Electronic report for antipsychotics a boon for de-prescribing

Aged care provider Southern Cross Care (NSW & ACT) is currently evaluating data from the third quarter since it introduced an electronic Quality Use of Medicines (QUM) report to assist in reducing the use of antipsychotics for behavioural and psychological symptoms of dementia (BPSD).

The QUM report, designed by NPS MedicineWise in association with pharmacy software specialist Webstercare, allows aged care facilities to identify residents who have been prescribed antipsychotics for more than 12 weeks, alert them to potential problems with polypharmacy and highlight the need for a medications review.

Launched last year, the report is integrated into Webstercare's Medications Management Software (MMS) and allows the pharmacist to quickly and easily produce a report on all residents who have been prescribed antipsychotics and for how long. Dose and strength for each medication are also recorded, as are any other drugs prescribed to deal with side-effects of the antipsychotics.

Figures from Alzheimer's Australia show that up to 80 per cent of people with dementia and nearly half of people in residential aged care are receiving psychotropic medications. However, international data suggests that only one in five people with dementia receive any clinical benefit from these medications.

In 2012, Southern Cross Care, which has 30 aged care facilities in NSW and the ACT, identified the use of antipsychotics and unnecessary polypharmacy as an area of concern and was looking for a way to easily collate data to help it evaluate psychotropic use in its facilities and benchmark itself against other facilities around the country.

SCC's dementia care consultant, Sonali Pinto, said that at the time the organisation was rewriting its behaviour management policy for residents with dementia, much of which was informed by the Time for Action report from the UK, an independent review of the use of antipsychotics in elderly people.

By chance, Ms Pinto and SCC's manager of care governance and research Andrew Fleming attended a workshop at the University of Sydney, where they began chatting to clinical pharmacologist Lisa Pont and dementia researcher Lee-Fay Low about what resources could be used to institute the new policy more effectively.

Ms Pinto said it was Dr Pont who suggested talking to Webstercare and its professional services pharmacist, Christine Veal, about the resources it had that could be tapped into. Webstercare was working with NPS MedicineWise on a new antipsychotic report at the time, so a partnership group was set up to introduce it throughout SCC's NSW and ACT facilities.

“Our policy talks about the recommendations that came out of the Time for Action report, which talked about reviewing antipsychotics at the 12-week point,” Ms Pinto said. “We were using a psychotropic drug report but not really looking at the report and analysing what was in it.

“It didn’t really match what we were trying to do with the reduction of antipsychotics because it just told you what people were on and it didn’t tell you how long they were on them for. That’s exactly what this report does. It identifies how long people have been on medications and that's why it sat so well. It supported the policy and it was an appropriate report to use to ensure that we got culture change.”

The partnership group – comprising Ms Pinto, Dr Fleming, Dr Pont, Dr Low and Ms Veal – decided that it would extract data four times a year and do a thorough evaluation. “We are now in the third quarter … and [Ms Veal] is collating it at the moment,” Ms Pinto said.

“We knew from the second quarter that we were going really, really well. There was policy change to support what we were doing but we also changed a lot of other things to support the new practice out in our facilities. There was education about antipsychotics, how to de-prescribe, and education was discussed in consultation with our partnership group.”

SCC has now established de-prescribing teams in each of its facilities, involving registered nurses, care assistants, pharmacists and some visiting doctors. Using the QUM report, these teams are now able to make decisions on de-prescribing based upon real evidence.

“They look at each resident that features on the report,” Ms Pinto said. “They look at how long the person has been on the medication and then if they’ve been on it for more than 12 weeks, as the policy states, we look to identify what is the outcome for this person. Is the behaviour still existing, are there side effects? Is it producing more ill-being than wellbeing? We take all of that decision making into consideration.

“The collaboration also comes from the pharmacist attending at every single site, I have to say the pharmacists have been absolutely fantastic. They attend every meeting and the sort of outcomes that we’ve had is not just de-prescribing the medication, as the second quarter results have shown.

“We’ve also been able to pick up polypharmacy and prescribing cascades. When that medication is de-prescribed, we are able to say we don’t need all these other medications just because of the consequences of the side-effects the antipsychotics were producing.

“As a result of that, we’re getting feedback from the staff saying they are not scared of de-prescribing anymore. That’s a change in culture. There’s historically been the belief that the moment you de-prescribe, that all previous BPSD behaviours are going to return.”

Another benefit of the QUM report is that care staff don't have to collate the data themselves. It is all done at the pharmacy end, with Webstercare's MMS is able to extract all of the required information in mere minutes rather than the hours or days it would take for a nurse to do it by hand.

This also avoids transcription errors, lack of knowledge of drugs that fall into the psychotropic class and any institutional bias to make the results look better.

“It's a lot more reliable and valid,” Ms Pinto said. “A lot of people don't know what antipsychotics are. They don’t know what a benzodiazepine is. They can probably name a couple, but they don’t know the entire list. So it's that old saying of rubbish in, rubbish out with report accuracy.

“Using the pharmacy system, there is no bias, and with the benchmarking that is happening, we don’t influence that in any way.”

Ms Pinto said some doctors have found the idea of de-prescribing confronting and some dislike having their prescribing decisions questioned, so SCC is using the NPS MedicineWise antipsychotic review checklist, which has been designed to streamline communication between GPs and RNs about residents using antipsychotics.

That checklist also allows de-prescribing teams to request a Revised Medication Management Review (RMMR) and other options such as slowly lowering the dose, ceasing the dose or ceasing a PRN antipsychotic, which Ms Pinto said does not work for the BPSD state.

“I felt the form really helped,” she said. “There were a few doctors that questioned it, but I think the issue is that the doctors need to feel secure that the teams know how to manage the behaviour with non-pharmacological approaches.

“In the end we had the biggest difficulty with people that had a combination of dementia and mental health. Doctors felt antipsychotics were beneficial for the mental health and that was the biggest concern, rather than the dementia, in balancing resident wellbeing.”

Ms Pinto is now working with Alzheimer's Australia to create a DVD for GPs about the use of antipsychotics in aged care, which is endorsed by the Australian Medical Association (AMA). An official launch is set for next month.

Webstercare and SCC were awarded a high commendation in the best implementation for infrastructure category at the 2014 ITAC awards for the collaboration.

Posted in Aged Care

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