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Medicines optimisation

About

What is covered

This pathway covers the decision-making processes to help optimise a person's medicines. The pathway is combined with recommendations from the medicines adherence guideline to demonstrate how this decision-making process supports patient compliance to a treatment regimen with an aim to managing long-term conditions, multi-morbidities and polypharmacy.
Medicines optimisation is defined as 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. In order to better guide this process, this pathway covers the shared decision-making between healthcare professionals and the people for whom the medicines are being considered to understand the person's needs, preferences and values.
In this pathway, the term 'medicines' covers all healthcare treatments, such as oral medicines, topical medicines, inhaled products, injections, wound care products, appliances and vaccines.

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
29 March 2016 Medicines optimisation (NICE quality standard 120) added.
30 November 2015 Link to NICE pathway on transition between inpatient hospital settings and community or care home settings for adults with social care needs added.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
3 March 2015 Medicines adherence pathway updated to include medicines optimisation guideline (NICE guideline NG5) and pathway title changed. Some recommendations from the medicines adherence guideline have been updated and replaced by NG5.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on shared decision-making and processes to optimise medicines and support adherence in an interactive flowchart

What is covered

This pathway covers the decision-making processes to help optimise a person's medicines. The pathway is combined with recommendations from the medicines adherence guideline to demonstrate how this decision-making process supports patient compliance to a treatment regimen with an aim to managing long-term conditions, multi-morbidities and polypharmacy.
Medicines optimisation is defined as 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. In order to better guide this process, this pathway covers the shared decision-making between healthcare professionals and the people for whom the medicines are being considered to understand the person's needs, preferences and values.
In this pathway, the term 'medicines' covers all healthcare treatments, such as oral medicines, topical medicines, inhaled products, injections, wound care products, appliances and vaccines.

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
29 March 2016 Medicines optimisation (NICE quality standard 120) added.
30 November 2015 Link to NICE pathway on transition between inpatient hospital settings and community or care home settings for adults with social care needs added.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
3 March 2015 Medicines adherence pathway updated to include medicines optimisation guideline (NICE guideline NG5) and pathway title changed. Some recommendations from the medicines adherence guideline have been updated and replaced by NG5.

Sources

NICE guidance and other sources used to create this pathway.
Medicines optimisation (2016) NICE quality standard 120

Quality standards

Quality statements

Shared decision-making

This quality statement is taken from the medicines optimisation quality standard. The quality standard defines clinical best practice in medicines optimisation and should be read in full.

Quality statement

People are given the opportunity to be involved in making decisions about their medicines.

Rationale

Clinical outcomes and patient satisfaction are likely to be better when decisions about medicines are made jointly between the person taking the medicine and the prescriber (shared decision making). A person’s preferences and how they value treatment options and outcomes should be taken into account. People also need to have enough information to make informed choices. Patient decision aids can be used to support shared decision-making. Choices may include decisions not to take specific medicines.

Quality measures

Structure
a) Evidence that prescribers give people information about the potential benefits and harms of using medicines.
Data source: Local data collection.
b) Evidence that prescribers take into account people’s preferences and values about treatment options that includes the use of medicines.
Data source: Local data collection.
c) Evidence that prescribers offer people the opportunity to use available decision aids to make informed choices about the use of medicines that take account of the trade-off between potential benefits and harms.
Data source: Local data collection.
Outcome
a) Medicines adherence.
Data source: Local data collection.
b) Patient satisfaction with outcomes from the use of medicines.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care and pharmacy services) ensure that people are given the opportunity to be involved in making decisions about their medicines in partnership with professionals who prescribe medicines.
Healthcare professionals (such as prescribers and community pharmacists) ensure that people are given the opportunity to be involved in making decisions about their medicines. For example, healthcare professionals can use patient decision aids to support shared decision-making and they should ensure that people who take medicines have information about the potential benefits and harms.
Commissioners (such as clinical commissioning groups and NHS England) ensure they commission services in which people are given the opportunity to be involved in making decisions about their medicines in partnership with professionals who prescribe medicines.

What the quality statement means for patients, service users and carers

People who are considering whether or not to take a medicine are given the opportunity to be involved in making the decision with their healthcare professional. The decision should be in line with the person’s preferences and what they consider is important, and should take into account information about the potential benefits and harms of the medicine.

