Association (CCA) multiple pharmacies was extremely low. The short
period of time the service has been running has prevented engagement with CCA
senior/regional managers.
Although actual service activity was lower than predicted the number of consultations
provided does demonstrate that community pharmacies can provide and deliver a falls
prevention service. One pharmacy in particular provided an average of 23 consultations per
month. With improvements to the paperwork involved to improve efficiency and increased
pharmacist confidence in providing the service activity may increase. Research into
provision of the MUR service has shown that the range, number and quality of MURs
conducted varies greatly across pharmacies and that this is likely to be due to skill-mix
differences between pharmacy teams, including levels of confidence of pharmacists and
incentives within local areas.34,35,36,37 Further research should be conducted to explore
barriers to service provision and identify ways to increase pharmacist confidence in
delivering this new service.
Costs
Overall spend on this service so far is almost equivalent to the average inpatient cost
for one patient who has suffered a hip fracture as a result of a fall. The estimated yearly cost
25
of providing the community pharmacy falls prevention service is less than £20,000, if the
current level of service activity remains. The average cost of in patient admission for one
person following a fall is £2683 and £6442 for one person who has suffered a hip fracture,
therefore if seven patients were prevented from falling or three patients from suffering a hip
fracture this would pay for the service for a year.23
The short time period that this service has been running for and the multifactorial
nature of falls make it difficult to identify whether or not this service has had an impact on the
number of people falling in Doncaster. This is a primary prevention service therefore the
aims are to raise awareness of the risk factors for falling at a younger age and encourage
people to make lifestyle changes/choices to reduce their risk of falling in the future. The
impact of this service on the number of people falling may not be seen for many years and
would be difficult to prove.
In practice this service is time consuming to provide particularly if a patient requires
referral to the specialist falls service and/or GP. Re-negotiation of fees for the service should
be undertaken with a possible additional fee paid for referral of high-risk patients.
Patient Demographics
The mean patient age was 75 years. Ages ranged from 54-92 years although the
service specification inclusion criteria were people aged 65 and over. From the data
provided it appears that seven patients under 65 were seen by a pharmacist, three of whom
had fallen and therefore the pharmacist may have felt it necessary to provide the service.
For the other five patients it is unclear why they were targeted for the service. This could be
the result of data recording, entry or transcription error.
Eighty-nine percent of patients were taking four or more medicines. There is
evidence that taking more than three or four regular medicines increases the risk of falling. 3
There is potential here to develop the service further to include strategies to try and reduce
the number of medicines being taken by this older patient population. The AGS/BGS
26
guideline recommends medication reduction/withdrawal for all older people.14,15. A recent
evaluation of a service provided by 25 pharmacies in Wigan targeted patients over 65 years
old taking four or more medicines. Pharmacists used the STOPP/START38 prescription
screening criteria to make recommendations to their GP. The number of falls among these
patients halved following the service and there were more recommendations to stop
medication than to start medication.39
Falls Risk Factors
The most frequently identified risk factors for falling were patients taking one or more
high-risk medicine and more than four regular medicines. A third of patients were
experiencing potentially fall-inducing side effects. Almost a quarter of patients were
experiencing problems with their balance/gait, vision or urinary incontinence. Ninety patients
were found to have fallen in the last year.
The majority of patients reporting having fallen in the last year were in the 75-79 year
age group and there was a significant relationship between increasing age and the patient
reporting having fallen (p<0.05). Fall-inducing side effects were also more commonly
reported by patients in this age group however the relationship between patient age and
experiencing side effects was not statistically significant.
Thirty-three percent of patients prescribed high-risk medicines reported experiencing
fall-inducing side effects. This was statistically significant (p<0.05). Community pharmacists
can provide advice to patients prescribed high-risk medicines to help them minimise the risk
of potentially fall-inducing side effects for example; counselling patients on antihypertensives, nitrates and medicines for Parkinson’s Disease about the importance of rising
slowly from lying/sitting to standing or to sit down before using a glyceryl trinitrate spray to
reduce postural hypotension. Thirty-one per-cent of those who reported experiencing
potentially fall-inducing side effects reported having fallen in the last year. This was also
found to be statistically significant (p<0.05).
27
These results demonstrate the need for this service. Community pharmacists can
