GUIDANCE FOR MEDICATION
REVIEW
MEDICINES MANAGEMENT 11&12
QUALITY AND OUTCOMES FRAMEWORK
2006-2007
Medicines Management Team
2007
Sati Ubhi
Pharmacist Team Manager
Huntingdon Locality
D:\106731616.doc
Page 1 of 10
SUMMARY
The GMS contract requires medication reviews to be performed to at least level 2. This is a
treatment review of medicines with the patient’s full notes.
The purpose of the review is to make sure patients get the best from their medicines.
A level 2 medication review should:









Confirm that treatments are still needed.
Ensures that medicines carry specific dosage instructions.
Check that medication is prescribed generically (where appropriate).
Highlight potential drug interactions.
Identify adverse drug reactions.
Identify items not being taken.
Review storage, administration, and timings of medication.
Check recording of administration.
Ensure that appropriate monitoring is carried out.
A level 2 medication review is a concordant review.
Patients should be given the opportunity to discuss their treatment and ask questions about
their medicines. They should always be asked about medicines they buy both over the
counter and any herbal remedies.
Introduction
A Medication Review is defined as:
‘A structured, critical examination of a patient's medicines with the objective of
reaching an agreement with the patient about treatment, optimising the impact
of medicines, minimising the number of medication-related problems and
reducing waste.’
Why Perform Medication Reviews?
There is an increasing body of published evidence supporting the effectiveness of
medication review as a means of optimising therapy, improving health outcomes,
reducing the likelihood of medicine-related problems and cutting waste. Evidence is
also emerging that targeted medication review can enable people to maintain their
independence and avoid admission to residential care or hospital.
Problems with repeat medication:
The key potential problems with repeat medication are:
Unnecessary therapy
Ineffective therapy
No, or inadequate routine monitoring
Inappropriate choice of therapy/dosing schedule
Non-compliance.
D:\106731616.doc
Page 2 of 10
Recent documents have summarised the evidence of problems associated with
medicine taking:
Adverse reactions to medicines are implicated in 5-17% of hospital admissions,
and once in hospital, 6-17% of older patients suffer an adverse drug reaction
during their stay.
Polypharmacy increases the risk of adverse drug reactions and of hospital
readmission in older people.
In the case of patients with long-term conditions, some 50% of prescribed
medicines are not taken as prescribed.
Following hospital discharge, changes to medication are frequently made by
patients and GPs, some intentional but many unintentional.
Effective medication review can minimise the incidence and impact of these
problems.
Relevant Quality Indicators in the GMS Contract
The GMS contract quality and outcomes framework refers to medication review in the
medicines management and records sections of the organisational domain.
Medicines Management 11 (7 points)
A medication review is recorded in the notes in the preceding 15 months for all
patients being prescribed four or more repeat medicines*: Standard 80%
Medicines Management 12 (8 points)
A medication review is recorded in the notes in the preceding 15 months for all
patients being prescribed repeat medicines*: Standard 80%
* Medicines DO NOT include dressings and emollients but would include topical
preparations with an active ingredient such as steroid creams and ointments and
hormone preparations.
Underlying principles:
All patients should have the chance to raise questions and highlight problems about
their medicines.
Medication review should improve or optimise impact of treatment for an individual
patient.
The review is undertaken in a systematic way, by a competent person.
Any changes resulting from the review are agreed with the patient and documented
in the patient’s notes.
The review is documented in the patient’s notes.
The impact of any change is monitored.
D:\106731616.doc
Page 3 of 10
In addition, medication review as part of the repeat prescribing process can also
contribute to reaching other GMS clinical quality indicators e.g. epilepsy, mental
health and asthma.
Who can carry out a medication review?
Medication review can only be carried out by:
A doctor
A practice/specialist nurse
A pharmacist
A suitably trained pharmacy support technician
NOTE: For the purposes of the GMS contract medication reviews may not be
carried out by: receptionists, practice staff or other individuals not stated
above.
What constitutes a medication review?
In practice there are several distinct approaches to medication review. These range
from a professional scrutinising a patient’s list of medication to look for anomalies
and problems, to a full face-to-face clinical review where medicines are considered in
the context of the patient’s condition(s) and the way they live their life.
Level 0:
Level 1:
Level 2:
Level 3:
Ad-hoc – unstructured, opportunistic
Prescription review – Technical review of list of patient’s medicines
Treatment review – Review of medicines with patient’s full notes
Clinical medication review – Face-to-face review of medicines and
condition
The GMS contract requires medication review to be performed at least at a level 2
as described in the Briefing Paper:
http://www.medicines-partnership.org/medication-review/room-for-review/downloads:
• Level 2: Treatment Review - review of medicines with patient’s full notes
with/without the patient.