Source guidance

Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015) NICE guideline NG5, recommendations 1.6.1, 1.6.2, 1.6.4 and 1.6.6

Definitions of terms used in this quality statement

Involved in making decisions
Patients should have the opportunity to make informed decisions about their medicines, in partnership with their healthcare professionals. Healthcare professionals should take account of a person’s values and preferences by discussing what is important to them about treating or managing their condition(s) and their medicines. They should ask open questions to understand the person’s ideas, concerns and expectations. This process can he helped by using patient decision aids. The person’s values and preferences about treatment options may be different from those of the healthcare professional, and making assumptions about these should be avoided.
[Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015) NICE guideline NG5, recommendation 1.6.2 and full guideline]

Equality and diversity considerations

People who are offered or prescribed medicines may have different values and preferences to those of their healthcare professional, and these values and preferences may affect their choices about medicines. Healthcare professionals should be sensitive and supportive to ensure that everyone can express their preferences about the use of medicines and take part in shared decision-making. Healthcare professionals should take into account that some people may need additional support in communicating their preferences or in understanding the information given to them. This might be, for example, because English is not their first language or they have communication or sensory difficulties.

Medicines reconciliation in acute settings

This quality statement is taken from the medicines optimisation quality standard. The quality standard defines clinical best practice in medicines optimisation and should be read in full.

Quality statement

People who are inpatients in an acute setting have a reconciled list of their medicines within 24 hours of admission.

Rationale

Medicines-related patient safety incidents are more likely when medicines reconciliation happens more than 24 hours after a person is admitted to an acute setting. Undertaking medicines reconciliation within 24 hours of admission to an acute setting (or sooner if clinically necessary) enables early action to be taken when discrepancies between lists of medicines are identified.

Quality measures

Structure
Evidence of local arrangements to ensure that people who are inpatients in an acute setting have a reconciled list of their medicines within 24 hours of admission.
Data source: Local data collection and Medicines optimisation dashboard.
Process
Proportion of people who are inpatients in an acute setting who have a reconciled list of their medicines within 24 hours of admission.
Numerator – the number in the denominator who have a reconciled list of their medicines within 24 hours of admission.
Denominator – the number of people who are inpatients in an acute setting.
Data source: Local data collection.
Outcome
a) Harm attributable to errors in medication following acute inpatient admission.
Data source: Local data collection.
b) Patient satisfaction with outcomes from the use of medicines.
Data source: Local data collection.
c) Number of patient complaints relating to medication issues.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care and mental health providers) ensure that systems are in place for people who are inpatients in an acute setting, to have a reconciled list of their medicines within 24 hours of admission.
Healthcare professionals (such as doctors, nurses, pharmacists and pharmacist technicians) ensure that they reconcile a list of medicines for people who are inpatients in an acute setting within 24 hours of admission (or sooner if clinically necessary).
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission acute services that reconcile a list of medicines for people who are inpatients in an acute setting within 24 hours of admission.

What the quality statement means for patients, service users and carers

People who go into hospital as inpatients have an up-to-date list of their medicines in their hospital record within 24 hours. They may be involved in this process if they wish to be. This ensures that any mistakes with their medicines are quickly noticed and sorted out.

Source guidance

Definitions of terms used in this quality statement

Acute care settings
Acute care settings include secondary care, tertiary care and mental health services.
[Expert opinion]
Reconciled list
Medicines reconciliation is the process of identifying an accurate list of a person’s current medicines and comparing it with the current list in use. The information can be obtained from a variety of sources such as: medication brought to hospital by the patient, GP surgery patient records, repeat prescription slips, hospital case notes, community pharmacy patient medication records and care home medicines administration record. The list should include name, dosage, frequency and route of administration. Any discrepancies should be identified and any changes documented. The result is a complete list of medicines, accurately communicated to all health and social care professionals involved in the person’s care, in which any issues with the medicines, such as wrong dosage or omission, have been addressed.
Within 24 hours of admission
Medicines reconciliation for people who are inpatients in an acute setting should occur within 24 hours of admission, regardless of the time of admission or the day of the week.
[Expert opinion]

Equality and diversity considerations

Healthcare professionals should recognise that people’s ability to understand the issue of medicines reconciliation may differ, and take this into account in discussions with the person. Some people may need additional support to understand the issue, for example, if English is not their first language or if they have communication or sensory difficulties.

