Contents Page
- Introduction
- Background and Importance
- Structure of a Clinical Medication Review 3.1. Opening the consultation 3.2. Reviewing the patient’s repeat medication list 3.3. Medication monitoring 3.4. Condition monitoring 3.5. Additional considerations 3.6. Making changes and providing advice 3.7. Closing the consultation
- Guidance to Support Implementation of the Service Requirements 4.1. Service Requirement 1: Identification of Patients 4.2. Service Requirement 2: Prioritisation and Capacity 4.3. Service Requirement 3: Invitations and Communication 4.4. Service Requirement 4: Qualifications and Training 4.5. Service Requirement 5: Recording of SMRs on GP IT Systems 4.6. Service Requirement 6: Collaboration on Wider Medicines Optimisation 4.7. Service Requirement 7: New Medicine Service
- Implementation and Resources
- Conclusion
What You Will Learn
From this article, you will learn:
- The definition and importance of Structured Medication Reviews (SMRs) in general practice
- The key differences between SMRs and medication use reviews in community settings
- The potential benefits of SMRs, including improved patient outcomes and NHS resource utilization
- The seven-step structure of a clinical medication review and what each step entails
- How to identify and prioritize patients who would benefit from an SMR
- The key principles of conducting SMRs, including shared decision-making and personalization
- The qualifications and training required for professionals conducting SMRs
- How to record SMRs on GP IT systems using specific SNOMED codes
- The importance of collaboration with other healthcare professionals in medicines optimization
- The role of the New Medicine Service in supporting patients with newly prescribed medicines
- Available resources and tools for implementing SMRs in Primary Care Networks (PCNs)
- The broader impact of SMRs on patient safety, treatment outcomes, and healthcare system efficiency
Introduction
In the realm of general practice, clinical medication reviews play a crucial role in ensuring patient safety and optimizing treatment outcomes. The structured medication review (SMR) is an evidence-based intervention focused on complex and problematic polypharmacy, employing a holistic approach that includes shared decision-making conversations with patients. This article explores the key aspects of conducting effective clinical medication reviews, based on insights from a Senior Clinical Pharmacist at MEDLRN and the updated guidance for Primary Care Networks (PCNs).
Background and Importance
SMRs in GP practices differ significantly from medication use reviews performed in community settings. They are based on several authoritative sources, including NICE Guidelines NG5 and Quality Standards QS120, NICE Guidelines for specific conditions, summary of product characteristics for each medication, BNF monographs, various CCG guidelines, and the Oxford Handbook of General Practice for red flags. The primary goal of these reviews is to ensure that medication regimens are safe, efficient, and evidence-based.
PCNs have prioritized SMRs due to their potential to significantly improve patient outcomes and NHS resource utilization. It’s estimated that up to £400 million is spent annually on unnecessary hospital admissions related to medication issues. SMRs offer opportunities for better value prescribing, waste reduction, and decreased NHS carbon footprint. Moreover, they can help reduce the number of people who are overprescribed medication, reducing the risk of adverse drug reactions, hospitalizations, or addiction to prescription medicines.
Structure of a Clinical Medication Review
A clinical medication review follows a structured approach, typically consisting of seven key steps:
1. Opening the consultation: The review begins with a proper introduction and setting of expectations. The pharmacist should introduce themselves, confirm the patient’s name and date of birth, outline the purpose of the medication review, and agree on the structure of the consultation. It’s important to allow the patient a “golden minute” to express any concerns they may have.
2. Reviewing the patient’s repeat medication list: Certainly. Here’s the section rewritten in sentences:
2. Reviewing the patient’s repeat medication list: The review of the patient’s repeat medication list is a crucial step in the structured medication review (SMR) process. The pharmacist or clinician conducting the review should begin by obtaining an up-to-date list of all medications the patient is currently taking. This comprehensive list should include prescribed medications, over-the-counter (OTC) medications, herbal supplements, vitamins, and any medications prescribed by specialists or obtained from other healthcare providers.
Once this list is compiled, it should be compared with the patient’s official repeat medication list in their electronic health record to identify any discrepancies. For each medication, the clinician should verify its name (both brand and generic), strength, dosage form, frequency of administration, and duration of treatment.
It’s essential to confirm with the patient that they are actually taking each medication as prescribed. This step can uncover issues with adherence that may not be apparent from the record alone. The clinician should identify any medications that the patient has stopped taking or is taking differently from the prescribed instructions, and explore the reasons for these changes.
