The Screening Tool for Older People’s Prescriptions (STOPP) criteria is often used to tackle problems that contribute to illness in the elderly1,2 where multiple medicines are taken.3
Potentially inappropriate medicines (PIMS) in older people can be seen in various clinical settings, ie. 21.4% in primary care, 34.5% in secondary care, and 73.1% in nursing home care.4 However, the use of STOPP tools and the types of pharmaceutical intervention made in intermediate care settings has only recently been explored.5,6
The North-West London STOPIT tool
The Screening Tool for Older People’s Inappropriate Treatments (STOPIT) was adapted for use at the Chelsea and Westminster Hospital NHS Foundation Trust (CWFT) from the ImPE tool,7 a medication review proforma derived from the validated evidence-based STOPP tool.8 Both STOPIT and ImPE projects are supported by Collaboration for Leadership in Applied Health Research & Care (CLAHRC) for north west London, whose vision is that “patients should experience a seamless journey with consistent delivery of the highest quality evidence-based care”.9
The medication review proforma was adapted so that it became the STOPIT tool, incorporating a procedure to “qualify” patients admitted to hospital for review of potentially inappropriate medicines. Qualifying patients are identified by pharmacy staff and highlighted through direct communication as well as documentation in the CWFT electronic prescribing system. The doctors then review accordingly. Changes made as a result (dose reductions or discontinuations) are similarly documented electronically allowing transcription onto the discharge summary.
Reviewing medicines during an acute admission to the hospital captures a large number of patients who may otherwise not have presented to primary care physicians or community pharmacies.
The Ellesmere House rehabilitation unit (EHRU)
The EHRU has 10 beds and is run by an independent healthcare provider, Care UK. It typically offers rehabilitation stays of up to six weeks. Medical and pharmaceutical services are provided by the neighbouring CWFT under a service level agreement, and most referrals originate from the Trust. A smaller number of referrals are sometimes accepted from other acute hospitals and directly from the community. Our referrals come from a variety of specialities including GPs, geriatricians, orthopaedic and general surgeons.
Medicines taken by EHRU patients are managed by the consultant-led care of the elderly team, which includes a senior pharmacist. Management typically involves ensuring accurate medicines reconciliation, optimisation of medicines and preparation for pharmaceutical discharge. Since many admissions are made from the neighbouring Trust, medicines reconciliation is usually straightforward, particularly since a medication history will have been verified during the hospital stay. Adherence to medication post-discharge is a major focus and the pharmacy team assess this and work towards overcoming barriers to taking medicines as prescribed.
The STOPIT proforma was used to collect data prospectively over a period of five months (September 2012–February 2013). Forms were not completed for patients where drug treatment was initiated and subsequently optimised on the EHRU. For patients transferred from CWFT, “step 1” of the form was not completed, since this will have been undertaken during the acute admission to hospital. “Step 2”, the medication review, was undertaken during the weekly ward round and typically involved the consultant and registrar for older people, a pharmacist and a nurse.
Changes were documented on the STOPIT form and results were tabulated on an Excel spreadsheet. Basic descriptive statistics were used in the analysis.
During the study period, EHRU provided rehabilitation for 36 patients. 15 rehabilitation patients (42%) had a STOPIT form completed. Table 1 outlines the source of referral and medication changes recorded on STOPIT forms for some of these patients.
The study population presented with a typical spectrum of medical conditions as well as a variety of medicines that are to be expected in elderly patients. In each case, patients and primary care physicians were informed of medication changes and a medication adherence assessment was conducted and the findings acted upon, in order to try and maximise the benefit of using the STOPIT tool.
This preliminary study looking into the use of a STOPP-type tool in an elderly care rehabilitation setting demonstrated that 42% of patients had at least one pre-prescribed medicine stopped or adjusted by the multidisciplinary team. EHRU patients will also have medicines initiated and adjusted during their stay on the unit. Whilst beyond the scope of this study, it is important to counter any notion that rehabilitation patients always have a stable medication regime that requires little intervention.
