PATIENT-CENTRED PRESCRIPTION MODEL TO IMPROVE EFFECTIVE PRESCRIBING AND MEDICATION ADHERENCE IN PATIENTS WITH MULTIMORBIDITY Integrated Care Matters Series 3: Appropriate Polypharmacy & Adherence Javier González Bueno. BCPS. Pharmacy Department. Consorci Hospitalari de Vic (Barcelona). 22 nd November 2018
Where do we come from? INTERVENTIONS AIMED AT IMPROVING MEDICATION ADHERENCE IN PATIENTS WITH MULTIMORBIDITY Lack of adherence Multimorbidity ✓ Poor disease control ✓ Frailty ✓ Reduced survival and quality of life ✓ Increased disability and reduced survival ✓ ✓ Increased healthcare expenditure Increased healthcare expenditure J. González Bueno
Where do we come from? N=57 (2005) N=182 (2014) N=73 (2008) +16 +109 J. González Bueno
Where do we come from? Survey of medication adherence in Spain 2016 1978 << If you want different results, do not do the same things >> A. Einstein J. González Bueno
OBJETIVO: SSDC compartido NEW APPROACHES to improve medication adherence in patients with multimorbidity J. González Bueno
A new approach for improving medication adherence in patients with multimorbidity Tool for adherence assessment Intervention model J. González Bueno
A new approach for improving medication adherence in patients with multimorbidity Tool for adherence assessment Intervention model J. González Bueno
Tools for medication adherence assessment OBJETIVO: SSDC compartido Self-report questionnaires Pharmacy records J. González Bueno
Tools for medication adherence assessment Self-report questionnaires J. González Bueno
OBJETIVO: SSDC compartido Strenght of Usefulness Ease of use evidence J. González Bueno
ARMS: Adherence to Refills and Medication Scale • How often do you forget to take your medicine? • How often do you decide not to take your medicine? None (1) • How often do you skip a dose of your medicine before you go to the doctor? • How often do you miss taking your medicine when you feel better? • How often do you miss taking your medicine when you feel sick? • How often do you miss taking your medicine when you are careless? How often do you change the dose of your medicines to suit your needs (like when you take more or less pill than you ´ re • supposed to)? Some (2) • How often do you forget to take your medicine when you are supposed to take it more than once a day? Adherence with taking medications Most (3) • How often do you forget to get prescriptions filled? • How often do you run out of medicine? • How often do you put off refilling your medicines because they cost too much money? • How often do you plan ahead and refill your medicines before they run out? All (4) Adherence with the refilling of prescriptions J. González Bueno
ARMS questionnaire: multidimensional assessment of adherence • How often do you forget to take your medicine? • How often do you decide not to take your medicine? • How often do you skip a dose of your medicine before you go to the doctor? • How often do you miss taking your medicine when you feel better? • How often do you miss taking your medicine when you feel sick? • How often do you miss taking your medicine when you are careless? • How often do you change the dose of your medicines to suit your needs (like when you take more or less Medication regimen Medication-related pill than you ´ re supposed to)? complexity adverse events • How often do you forget to take your medicine when you are supposed to take it more than once a day? Adherence with taking medications • How often do you forget to get prescriptions filled? • How often do you run out of medicine? • How often do you put off refilling your medicines because they cost too much money? • How often do you plan ahead and refill your medicines before they run out? Inadequate Socioeconomic Adherence with the refilling of prescriptions knowledge and/or aspects beliefs about drug therapy J. González Bueno
A new approach for improving medication adherence in patients with multimorbidity Tool for adherence assessment Intervention model J. González Bueno
OBJETIVO: SSDC compartido Effective prescribing Adherence J. González Bueno
OBJETIVO: SSDC compartido J. González Bueno
Strategies to reduce medication regimen complexity through simplifying dosing Overview of schedules and/or deprescribing. systematic reviews Delivery personalized dosage systems Strategies to enhance communication between patients and healthcare professionals. Delphi methodology Counselling and educational interventions for patients and/or caregivers regarding their clinical condition, relevance of treatment and medication adherence. J. González Bueno
