Prescribing & Medicines
Management
page PM2
December 2004
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Prescribing & Medicines
Management |
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Features |
Supplementation with calcium and vitamin D: Isle of Wight PCT strategy
The Isle of Wight has a large elderly population, many
of whom may be at risk of osteoporotic fracture. Analysis of prescribing
data showed
local prescribing of
calcium and vitamin D, a cost-effective treatment for preventing osteoporotic
fracture, to be below the national average. The burden of osteoporotic fractures Currently there are 310,000 osteoporotic fractures each year in the UK at a cost of £1.7bn.1 The National Service Framework for Older People aims to reduce the incidence of, and deaths following, hip fracture. Standard 6 suggests: “Older people who are frail or housebound or who have had previous fragility fractures may benefit from supplements of calcium and vitamin D to help prevent fractures. Institutionalised or housebound females over 70 are known to be particularly at risk of hip fracture as a result of falling and identifying these should be a priority in primary care.” Calcium and vitamin D has been found to reduce the incidence of fractures in men and women. In one study calcium and vitamin D reduced hip fractures by 43 per cent.2 Applying this percentage to the annual cost of hip fracture on the Isle of Wight in the over-75s, a potential saving of £2m can be identified.3 This estimated saving does not take into account the costs of fractures other than hip fractures and so is probably conservative. Raising awareness of the benefits GPs have been advised of the value of prescribing calcium and vitamin D for certain risk groups by a series of regularly repeated messages in local prescribing newsletters issued by the island prescribing team. This team consists of pharmacists, technicians, nurses and doctors supported by multiple disciplines within both primary and secondary care. Choice of preparation Compliance with calcium and vitamin D is often regarded as poor because of the size, taste and consistency of the product. A taste test, undertaken in an island nursing home, found that residents preferred Calcichew D3 Forte. Taste tests were repeated elsewhere with similar results and Calcichew D3 Forte was therefore chosen to be the product available on the island. Although this is not the most robust piece of research it was important to choose one preferred product to simplify both PGDs and bulk prescriptions. Targeting patients Four groups of patients at risk of osteoporotic fractures were identified as being suitable for calcium and vitamin D supplementation. These included: · Residents in care homes Treating our four key groups of patients Residents in care homes Residents living in care homes have their medication reviewed by a medication review pharmacist employed by the PCT. Medication review is undertaken at least once per annum and six-monthly for those residents on four or more medicines. During the review, appropriate patients, who it is believed may benefit from calcium and vitamin D, are identified and GPs advised according to a standard protocol. With GP and patient agreement, calcium and vitamin D is added to the patient’s repeat medication file. Patients living in nursing homes Here trained nurses working to protocols can initiate treatment with calcium and vitamin D from bulk prescribed stock or refer the patient back to the GP as appropriate. A bulk prescription is one that is written in the name of the nursing home and meets certain criteria laid down in the Drug Tariff. Housebound patients Since this group may rely on third parties to pick up prescriptions, patient/doctor interaction may be limited. District nurses are probably the professionals most frequently in contact with the housebound and locally are able to initiate Calcichew D3 Forte under a PGD for appropriate patients. The nurses counsel the patients and check that they are able and wish to take the tablets before making the initial supply and advising the GP, who then adds the medication to the patient’s repeat medication profile. Practice nurses who identify appropriate patients during their clinics can also initiate treatment under the same PGD. Patients taking oral steroids Patients on long-term steroids are identified by audit with computer searches undertaken by technicians or nurses at GP surgeries. GPs are then advised and nurse-led clinics are undertaken for these patients. Safety is the number one priority To ensure patients are receiving the correct medicine at the correct dose and in a safe manner, a six-monthly review of all registered patients is conducted within surgeries. A technician undertakes computer searches and uses the information to complete a PowerPoint template, which is then presented by nurse and pharmacist members of the prescribing team to GPs in the surgery. Interim results In the long term it is hoped that this targeted approach to treating patients at risk of osteoporotic fracture will lead to a measurable reduction in fractures as well as the concomitant associated health costs. However, as an interim marker of success, the PCT has studied prescribing data for calcium and vitamin D. The number of prescriptions issued has increased threefold from 1,027 in the third quarter of 2001/02 to 2,990 in the fourth quarter of 2003/04. Conclusion Medicines management initiatives are able to dramatically increase use of a cost-effective treatment. 1. Torgerson DJ, Iglesias CP, Reid DM. The economics of
fracture prevention. In: Barlow DH, Francis RM, Miles A, editors. The
effective management
of osteoporosis. London: Aesculapius Medical Press; 2001. |