The review should also check for any duplicate therapies or medications from the same therapeutic class that may be unnecessary. The indication for each medication should be reviewed to ensure it’s still relevant to the patient’s current health status and treatment goals.
An important part of this process is assessing the potential for any drug-drug interactions, drug-disease interactions, or contraindications based on the patient’s full medication list and medical history. The medication regimen should be evaluated for any unnecessary complexity that could be simplified to improve adherence and reduce the risk of errors.
The clinician should consider whether any high-risk medications (such as those on the STOPP/START criteria or Beers list for older adults) are present and if their benefits outweigh the potential risks. Any medications that require additional monitoring, such as regular blood tests or other clinical measurements, should be identified.
It’s crucial to note any medications that may be contributing to the patient’s current symptoms or side effects they’re experiencing. The clinician should check if any medications on the list are due for a dosage adjustment based on the patient’s age, weight, renal function, or other clinical parameters.
The review should assess whether there are any gaps in the patient’s therapy where additional medications might be beneficial, based on current clinical guidelines and the patient’s individual needs. This thorough review of the patient’s repeat medication list allows the clinician to gain a comprehensive understanding of the patient’s current medication regimen, identify potential issues or areas for optimization, and prepare for an informed discussion with the patient about their medications during the subsequent steps of the SMR.
3. Medication monitoring: This crucial step involves checking indications for each medication and verifying patient compliance. The pharmacist should assess side effects, review recent blood tests and examinations, and ensure correct dosage based on patient factors. They should also consider medication optimization switches where appropriate.
4. Condition monitoring: This step focuses on checking if relevant tests and examinations are up-to-date and assessing the patient’s understanding of their condition. The pharmacist should evaluate disease progression and identify any exacerbations or flare-ups.
5. Additional considerations: Other factors to consider during the review include over-the-counter medications and medications from secondary care. The pharmacist should also take into account the patient’s social and occupational history, as well as their family medical history.
6. Making changes and providing advice: After gathering all necessary information, the pharmacist should summarize their findings and suggest appropriate changes. They should obtain patient agreement for any modifications and provide relevant advice on the patient’s condition, medications, and lifestyle.
7. Closing the consultation: The final step involves summarizing findings and agreed changes. The pharmacist should discuss next actions and monitoring requirements, arrange follow-up appointments, and provide safety netting advice.
It’s important to distinguish between medication monitoring and condition monitoring. Medication monitoring focuses on the safety of the medicine, while condition monitoring looks at disease progression and control.
Guidance to Support Implementation of the Service Requirements
Service Requirement 1: Identification of Patients
From October 1, 2020, PCNs must use appropriate tools to identify and prioritize patients who would benefit from a SMR. Priority groups include:
a) Patients in care homes
b) Those with complex and problematic polypharmacy, specifically on 10 or more medications
c) Patients on medicines commonly associated with medication errors
d) Those with severe frailty, particularly isolated or housebound, or with recent hospital admissions and/or falls
e) Patients using potentially addictive medications (opioids, gabapentinoids, benzodiazepines, and z-drugs)
PCNs should also consider offering SMRs to patients with multiple long-term conditions, multiple co-morbidities, and those at risk of health inequalities or COVID-19. Various tools can be used for patient identification, including audit and reporting modules in core GP IT systems, NHS Business Services Authority (BSA) polypharmacy prescribing comparators, and the PINCER intervention.
PCNs should also develop processes for reactively identifying patients who need SMRs, such as after a crisis or hospital admission, when personal concerns are raised, or upon professional referral. This could include situations where a patient or their carer raises concerns about the growing number of medicines they are taking, or when a health or care professional identifies potential issues.
Service Requirement 2: Prioritisation and Capacity
Once patients are identified, PCNs should create a process for developing SMR caseloads, ensuring those in greatest need are seen promptly. They should offer a range of appointment slots for new SMRs, follow-ups, and reactively identified patients.
The number of SMRs offered will be determined by the PCN’s clinical pharmacist capacity. PCNs and commissioners must agree on a reasonable volume of SMRs, acknowledging that clinical pharmacists have various responsibilities. This discussion should take into account the available capacity and other duties of the clinical pharmacists.
Conducting SMRs
A SMR is a structured, holistic, and personalized review, typically taking 30 minutes or more, though flexibility in appointment length is encouraged based on case complexity. It should be conducted in line with shared decision-making principles, considering the patient’s health literacy and holistic needs.
