“Don’t forget to take your medicine!” Improving the use of medicine by elderly patients in the region of Madrid
This case study was written by Fernando Gil and Salvador Parrado (2012).
Introduction
In Spain a high percentage of elderly people aged over 75 experience chronic diseases and multiple health problems. Patients are often faced with complex therapies and taking multiple medications, so that forget some them or get confused on what should be taken and when.
To tackle these problems, the Health Agency of Madrid region designed and delivered a prevention programme in 2006 that was specifically targeted at elderly patients. Its objective was to reduce health risks and adverse impacts that can result from misuse of multiple medicines.
The programme is based on personalised medication schemes which are co-designed by health professionals and patients. It offers regular reviews involving primary care centres and pharmacies in the Madrid region.
Currently more than 100,000 patients are taking part in the programme, which has produced very positive results for them and and also achieved savings for the public sector. As a result, other regions such as Extremadura and the Canary Islands are now seeking to implement similar prevention programmes. The programme has won a special distinction in the category ‘good practices’ from the VI Quality Excellence Award for Public Services in Spain.
Objectives
The overall aim of the programme is to improve the health and wellbeing of residents over 75 years of age who live in the Madrid region and have to take more than 6 different medicines on a permanent basis. In particular, this implies the following objectives:
- To identify and solve problems arising from use of multiple medications;
- To influence patients to take their prescribed medication according to the right schedule; and
- To get patients to pursue the full therapies related to their use of multiple prescriptions.
Leadership and change management
The first challenge was to reach out to the patients who were eligible for the programme and to persuade them to get involved. This was achieved through a combination of active, passive and targeted outreach initiatives.
In the first place, medical staff working in health centres approached patients who were visiting the health care centre or who had home visits. Pharmacists also made patients aware of the programme when they picked up medication from the pharmacy. At the same time, a public campaign was launched by putting up posters about the programme in facilities frequented by the elderly. In addition, the Health Agency of Madrid Region identified every patient who was eligible for the programme and requested their GPs to tell them about the new programme.
At the start of the programme patients have an appointment with a nurse to make an assessment of all the medications they are taking. This includes prescribed medications but also those medications available without prescriptions and 'alternative' medicines.
This initial assessment is followed by an in-depth assessment by medical staff in order to:
- assure that the medications taken by the patients conform with those prescribed in their medical history - this identifies both gaps, where medicines prescribed are NOT being taken, and also use of medication which was not prescribed;
- improve patient's knowledge about the purpose of various medications;
- identify the degree to which medications are taken according to the prescription;
- identify problems such as lack of regular taking of medications, duplication, and suspected adverse reactions to medication;
- agree a set of personalised tools and triggers with the patient which help the patient to achieve a successful outcome (e.g. user-friendly and memorable labels on medicines, and personalised mechanisms for dispensing the daily medications, sometimes in an apparatus which is recyclable, sometimes single use only).
This approach entails a number of tests to enable medical staff to get to know the patients and understand their capacities and attitudes. Then a medication plan is co-designed with each patient taking part in the programme.
Figure 1 provides an overview of the tests carried out with the patient to assess needs and capacities.
Figure 1: Needs and capacity assessments for elderly patients requiring multiple medication
Based on this assessment the GP produces a ‘medication leaf’ which shows the relation of all the medication the patient needs to take with his/her condition as well as the start and end date of the treatment. Particular attention is given to issues of safety in the use of medication by avoiding medication which is not adequate for elderly people or is more likely to produce adverse effects and the prevention of possible medication mistakes. The ‘medication leaf’ needs to be reviewed at least every six months.
In order to ensure compliance with the personalised medication plan health visitors and staff of pharmacies continue to engage with the patient in a number of follow-up activities, including:
a) health education of the patient;
b) checks whether the medication is taken properly to identify problems at an early stage and jointly discuss possible solutions; and solutions
c) the distribution of tools and materials to achieve a successful therapy.
The biggest challenge is to ensure that elderly patients with chronic conditions do not stop taking prescribed medication too early. Therefore, the health programme for patients with multiple medication of the region of Madrid foresees three levels of support:
1) Self-sticking labels to stick on medication containers which provide instructions how to use the medication
2) Personalised medication systems which can be reused (weekly medication trays)
3) Personalised medication systems for single use
Outcomes
During more than six years of running this programme the personal outcomes of many patients have been improved significantly, as highlighted by the following reports from the pharmacists participating in the programme.