Patient-Centred Prescription model to improve effective prescribing and medication adherence in patients with multimorbidity J. González Bueno
PCP Model A case report Male, 84 years Patient with frailty and multimorbidity Hospital Admission He was admitted in an intermediate care centre after supracondylar amputation of the lower left extremity. Manuel J. González Bueno
PCP Model A case report Conditions at baseline Drug therapy at baseline • Insulin glargin 18 UI/24h • Insulin glulisine /8h Type 2 Diabetes Mellitus • Repaglinide 0.5mg/8h • Aspirin 100mg/24h • Clopidogrel 75mg/24h • Isosorbide mononitrate 40mg/8h Coronary Heart Disease • Ranolazine 750mg/12h • Atorvastatin 40mg/24h • Furosemide 40mg/24h • Pantoprazol 40mg c/24h Peptic Ulcer • Long-acting tolterodine 4mg/24h Overactive bladder • Acetaminophen 1g/6h Peripheral Arterial Disease • Oxycodone 10mg-0-20mg • Latanoprost 0,005% 1 drop upon awakening Glaucoma • Lorazepam 1mg/12h Anxiety-depressive disorder J. González Bueno
PCP Model: a case report Patient Diagnosis Drug centered Treatment centered centered assessment plan assessment assessment Instrumental activities: Partially preserved. Functional Activities of daily living: Barthel index 60/100 Mental No cognitive impairment (Pfeiffer 1). Social Social vulnerability Falls + Pressure ulcers - Polypharmacy + Geriatric Dysphagia - Constipation + Malnutrition - syndromes Pain + Dyspnoea - Insomnia + Frailty index (FRÀGIL-VIG): 0.36 (moderate frailty) J. González Bueno
PCP Model: a case report Potential barriers for non-adherence Adherence assessment. ARMS questionnaire Inadequate Adverse Socioeconomic knowledge Answers Complexity aspects events and/or beliefs Adherence with TAKING medications How often do you forget to take your medicine? Some How often do you decide not to take your medicine? Most (tolterodine) How often do you skip a dose of your medicine before you go to the doctor? None How often do you miss taking your medicine when you feel better? Most (acetaminophen) How often do you miss taking your medicine when you feel sick? None How often do you miss taking your medicine when you are careless? Some How often do you change the dose of your medicines to suit your needs (like None when you take more or less pill than you´re supposed to)? How often do you forget to take your medicine when you are supposed to take it Some more than once a day? J. González Bueno
PCP Model: a case report Potential barriers for non-adherence Adherence assessment. ARMS questionnaire Inadequate Adverse Socioeconomic Answers Complexity knowledge and/or aspects events beliefs Adherence with the REFILLING of prescriptions None How often do you forget to get prescriptions filled? How often do you run out of medicine? None How often do you put off refilling your medicines because they cost too much None money? All How often do you plan ahead and refill your medicines before they run out? J. González Bueno
PCP Model: a case report Patient- Diagnosis Drug centered Treatment centered centered assessment plan assessment assessment Maintaining function Ease the management of medication regimen complexity Safety of pharmacotherapy Education J. González Bueno
PCP Model: a case report. DIAGNOSIS centred assessment. Baseline conditions Drug therapy at baseline DIAGNOSIS centered assessment • STOP Repaglinide: Hb A1c 7,2% Insulin glargin 18 UI/24h • Ambulatory blood glucose monitoring Type 2 Diabetes Mellitus Insulin glulisine /8h • Insulin therapy optimization Repaglinide 0.5mg/8h Aspirin 100mg/24h • STOP Ranolazine: Clopidogrel 75mg/24h Scarce efficacy Isosorbide mononitrate 40mg/8h Coronary Heart Disease Ranolazine 750mg/12h • STOP Clopidogrel: Atorvastatin 40mg/24h >12 months on therapy Furosemide 40mg/24h Peptic Ulcer Pantoprazol 40mg c/24h Overactive bladder Long-acting tolterodine 4mg/24h • START Gabapentin 300 mg/12h: Uncontrolled neuropathic pain Peripheral Arterial Acetaminophen 1g/6h • CHANGE Acetaminophen 1g/8h Disease Oxycodone 10mg-0-20mg • REDUCTION Oxicodone 10 mg c/12h Latanoprost 0,005% 1 drop upon Glaucoma awakening • START Sertraline 50 mg c/24h Anxiety-depressive Lorazepam 1mg/12h • CHANGE Lorazepam 1 mg “if needed” disorder J. González Bueno
Dosing Administration frequencies Dosage form instructions J. González Bueno
MRCI predicts in geriatric population… Non-adherence Hospital Admissions Mortality J. González Bueno
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