successfully identify patients experiencing fall-inducing side effects and notify the patients
GP. Discussion with GPs about these findings should take place in order to explore the best
way to address review of these patients so that the potentially fall-inducing side effects are
investigated to prevent people falling without impacting on GP workload.
Of the 94.9% of patients prescribed high risk medicines 22.3% had fallen in the last
year however there was no significant relationship between patients taking high risk
medicines and falling in the last year. Sixty-five per-cent of patients who said they were
afraid of falling had fallen in the last year. This was found to be statistically significant
(p<0.001). It is unknown whether or not being afraid of falling led to the patient falling or
patients who have fallen then became afraid. There is evidence that a fear of falling
increases a patients risk of falling.3 Overall the number of patients who reported being afraid
was low.
Forty-three percent of patients with balance/gait problems had fallen in the last year
and this was found to be statistically significant (p<0.001). Currently community pharmacists
who identify patients as having balance/gait problems but who have not fallen in the last year
have no where to refer them to for further assessment other than their GP. Further work
needs to be done to identify or develop referral pathways for patients with balance/gait
problems for further assessment with a physiotherapist.
Twenty-two percent of patients were identified as experiencing problems with their
vision, 27.8% of whom had fallen in the last year but the relationship between reporting
vision problems and having fallen was not significant. Discussions could be held with local
opticians to develop referral pathways for pharmacists to refer patients to opticians rather
than just sign-posting patients. There may also be the potential for opticians to identify
patients who may benefit from a falls assessment and refer them in to the community
28
pharmacy falls prevention service improving inter-professional working and increasing case
finding of people at risk.
Twenty-two percent of patients were identified as having urinary incontinence, 27.6%
of whom had fallen in the last year but again this was not significant. Further discussion with
GPs about assessment and management of patients reporting urinary frequency or urgency
should be explored.
Bone Health
More than half of all patients (54.8%) who reported having previously suffered a
fragility fracture are not currently prescribed bone protective/sparing medication. The key risk
factors for fracture are low bone mineral density (BMD), past history of fracture, age and the
risk of falling. The importance of non-vertebral fragility fracture is that it at least doubles the
potential fracture risk at that or other skeletal sites.40 It is recommended that patients who
have suffered one or more fragility fractures are priority targets for investigation and
treatment for osteoporosis.40,41
By identifying patients who have had a previous fragility fracture and notifying the
patients GP community pharmacists will help GP’s to achieve Quality and Outcomes
Framework (QOF) points. The 2014/15 QOF requires the recording of patients with previous
fragility fractures and ensuring patients are appropriately prescribed a bone-sparing agent.41
Community pharmacists must ensure they notify GPs of patients who report previous fragility
fractures. Community pharmacist access to GP patient records would enable a community
pharmacist to check whether or not this has previously been recorded and osteoporosis
investigated with out the need for contacting the GP and potentially duplicating work.
Thirty-seven percent of patients prescribed bone protective medication
(bisphosphonates and/or calcium and vitamin D) reported compliance issues. Community
pharmacists can provide support to improve compliance or make suggestions for alternative
treatments/formulations which may be more acceptable to patients and therefore increase
29
compliance. Bisphosphonates are poorly absorbed. Only between one and five per-cent of
the ingested dose is actually absorbed. Optimal absorption requires bisphosphonates to be
ingested on an empty stomach, either first thing in a morning with subsequent avoidance of
food for thirty minutes or in the middle of a four hour fast. They should be swallowed whole
with a large glass of water. All bisphosphonates can potentially cause gastro-intestinal side
effects and very rarely oesophageal ulceration. The risk of these side effects can be reduced
by avoidance of lying flat within thirty minutes of ingestion.40 Encouraging compliance with
bone-sparing medication and educating patients on the correct way to take bisphosphonates
is a key part of this service to ensure patients get the most out of their prescribed medication
in order to reduce their future fracture risk.
Interventions
The vast majority of consultations resulted in interventions provided by the
pharmacist alone indicating a relatively low impact on GP and falls clinic workload. Over
94% of patients were given both oral and written prevention advice and over 98% oral advice
which included advice about regular physical activity, calcium and vitamin D intake, home
hazards, regular vision checks, appropriately fitting footwear and clothing, smoking cessation
and alcohol consumption. This demonstrates by providing this service community
pharmacists are contributing to improved public health.