• Level 3: Clinical Medication Review - a face-to-face review of medicines and
condition.
Ultimately, fully concordant face-to-face clinical medication reviews (level 3) should
be available to all patients who would benefit from and want them. Reviews, which
are undertaken without patient involvement, may be an effective means of
highlighting those patients who may need a face-to-face review. The level of review
used should meet individual patient need and this will change dependent on different
patients and at different times.
Whatever the level of review it is essential that the patient and/or carer is informed
and involved in the decision making around changes and is provided with the
opportunity to discuss and feedback how they feel about their medication. Involving
patients in prescribing decisions and supporting them in taking their medicines is a
key part of improving patient safety, health outcomes and satisfaction with care.
D:\106731616.doc
Page 4 of 10
It is good practice for practices to have an agreed written protocol for medication
review in place. This will ensure a consistent systematic approach within the practice
and will facilitate demonstration of the system to the GMS contract assessor.
What constitutes a Medication Review?
Areas to cover:
The review should at least:
Establish that the medicines being taken are best for the patient’s needs
Evaluate the medicines effectiveness (including the patients’ point of view)
Ensure cost-effectiveness of therapy (e.g. generics where appropriate) refer to
‘Generic Prescribing switching from branded to generic medicines in primary
care’ Jan 2006
Consider arrangements for any safety monitoring tests refer to ‘Summary of
Monitoring Requirements for Commonly Used Drugs’ Western Area Prescribing
Forum, June 05.
Consider potential drug interactions
Identify reasons for non-compliance
What Does Not Constitute a Medication Review?
Activities that are not appropriate to be coded as a medication review include:
Tidy up of patients records by reception / practice staff (e.g. removing
discontinued medication from active repeats)
Identifying patients on a particular medicine and switching to an alternative
product
Re-authorising repeat prescriptions for individual medications without reviewing
a patient's total medication according to the standards above.
Note: Whilst a ‘tidy up’ of records is not considered as a ‘medication review’, it
may benefit the medication review process.
A Systematic Approach to Medication Review
Starting to carry out medication reviews can be quite daunting particularly where
there are large numbers of patients involved.
Important aspects to consider include:
Initially prioritising patients who are at relatively high risk of medicines-related
problems (see below).
Using the appropriate level of review.
Carrying out the review (medication review templates on the clinical systems
can be used refer to What constitutes a Medication Review-Areas to cover)
D:\106731616.doc
Page 5 of 10
Recording review outcomes (medication review templates on the clinical
systems can be used) / Feedback results
Audit / Quality assurance
Patient notification
There are several ways that practices can use to notify patients of the need for
medication review:
The practice may write to patients to invite them for review (see Appendix A for
an example of a letter of invitation, a patient information leaflet, a guide to
medication review entitled ‘Focus on Your Medicines’ is also available
(Appendix B)
A message can be inserted and will be flagged up on the medication screen
and patients may be invited to make appointments when they phone for their
repeat prescriptions.
A note can be made in the consultation computer or paper record.
The practice needs to have a recall system in place to invite patients to attend for
review, and a protocol detailing the review process. This should include what should
be done in the case of patients who do not keep their appointment or non-responders
to the invitation. In these events some practices do not authorise issue of further
repeat prescriptions until a review appointment has been made. A protocol relating
to the review of specialist medicines and actions to be taken when patients do not
attend for the required monitoring also needs to be in place.
Prioritising Patients with Relatively High Risk of MedicinesRelated Problems
The following groups are known to be at relatively high risk:
Older people
Those prescribed 4 or more medicines
Polypharmacy is a risk factor for adverse drug reactions and for re-admissions of
patients discharged from hospital.
Post-discharge from hospital
Changes in medication after discharge may be intentional, but unintentional
discrepancies in medication are found in half of patients after they have left hospital.
These include patients or the GP practice restarting medicines that were stopped in
hospital, and duplication of treatment (for example, a medicine being prescribed by
both its generic and branded names).
Older people in care homes
A study of pharmacist-conducted medication review of all medicines showed that
modifications to treatment were needed for half of the medicines prescribed; the most
frequent recommendation (47%) was to stop medication and in two-thirds of these
cases there was no stated indication for the medicine being prescribed. Longer-term
D:\106731616.doc
Page 6 of 10
follow-up showed the number of medicines prescribed for older people can be
reduced with no adverse impact on morbidity or mortality.
Patients with special psychiatric needs
Patients prescribed high risk medication
Those that require special monitoring (e.g. warfarin), those with a wide range of side
effects (e.g. NSAIDs) or those with a narrow therapeutic range (e.g. digoxin)
Other high priorities for medication review include:
When medicines-related problems have been identified through routine monitoring or
assessment
Following an adverse change in health such as dizzy spells or confusion - could a
medicine have caused or contributed to the problem?