SMRs can be face-to-face or remote, depending on clinical appropriateness and patient preference. They can be undertaken in the patient’s home, care home, or during extended hours appointments, always considering infection prevention and control measures, especially in light of COVID-19.
Key principles of SMRs include:
– Shared decision-making
– Personalization and tailoring to the patient
– Consideration of safety and risk-benefit of medications
– Evaluation of prescribing effectiveness
– Arrangement of appropriate follow-up
The SMR should follow high-level principles and evidenced best practice, including NICE guideline 5 and the Royal Pharmaceutical Society’s polypharmacy guidance. This includes considering the balance of benefit and risk, the effectiveness of prescribing, and the appropriateness of each medication.
Service Requirement 3: Invitations and Communication
Invitations to SMRs should explain what the review involves and emphasize the shared decision-making aspect. Patients should be advised to bring their medications and prepare questions. They can be supported by carers or family members as appropriate. The invitation should clearly state that the SMR is a conversation to review all medications and ensure they are working well for the patient.
Service Requirement 4: Qualifications and Training
PCNs must ensure that only appropriately trained clinicians conduct SMRs. These professionals should have prescribing qualifications and advanced assessment skills. Clinical pharmacists must have completed or be enrolled in the Primary Care Pharmacy Educational Pathway (PCPEP) or a similar program. Experienced clinical pharmacists without PCPEP enrollment may undertake SMRs after completing a recognition process offered by the Centre for Pharmacy Postgraduate Education (CPPE).
While clinical pharmacists are primarily expected to conduct SMRs, suitably qualified advanced nurse practitioners (ANPs) and GPs can also perform them if they follow the specified approach. ANPs should be experienced in working in a generalist setting and able to take a holistic view of a patient’s medication.
Service Requirement 5: Recording of SMRs on GP IT Systems
PCNs should use specific SNOMED codes to record each SMR, including follow-ups. These codes are published in the supporting Business Rules on the NHS Digital website. This ensures proper documentation and tracking of SMRs within the practice.
Service Requirement 6: Collaboration on Wider Medicines Optimisation
PCNs should work with various healthcare professionals to share expertise and lessons learned, focusing on optimizing prescribing of antimicrobial medicines, medicines that can cause dependency, metered-dose inhalers, and nationally identified medicines of low priority. They should also consider optimizing prescribing of sodium valproate in women of child-bearing age and integrate national-level programs into their local implementation of SMRs.
This collaboration should extend to working with pharmacy, medical, nursing, and allied healthcare professional leadership at Regional and Integrated Care System levels. PCNs should focus on regular reviews of prescribing data and targeted improvement activities to optimize prescribing quality.
Service Requirement 7: New Medicine Service
PCNs are required to work with community pharmacies to connect patients to the New Medicine Service, which supports adherence to newly prescribed medicines for conditions such as asthma, COPD, type 2 diabetes, hypertension, and new blood-thinning medicines. This collaboration helps ensure continuity of care and supports patients in managing their new medications effectively.
Implementation and Resources
The guidance document provides extensive resources and tools in its annexes, including information on health literacy, brief advice interventions on public health issues, and tools for patient identification and analysis. PCNs are encouraged to explore these resources to support their implementation of SMRs.
These resources include information on the NHS Community Pharmacist Consultation Service, NHS Community Pharmacy Discharge Medicines Service, and various public health interventions that can be incorporated into SMRs, such as smoking cessation advice, falls prevention, physical activity promotion, weight management, and alcohol use review.
Conclusion
Conducting thorough clinical medication reviews requires a systematic approach and comprehensive understanding of both medication and condition monitoring. By following this structured guidance, PCNs can ensure patients receive safe, effective, and optimized medication regimens in general practice settings.
The implementation of SMRs represents a complex but valuable intervention that can significantly improve patient care and NHS resource utilization. It not only enhances patient safety and treatment outcomes but also contributes to the overall efficiency of the healthcare system by reducing unnecessary hospital admissions, optimizing prescribing practices, and promoting better collaboration between different healthcare providers.
As PCNs continue to implement and refine their SMR processes, it’s crucial to maintain a focus on patient-centered care, shared decision-making, and continuous improvement in medication management practices. By doing so, they can make significant strides in improving the quality of care for patients with complex medication regimens and contribute to the broader goals of the NHS in terms of patient safety, resource optimization, and improved health outcomes.