A small proportion (10.2%) of patients assessed by community pharmacists between
January and March 2014 were referred to the falls clinic at Tickhill Road Hospital. A meeting
with the Falls Co-ordinator in April was positive; the majority of referrals have been
appropriate; there has not been a major impact on their work load and the Falls Co-ordinator
felt that this new service is beneficial because it is accessing people at risk who are not
accessing other services. A previous fall is the most significant risk factor for falling.3 The
10% of patients referred to the specialist falls clinic by the community pharmacists are
30
unlikely to have been referred/had access to falls prevention interventions and advice if this
new service had not existed.
Patient Feedback/Satisfaction
Eighty-five percent of patients did not know that the service existed before they were
approached in the pharmacy. Due to the time pressures to set up the service no promotional
materials were developed. If re-commissioned the service should be promoted e.g. with a
poster and leaflet campaign, in the local news and on social media sites.
Patient feedback was very positive with 99.3% of patients agreeing/strongly agreeing
that the advice they were given was useful and 98.7% of patients stating they would
recommend the service to others suggesting that patients were highly satisfied with the
service. This is supported by additional comments that the service was “very useful” and
“excellent”. There were a number of ‘revelation’ comments such as “support was amazing
after poor service at from DRI A&E. The pharmacy has done more to support my falls and
reduce readmission to A&E which is for me a step in the right direction”. Often patients
present at accident and emergency (A&E) with an injury following a fall, the injury is dealt
with but the reason behind the fall may not be investigated. Further work should be done to
explore the possibility of patients presenting at A&E following a fall being referred into this
community pharmacy falls prevention service for a falls assessment.
Ninety-seven percent of patients also said they felt their knowledge of falls and
fracture prevention had increased and 85% said they would make lifestyle changes following
their consultation. Raising awareness of the risks of falls and the potentially serious
consequences with the general population is extremely important to tackle the increasing
problem of falls and fractures as the population ages. These results demonstrate that
community pharmacists can raise awareness of the risks and consequences and also
provide education to patients to help them make lifestyle changes/choices to help reduce
31
their risk of falls and fractures and maintain their physical fitness and well being helping them
to live independently for longer.
One of the key benefits of this new service is that community pharmacists can
directly refer patients who have fallen in the last year to the falls clinic at Tickhill Road
Hospital. This will hopefully increase the number of patients who are assessed, helped and
supported to reduce their risk of future falls. One patient expressed her satisfaction with
being referred to the falls clinic because she lives alone and had just broken her wrist
following a fall. Many of the patients who could be recruited in to this new service may be
vulnerable living alone like this lady, the service provides an opportunity to identify and
support patients in this vulnerable patient group.
Role for community pharmacists
The results from this evaluation obtained support the findings of the pilot study
conducted previously that there is a role for community pharmacists in falls and fracture
prevention.24 These findings are important as they demonstrate that there is a real need for
this falls prevention service to continue to help prevent falls and fractures in Doncaster. It
also demonstrates that community pharmacists are ideally placed to identify patients at risk
and provide appropriate advice and referrals for interventions to prevent them falling. The
cost of fall related admissions from March 2013 to February 2014 totalled £6,463,415. This
service could potentially lead to huge savings for NHS Doncaster. Savings made by any
reduction in fall and fracture rates could be used to help continue to fund the service.
4.1 Limitations
Time pressures to implement the service as soon as possible prevented proper
piloting of the paperwork involved in delivering the service and the data collection tools.
There was also no time to develop promotional materials to promote the service to the
public. The audit enabled information to be gathered regarding the number of patients
identified with risk factors for falling and interventions provided to reduce risk of falls and
32
fractures, however this method was limited by information and investigator bias and the poor
piloting and design of the data collection record sheet. Electronic data collection would have
prevented any missing data.
The patient questionnaire provided an insight into patients’ views of the service and
their level of satisfaction. The response rate was high minimising bias however the findings
were limited by the questionnaire design and scale structure and by asking patients to
complete the questionnaire in the pharmacy. A face-to-face interview using a
structured/semi-structured interview schedule with the Falls Co-ordinator would have
provided more in-depth, rich data for analysis.
4.2 Recommendations/Implications for practice