Many of our referrals came from CWHT where it may be expected that medicines will have been rationalised. Our experience was that this was often not the case and there was scope to initiate and optimise appropriate medicines as well as stopping them.
Focus groups at CWHT have previously suggested that junior doctors feel uncomfortable stopping medicines that more senior doctors have initiated. Moreover, indications for medicines are frequently not known to the admitting team in the acute environment, current medication lists may not be up-to-date and primary care physicians are sometimes not informed of reasons for hospital-initiated medication changes. We are also aware of anecdotal reports that surgical teams are reluctant to change regular medications. These factors may contribute to unnecessary continuation of previous prescriptions which can be reviewed effectively in the rehabilitation environment.
As such, rehabilitation wards can be a better setting for medication reviews than the acute phase of hospitalisation. Rehabilitation patients may also be more physiologically and pharmacodynamically stable, or may be in the process of normalisation, making it easier to follow the impact of medication changes.
At the EHRU, the typical stay of six weeks provides an excellent opportunity to monitor the therapeutic effect of medication changes closely, compared with other settings including outpatients.
Our results demonstrate that medicines optimisation10 on the EHRU varied in complexity. Simpler examples included stopping or reducing doses of proton pump inhibitors (PPI), and laxatives, whilst complex management was also necessary,5 for example optimising treatment in a patient with concurrent hypertension and postural hypotension. We also updated medication regimens (eg. nifedipine to amlodipine and metoprolol to bisoprolol). We would argue that the simpler modifications are particularly important in rehabilitation patients who are recovering from acute episodes of care and may therefore be at greater risk of, for example, Clostridium Difficile infection exacerbated by PPIs or laxative-induced dehydration.
Non-prescription “over-the-counter” (OTC) medicines were not covered in our study, and we acknowledge that some adverse effects in older patients are likely to be related to OTCs.4 However, we have included in our results one significant case where gingko biloba was being taken by a patient with important risk factors, which illustrates the potential impact of OTC or herbal medicines in our study cohort.
We are mindful of limitations with this preliminary study, including the potential for the EHRU team to make more interventions during the study period. We also experienced a small number of cases where stopping medication was not successful, including one particular patient with strong beliefs about her medication that had led her to inappropriately manage her medicines at home. Our attempts to rationalise her medicines caused her anxiety but even then, the rehabilitation stay allowed for ongoing dialogue, working towards a discharge plan.
Conclusion: potential bias and recommendations
This small study explores the potential to optimise medicines in a rehabilitation environment. We have reviewed a variety of medicines in a diverse patient population with a range of referral sources. It was beyond the scope of our project to look at cost savings but we believe that this type of work in rehabilitation settings can successfully contribute to the QIPP agenda that continues to have a high profile in the UK health economy.11
We note a view by Clifford et al, that published research regarding potentially inappropriate prescribing leads to poor patient outcomes is mixed at best12 and that it remains unclear whether stopping these medications helps patients avoid medication-related harms.
Clearly there is a need for further research in relation to outcomes. However, we would argue that the use of STOPP-type tools must be part of a wider strategy of adequate communication between care settings with patients and professionals, particularly during transfer of care.13 Use of STOPP tools should also facilitate medication adherence as much as possible. Unintentional non-adherence,12 which may include dementia-related causes is an important variable to consider in this respect.
Empowering doctors to stop what is “inappropriate” as readily as starting evidence-based treatments, should improve the quality of prescribing which decreases risk and should reduce overall costs. (“Inappropriate” is defined as no perceivable benefit to that individual—we note that ‘inappropriate’ is a personal/individual term prone to some subjectivity).
We believe that our findings from a rehabilitation setting arise from a commitment from doctors and pharmacists to work together and exercise willingness to stop or adjust medicines that are deemed unnecessary. We therefore recommend that primary and secondary care physicians and pharmacists work together to actively review the need to continue medications in intermediate care settings, such as rehabilitation units.
We hope on the EHRU to evaluate more patients over a longer period of time, to apply models of costing and to evaluate other factors such as risk and length of stay in the rehabilitation environment.
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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