Medicines reconciliation in primary care

This quality statement is taken from the medicines optimisation quality standard. The quality standard defines clinical best practice in medicines optimisation and should be read in full.

Quality statement

People discharged from a care setting have a reconciled list of their medicines in their GP record within 1 week of the GP practice receiving the information, and before a prescription or new supply of medicines is issued.

Rationale

Medicines-related patient safety incidents are more likely when medicines reconciliation happens more than a week after discharge from a care setting such as a hospital or care home. Undertaking medicines reconciliation in primary care within 1 week of the GP practice receiving the information, and before a prescription or new supply of medicines is issued, allows early action to be taken when discrepancies between lists of medicines are identified. For example, it can prevent people from being prescribed medicines that were stopped while they were in hospital.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people discharged from a care setting have a reconciled list of their medicines in their GP record within 1 week of the GP practice receiving the information.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people discharged from a care setting are not issued a prescription or new supply of medicines until they have a reconciled list of their medicines in their GP record.
Data source: Local data collection.
Process
a) The proportion of people on medicines discharged from a care setting who have a reconciled list of their medicines within 1 week of the GP practice receiving the information.
Numerator – the number in the denominator who have a reconciled list of their medicines within 1 week of the GP practice receiving the information.
Denominator – the number of people on medicines who are discharged from a care setting.
Data source: Local data collection.
b) Proportion of new prescriptions within 1 month of discharge from a care setting where there was a reconciled list of medicines in the patient’s GP record.
Numerator – Number in the denominator where there was a reconciled list of medicines in the patient’s GP record.
Denominator – Number of new prescriptions within 1 month of discharge from a care setting.
Data source: Local data collection.
Outcome
a) Harm attributable to errors in medication following discharge from a care setting.
Data source: Local data collection.
b) Patient satisfaction with outcomes from the use of medicines.
Data source: Local data collection.
c) Number of patient complaints relating to medication issues following discharge from a care setting.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GP practices, secondary care and mental health providers) ensure that systems are in place for people discharged from a care setting to have a reconciled list of their medicines in their GP record within 1 week of the GP practice receiving the information, and before a prescription or new supply of medicines is issued. Care providers should ensure comprehensive and accurate information on medicines is supplied to general practices in a timely manner on discharge. GP practices should have systems in place to act on the information received within 1 week.
Health and social care practitioners (such as GPs, secondary care consultants and residential care practitioners) ensure that people discharged from a care setting have a reconciled list of their medicines in their GP record within 1 week of the GP practice receiving the information, and before a prescription or new supply of medicines is issued. Health and social care practitioners should send comprehensive and accurate information on medicines to general practices in a timely manner on discharge. GPs should undertake medicines reconciliation within 1 week, and should not issue new prescriptions or supplies of medicines before medicines reconciliation is complete. General practices may also liaise with community pharmacies about any medicines discharge information the pharmacies receive.
Commissioners (such as clinical commissioning groups and NHS England) commission services that ensure that people discharged from a care setting have a reconciled list of their medicines in their GP record within 1 week of the GP practice receiving the information, and before a prescription or new supply of medicines is issued.

What the quality statement means for patients, service users and carers

People who take medicines who are discharged from a care setting such as a hospital or residential care have an up-to-date list of any medicines they are taking in their GP record within 1 week of the GP practice receiving the information. The person may be involved in making the list if they wish to be. The GP practice should not give new prescriptions or a new supply of medicines until the person’s list of medicines has been made and checked.

Source guidance

Definitions of terms used in this quality statement

Care settings
Care settings from which people are discharged include hospitals, mental health settings and social care residential settings. These care settings should provide lists of medicines to general practices for medicines reconciliation in primary care.
[Expert opinion]
Reconciled list
Medicines reconciliation is the process of identifying an accurate list of a person’s current medicines and comparing it with the current list in use. The information can be obtained from a variety of sources such as: medication brought to hospital by the patient, GP surgery patient records, repeat prescription slips, hospital case notes, community pharmacy patient medication records and care home medicines administration record. The list should include name, dosage, frequency and route of administration. Any discrepancies should be identified and any changes documented. The result is a complete list of medicines, accurately communicated to all health and social care professionals involved in the person’s care, in which any issues with the medicines, such as wrong dosage or omission, have been addressed.