GMS Contract Assessment visit 07/08
Medicines Management 11&12
Inspection of records should be carried out annually by a member of the Medicines
Management Team.
Staff should be able to demonstrate how the system works and in particular how an
annual review is ensured.
Audit criteria and quality assurance
The following audit criteria are supplied to help you collate evidence** of the current
quality of the medication review process in your practice:
Practices should have a written medication review protocol. This should address the
areas of patient compliance, appropriate choice of drug treatment including dose,
form and length of treatment, drug contraindications and interactions. It should state
the responsibilities of all staff involved, how an annual review is ensured and should
be regularly reviewed. Standard 100%
Medication reviews should only be carried out by a doctor, practice/specialist nurse,
pharmacist or suitably trained pharmacy support technician. Standard 100%.
For repeat medicines, an indication for the drug can be identified in the records.
Minimum standard 80% (Records 9; 4 points)
All medications should have clear, practical directions for use when applicable. In
some cases the use of mdu is appropriate but generally the use of ‘mdu/md’ or ‘as
directed’ is unacceptable. Standard 95%.
Appropriate monitoring should be recorded for identified drugs. Minimum standard
80%, 100% for high-risk groups (see page 5).
One method of assessing the quality of the review system is by evaluating the
feedback from patients or their carers who have participated in the medication review
process. This might include an evaluation of their experience of the review and the
level of satisfaction with its outcome. If READ codes for medication review are used
D:\106731616.doc
Page 7 of 10
to document that reviews have been undertaken, then a search of the practice
computer system should easily identify those patients who have had a medication
review within the previous 15 months.
** Note that in 07/08 evidence is only required by assessors for audit criteria (above).
However, it is likely that further evidence of quality of medication review will be
required in the future.
Documenting an audit trail for the medication review
A clear auditable system should be used to record medication reviews. It is
recommended that the medication review templates available on the clinical systems
are used.
READ codes could be used to record reviews. If the read codes are used it is vital to
ensure that the computer record of every patient who has had a medication review is
given the READ code for the appropriate type of medication review. The following
READ CODES are suggested:
8B3x
WITH PATIENT
8B3h
WITHOUT PATIENT
Medication review in the presence of the patient
with access to the patients’ clinical record and
laboratory test results as required.
Medication review in the absence of the patient but
with access to the patients’ clinical record and
laboratory test results as required.
Practices should consider the medico-legal issues of undertaking and documenting
medication reviews. Practices should ensure (where possible) that there is an audit
trail to identify the person responsible for undertaking the medication review (e.g.
individual log-in for doctors, practice/specialist nurses, pharmacists or suitably trained
pharmacy support technicians when recording medication review READ codes).
Resources
Further information and a number of useful tools to support the medication review
process are available including:
Room for Review: a guide for medication review. The guide and tools are available
on the Medicines Partnership website www.medicines-partnership.org/medicationreview.
Appendix A of this document provides a sample patient invitation letter.
A patient information leaflet entitled ‘Focus on Your Medicines’ has been produced
by the Department of Health to help prepare patients for a medication review –
Appendix B.
Acknowledgement for this publication should be given to:
Western Health and Social Services Board
Pharmacy and Prescribing Team 2006
D:\106731616.doc
Page 8 of 10
Appendix A
Sample Patient Invitation Letter
Practice Header etc
Dear
MEDICATION REVIEW
We are writing to invite you to come into the surgery for a routine review of the
medicines you are currently taking. It is good practice for us to review your repeat
medicines at least once a year.
The purpose of the review is to check that you are getting the best treatment and to
agree what medicines you are going to take. A medication review is a chance to
check that your medicines are the best ones for you. It involves checking your
medicines are working and not causing side effects. It is also a chance for you to tell
us how you are getting on with your medicines and to ask questions and find out
more about them.
We recommend that you make an appointment to have a medication review with your
GP or practice nurse (delete as appropriate). The review lasts about 20 minutes. At
the review there will be a chance to have your questions answered and to have the
purpose of your medicines explained. A check will be made on any monitoring or
changes to your medicines that are needed.
Please find enclosed a leaflet to help you prepare for your medication review. When
you come to the medicine review clinic please bring along all of your medicines. This
includes the medicines you get on prescription from your doctor as well as herbal
remedies and medicines you buy from the chemist or supermarket. By medicines we
mean anything you take or use, including tablets, liquids, inhalers, creams and
ointments. Please also bring along medicines you no longer take.
The purpose of the review is to help you get the best from your medicines. No
medicines will be altered without agreement with you and your doctor.
Yours sincerely
D:\106731616.doc
Page 9 of 10
APPENDIX B - attached
LEAFLET – FOCUS ON YOUR MEDICINES by The Department of Health
D:\106731616.doc
Page 10 of 10