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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR15

Audit of transdermal fentanyl use in West Midlands palliative care settings

By C. Hirsch, C. Faull*, S. Johnson*, J. Marriott and K. Wilson

Introduction Pilot studies conducted in the palliative care settings of the West Midlands in 1996 revealed irrational and inappropriate use of transdermal fentanyl (TDF). These findings were confirmed in the same year by an audit of TDF use. The results of this audit were used to identify the educational needs of prescribers and to update the West Midlands guidelines for palliative care prescribing which were distributed in 1997.1 A follow-up audit was conducted in 1998 in order to re-examine the previous findings.

Method The audits were conducted between April and July in 1996 and 1998 using piloted self-completion data collection forms directed to pharmacy or nursing staff serving palliative care patients in hospices, NHS hospitals and community outreach hospice programmes of the West Midlands. Aspects of TDF use were recorded after participating individuals were briefed on use of the data collection tool.

Results The numbers of completed patient assessments were 157 and 139 in 1996 and 1998, respectively. In 1996, 42 per cent of patients were prescribed TDF as first line therapy: a similar percentage (32 per cent) received first line TDF therapy in 1998.
Use of breakthrough analgesia was reported in 73 and 86 per cent of patients treated with TDF in 1996 and 1998, respectively. The dose of breakthrough analgesia was considered correct according to West Midlands guidelines in 30 per cent cases in 1996 and 29 per cent cases in 1998. In 1996, 92 per cent of patients appeared to understand the purpose of TDF therapy compared with 85 per cent in 1998.

Focal points

  • The use of prescribing guidelines to optimise palliative care therapy was studied
  • Transdermal fentanyl is a novel, relatively expensive therapy option in palliative care that would benefit from effective guidelines for use
  • A patient audit was conducted in specialist palliative care settings of the West Midlands by nurses and pharmacists
  • Little change was detected in markers of transdermal fentanyl prescribing and patient outcome before and after issue of written guidelines for use
  • The study forms part of a larger investigation into ways of optimising prescribing in palliative care

Discussion The present study allows comparison of TDF use before and after the issue of updated prescribing guidelines that included specific instructions on TDF use. The audits were performed under similar conditions and were subject to similar constraints.
The use of TDF as first line therapy is similar in the two audits, indicating little change in the place of TDF in palliative therapy. Similarly, the reported use of breakthrough analgesia, at both appropriate and inappropriate doses, is similar in the two audits. This indicates that the mode of use of TDF was unchanged between the audits. Moreover, the reported level of patients' understanding of their therapy remained relatively unchanged.
The results presented here indicate that the issue of written guidelines for palliative care therapy does not necessarily lead to changes in either prescribing habit or outcome for the patient. Further studies are being conducted in order to elucidate alternative ways of optimising prescribing and the outcomes of drug therapy in palliative care.

Pharmacy practice group, school of pharmacy, Aston university, Birmingham B4 7ET; *department of medicine, University Hospital NHS trust, Birmingham B15 2TH

References

1. Guidelines for the use of drugs in symptom control. West Midlands palliative care physicians, researched by Carole Blackshaw. 2nd ed. Keele: Department of Medicines Management, Keele University; 1997.