Funding for this service should continue. This new and unique service addresses
primary prevention of falls which are an increasing problem in Doncaster. Patient
satisfaction with the service is high, it is supported by the specialist falls service and it
is accessing patients who are not accessing other services.

Review paperwork and processes involved to improve efficiency of service provision.
Develop an electronic method of recording data or make use of an existing electronic
system such as PharmOutcomes.

Evaluation findings should be presented to local GPs and discussions held about
identifying the best way to ensure patients identified with risk factors such as
potentially fall-inducing side effects or urinary continence problems are assessed.

Explore the possibility of developing a referral pathway for patients with balance/gait
problems to be assessed by a physiotherapist and patients with vision problems to
an optician.

The service should be promoted to raise public awareness of the risks and
consequences of falls and fractures and to help improve patient recruitment.
33

Further research should be conducted to explore in more detail benefits of the
service, barriers to service provision and lack of engagement by
pharmacies/pharmacists in particular CCA pharmacies.

Continue to work closely with the Falls Co-ordinators and their team at Tickhill Road
Hospital falls clinic to ensure referrals from community pharmacists are appropriate.
Future service development:

Extend the service to include domiciliary consultations (this should include an
additional fee for expenses/costs incurred). Housebound patients would benefit from
this service as many of these patients are on multiple medicines and do not regularly
come in to contact with health professionals. Many falls occur in the home and it is
also recommended that housebound patients are prescribed a calcium and vitamin D
supplement.40

Explore the possibility of patients presenting at A&E following a fall referred into the
community pharmacy service.

Discussion with GPs about introducing a STOPP/START38 element to the service to
try and reduce the number of medicines being taken by patients aged 65 and over.

Osteoporosis increases susceptibility to fracture and affects 1 in 3 women and 1 in
12 men over the age of 50.8,9 Developing a community pharmacy osteoporosis
screening service where pharmacists can target patients aged 50 years and over for
an osteoporosis risk assessment would further help reduce the number of fractures
suffered by people in Doncaster.
5. Conclusion
This evaluation has demonstrated that there is a role for community pharmacists in
falls and fracture prevention; they can successfully identify patients at risk of falls, provide
patient education and make appropriate referrals to the specialist falls clinic. Patients
reported a high level of satisfaction with the service and would recommend it to others.
34
Due to the multifactorial nature of falls and the short timescale of service provision it
is difficult to see any reduction in the number of falls and fractures however the evaluation
findings clearly show that this community pharmacy service is beneficial.
This service should be continued and developed further to work more closely with
other health professionals, include service provision for housebound patients and help
reduce the number of medicines being taken by older people. An additional osteoporosis
screening service should be developed to complement this service to tackle the increasing
problem of falls and fractures in Doncaster.
35
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39
Appendices
1. Falls Prevention Service Specification (see separate file)
1a High Risk Medicines
1b 180 degree turn test
1c Falls Prevention Advice
1d Falls Prevention Leaflet
1e Consultation Checklist
1f Audit data collection tool/dataset
1g Patient Satisfaction Questionnaire
40
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