Patient 1 – an 82 year old woman ...
...took medication in an erratic way until she joined the programme. Her therapy has improved and her condition is more controlled. In particular, she reports less pain and is more stable, showing much lower levels of stress.
Patient 2 – an 82 year old woman ...
...chronic skin condition of her hands, arterial hypertension (HTA), diabetes, depression, osteoporosis, hipercolesterolemia, Alzheimer's. All in all, a very frail person with difficulties in following her treatment plan. Since she took part in the programme, she has been better able to control her skin condition, her glycemia levels are stable and her hypertension now has normal values. She now also gets a calcium treatment which she did not have before. The programme has not only improved her health but also her quality of life.
Patient 3 - an 88 year old man ...
...Alzheimer's and other conditions related to his age. Since his inclusión in the programme, pharmacists have prepared his medication dosage system on a weekly basis and reduced errors in both dosage and the time of the day when he took the medication, etc.
Success indicators
The programme is being coordinated by the Directorate General of Economic Management and Provision of Health and Pharmaceutical Products of the Health Agency of the Region of Madrid. This unit conducts regular evaluations of the programme, which are disseminated to 7 sub-ordinate administrative units, which again pass the information onto the health professionals working in primary care.
In the first four years after the start of the programme, more than 100,000 patients benefitted from the programme, with more than 1000 pharmacies participating (35% of all pharmacies in the region of Madrid).
The programme has brought very positive results for the improvement of health of the patients. By the end of the second year of the programme, the proportion of patients aged over 74 who were at a high risk of adverse effects from their medication (medication which fulfils the so-called Beers criteria) fell from 16.3% in 2006 to 14.4% in 2008.
As far as the overall impact of the programme is concerned, a survey conducted with the 127,206 patients engaged in the programme in June 2011 (with an average response rate of 64%) indicated that:
- 91.6% of the respondents knew how they were supposed to take their prescribed medications
- 92.4% knew the prescribed dosage
- 95.37% exhibited good compliance (indicated by the Morisky test)
Costs and savings
Before the implementation of the programme in 2006 a cost-benefit analysis was carried out. The model was based on the initial target group of the programme (elderly residents aged 75 years or above who use more than 6 different medications on a regular basis) and focussed on the following direct benefits of the programme:
- reduction of duplication of medication;
- reduction of adverse reactions to medication.
The estimation of benefits did not include other variables such as the reduction of unnessary medication and the improvement of medical treatment plans as no reliable data of these variables existed.
The model included the following costs:
- costs for the time invested by professionals to co-produce personalised medication schemes for patients;
- costs for the training of professionals;
- costs for the awareness campaign and drafting of support material for the programme.
The results of the cost-benefit analysis are summarised in the table below.
Table 1: Costs and benefits of the programme
Learning points
- The delivery of this specific health programme requires close partnership working between different health professionals, including GPs, pharmacists, nurses and health visitors.
- The personalisation of medication schemes is one of the pillars of this programme. Each medicine has to be reviewed with regard to its effectiveness, safety and cost-effectiveness, in order that the most suitable medicines are chosen for each patient. In the case of elderly patients, issues of safety are of particular importance when using multiple medicines. Particular attention has had to be paid to avoiding the use of medications considered to be unsuitable for elderly patients.
- The co-design of personalised medication schemes between health professionals and patients requires that health professionals are trained ‘to put themselves into the shoes of patients’ and to take into account the personal context and wider social network of patients.
Further information
- Dirección General de Farmacia y Productos Sanitarios Consejería de Sanidad y Consumo (Ed.) (2006), Programa de Atención al Mayor Polimedicado en la Comunidad de Madrid. Disponible en: http://www.madrid.org
- Dirección General de Farmacia y Productos Sanitarios. Consejería de Sanidad y Consumo Comunidad de Madrid (Ed.) (2004), Guía Farmacogeriátrica de la Comunidad de Madrid. Disponible en: http://www.madrid.org/sanidad/farmacia/guia/pdf/Farmacogeriatrica.pdf
Main Contact
Salvador Parrado
Director
Email: Salvador.parrado@govint.org