Equality and diversity considerations

Primary healthcare professionals should recognise that people’s ability to understand the issue of medicines reconciliation may differ, and take this into account if the person wishes to be involved in the medicines reconciliation process. Health and social care practitioners should consider that people may need additional support to understand the issue, for example, if English is not their first language or if they have communication or sensory difficulties.

Structured medication review

This quality statement is taken from the medicines optimisation quality standard. The quality standard defines clinical best practice in medicines optimisation and should be read in full.

Quality statement

Local healthcare providers identify people taking medicines who would benefit from a structured medication review.

Rationale

A structured medication review, with the clear purpose of optimising the use of medicines for some people (such as those who have long-term conditions or who take multiple medicines), can identify medicines that could be stopped or need a dosage change, or new medicines that are needed. Structured medication review can lead to a reduction in adverse events. To offer a structured medication review to people who would benefit, local healthcare providers must first have systems in place to identify those people.

Quality measures

Structure
a) Evidence that local healthcare providers have arrangements to identify people taking medicines who would benefit from a structured medication review.
Data source: Local data collection.
b) Evidence that local healthcare providers have arrangements to offer structured medication reviews to people who are likely to benefit.
Data source: Local data collection.
Process
a) Proportion of people taking medicines for long-term conditions who are identified as potentially benefiting from a structured medication review.
Numerator – the number in the denominator who are identified as potentially benefiting from a structured medication review.
Denominator – the number of people taking medicines for long-term conditions.
b) Proportion of people taking multiple medicines who are identified as potentially benefiting from a structured medication review.
Numerator – the number in the denominator who are identified as potentially benefiting from a structured medication review.
Denominator – the number of people taking multiple medicines.
Data source: Local data collection.
c) The proportion of people identified as potentially benefiting from a structured medication review who have a structured medication review.
Numerator – the number in the denominator who have a structured medication review.
Denominator – the number of people identified as potentially benefiting from a structured medication review.
Data source: Local data collection.
Outcome
a) People with long term conditions gain optimum outcomes from use of medicines.
Data source: Local data collection.
b) People using multiple medicines gain optimum outcomes from use of medicines.
Data source: Local data collection.
c) Patient satisfaction with outcomes from the use of medicines.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, acute and mental health services) ensure that systems are in place to identify people taking medicines who would benefit from a structured medication review. Such patients may include people taking medicines for long-term conditions and people taking multiple medicines.
Healthcare professionals (such as GPs and pharmacists) ensure that they identify people taking medicines who would benefit from a structured medication review. Such patients may include people taking medicines for long-term conditions and people taking multiple medicines. Healthcare professionals should carry out the review with patients who agree to attend when the need and purpose of the structured medication review is clear. The healthcare professional should take into account the person’s views, whether the person has had or has any risk factors for developing adverse drug reactions and any monitoring that is needed.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services that identify people taking medicines who would benefit from a structured medication review. Where the need and purpose is clear, structured medication reviews should be carried out with patients who agree to attend.

What the quality statement means for patients, service users and carers

People who may benefit from a structured medication review of their medicines are invited to talk about this with their healthcare professional. They might be asked because they are taking several medicines or are taking medicines for long term conditions. The review can help to identify any medicines that are no longer needed or any that need the dosage changed. The healthcare professional should listen to the person’s views and take these into account. They should also think about whether the person has had or has any risk factors for developing adverse drug reactions and whether any monitoring is needed.

Source guidance

Definitions of terms used in this quality statement

Structured medication review
A structured medication review is a critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste.

Equality and diversity considerations

Healthcare professionals should recognise that people’s ability to understand the importance of medication reviews may differ, and ensure that people are supported to understand the purpose and benefits of a structured medication review. Healthcare professionals should take into account that people may need additional support to understand the issue, for example, if English is not their first language or if they have communication or sensory difficulties.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

screening tool to alert to right treatment
screening tool of older persons' potentially inappropriate prescriptions
Patient information leaflets contain information for patients on how medicines should be used. It is a legal requirement that this information is included on the label or within the packaging of a medicine.

Paths in this pathway

Pathway created: March 2015 Last updated: November 2016

© NICE 2016

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