Clinical audit template

The clinical audit process has been tested and refined over time. Its purpose is to encourage teams to reflect and act on the best information available to improve clinical practice. The method can be applied to any aspect of practitioner or practice activity to assist with identifying ‘where you are now’, ‘where you could do better’ and ‘how to get there’.

TOPIC /

Polypharmacy in older people

Why is this topic of interest?

Polypharmacy can refer to the prescribing of many medicines (five or more medicines is often quoted) or to the addition of inappropriate medicines to an existing regime.[1]
Polypharmacy is associated with negative health outcomes including adverse drug reactions, poor adherence and clusters of health problems described as “geriatric syndromes”, for example, urinary incontinence, cognitive impairment and impaired balance leading to falls.[2]
Older people (defined here as those aged 65 years and over), especially those with frailty or multiple comorbid conditions, are more susceptible to medicine-related morbidity and mortality.

What is this audit about?

This audit consists of a review of 15 people aged 65 years and over who are receiving:
·  5 or more medications
·  8 or more medications
·  11 or more medications.

References

1.  Aronson J. 2004. In defence of polypharmacy. British Journal of Clinical Pharmacology. 57(2): 119–20.
2.  Haijar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5:345–51.

Recommended reading

Ministry of Health. Medicines Care Guides for Residential Aged Care. Wellington: Ministry of Health, 2011.
PLAN /

Indicators

The doctor/practice reviews prescription practices and appropriateness for older patients.
·  Local DHB prescribing practice is compared with other DHBs across a range of indicators. Indicators where local DHB is significantly lower or higher than the national mean are identified (from the Atlas: http://tinyurl.com/PolypharmAtlas).
·  Patients who meet the criteria are identified and reviewed (from practice’s PMS).

Criteria (how will the indicator be measured)

The aim of this audit is to identify people who may benefit from medication review:
1.  People aged 65 years and over who are receiving 5 or more medicines or 8 or more medicines.
Depending on how many patients meet this criteria, further subanalyses could be considered:
·  By number of medications: 5 or more medicines or 8 or more medicines
·  By age band: 65-74 years, 75-84 and 85+.

Standards (the standards to be achieved)

·  Prescribing patterns have been examined.
·  80% of own patients in identified categories have had prescribing reviewed.
Note that the focus is on improving standards of clinical practice, with 80% achievement identified by the RNZCGP as an appropriate target and 100% as an ideal. Individual GPs and practices may choose to set a differing target for a first or subsequent audit/s, with a view to increasing standards over time.
DO /

Discover what you are doing now (collect data)

1.  Look at your DHB’s results in the Atlas of Healthcare Variation: Polypharmacy in Older People. This is a good activity to do as part of a peer review group or as a practice.
The Atlas presents data by DHB and provides analyses by ethnicity and age group. http://tinyurl.com/PolypharmAtlas
a.  Identify the gap between your DHBs results and the national mean across different indicators. How do your DHB results compare with similar DHBs?
b.  Are your DHB’s rates lower or higher than average when you look at different age groups, ethnicities or gender?
c.  Based on these results, are there particular indicators, age groups, ethnicities or gender in your patient population that may warrant particular attention?
2.  Free patient management system (PMS) queries to identify a list of your patients meeting the search criteria are available to MedTech and MyPractice users. For detail on how to run these queries and which queries are available, choose the ‘find my patients’ button on the polypharmacy atlas page. (Note: these queries can take 5 or 10 minutes to run, it is recommended to run these outside of office hours.)
In your PMS, select and run polypharmacy queries. This is recommended outside of office hours. Instructions to find the queries are available here: http://www.healthstathqsc.co.nz/?atlas=polypharmacy1) or for MedTech at the end of this document. This will generate a list of your patients.
Note: calculating rates / dealing with small numbers:
The Atlas presents rates. These are calculated using a defined denominator population, such as people aged 65 years and over residing in a DHB. For this purpose, calculation of rates is not recommended as the number of patients meeting the criteria is expected to be low. As a rule of thumb there should be 30 or more events per clinician or practice before statistical analysis is attempted. Where events are less than 100, close attention should be paid to the statistics of small numbers..
STUDY /

Analyse what the results tell you

1.  Analyse your results using the data sheet on the next pages. Consider the following:
a.  Does your data appear complete?
Note that there are differences between Atlas data which shows medications dispensed compared with your data which shows medications prescribed. Your PMS may not include medicines prescribed by specialists.
b.  Data coding. Is coding consistently applied? Is the query identifying your patients as it should? For example, depending on how you categorise medicines, it is possible that one or more PRNs are listed as the long term medicines. These should be excluded from the count in your review.
2.  Examine the individual patients on your list. For methods of medication review in older people, see BPAC: http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx
The link below takes you to some patient decision aids that have developed by the NHS. These patient decision aids (PDAs) might be helpful to support decisions in which patients need to consider benefits versus risks. http://www.npc.nhs.uk/patient_decision_aids/pda.php#BNF
ACT /

Make changes – what changes can be made to improve patient care?

·  Based on your DHBs results in the Atlas, what variation have you identified?
·  Is any change in your prescribing pattern needed? What changes will you make?
·  Plan and implement a patient recall and review strategy.
·  Plan a review date to follow up on changes.
The practice quality improvement plan can be used to record actions identified for ongoing discussion, to monitor progress, and to provide information for team learning and reflection.

RNZCGP Summary Sheet: Continuous Quality Improvement (CQI) Activity

Topic: Polypharmacy in older people

Doctor's name: ______Date of collection: ______
First cycle

Sample size: If the query identifies more than 30 patients, it is suggested that those in highest risk groups be targeted. This could be:

  1. those receiving 8 or more medicines,
  2. those receiving 11 or more medicines,
  3. those aged 85 and over.

For methods of medication review in older people, see BPAC: http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx.

Patients receiving 5 or more long term medications

Patient / How many long term medicines is this patient receiving? (number) / If they are receiving more than 5 medicines, has their medication been reviewed in the last 6 months? (Yes/No) / Medication review.
If no, set alert or recall? (Alert, recall, no action)
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Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working.
Comments:

Second cycle

For methods of medication review in older people, see BPAC: http://www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx

Patients receiving 5 or more long term medications

Patient / How many long term medicines is this patient receiving? (number) / If they are receiving more than 5 medicines, has their medication been reviewed in the last 6 months? (Yes/No) / Medication review.
If no, set alert or recall? (Alert, recall, no action)
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Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working.
Comments:

Running Find My Patients queries in MedTech32

Instructions on how to run the HQSC Atlas of Healthcare Variation Queries in Medtech32 and identify which patients contribute to the measures.

These queries can take 5 or 10 minutes to run. They can slow your system and it is recommended to run them outside business hours.