The purpose of this project was to improve medicines optimisation for the management of patients with spasticity or neuropathic pain who attended multidisciplinary specialist neuro outpatient clinics at West Midlands Rehabilitation Centre. The secondary purpose was to identify how much input was required to optimise medication after a change in medication was advised and if this input could be adequately carried out by a Physiotherapist Independent Prescriber.
Historically the Consultant (prescriber) would review and make changes as required to a patient’s medication for managing their spasticity and neuropathic pain. Patients could contact in case of concerns, however, there was usually no medication follow up initiated by the Consultant between clinic appointments. This was due to limitations on Consultant capacity. Time periods between clinic appointments for each patient could be between 3-12 months depending on the request of the Consultant. This meant that if there were issues with obtaining or taking the medication and the patient did not initiate contact, the issue would not be addressed until the patient returned to clinic.
NICE provides guidance that the prescriber should review the patient with regards to their medication after starting or altering a medication within a timely period. This is important as it ensures that patients receive the right choice of medication for them, at the right dose and right time to benefit their health.
Medication reviews following a face to face appointment do not necessitate a face to face appointment and telephone reviews can be completely adequate. This is because patient achievement of goals of treatment with medication is primarily identified through subjective assessment. The standard in this project was set that all patients who required a medication change in clinic would be reviewed, on time via telephone consultation(s). The time at which the patient would be need to be reviewed would be dependent on the time period in which the prescriber advised the medication change to occur over.
A single Independent Prescriber Physiotherapist reviewed all patients via telephone, who she had seen in clinic, where changes to their oral spasticity/ neuropathic pain medication had been made. This was between July 2018-February 2019. The project was a time limited pilot as the clinician was due to rotate to another clinical area and was carried out in addition to the clinician’s existing workload. The sample size at the end of this period was 60 telephone consultations which equated to 24 patients. Data was collected on an excel spreadsheet.
All 24 patients were followed up on time (or the patient rang up before the review with a query). Out of the 24 patients each patient required between 9 and 1 follow up telephone contacts. 20 patients needed more than one telephone contacts post clinic with the mean average being 2.5 and median being 2. The reasons for needing more than one follow up via telephone were; A) The therapeutic effect was not achieved therefore the medication needed to be increased further. B) The medication needed to be reduced due to intolerable side effects or stopped and alternative medication trialled. C) The patient had not initiated a GP appointment for Liver Function Tests prior to initiating or increasing Tizanidine and Dantrolene. D) The patient had been unwell therefore delayed starting medication changes. E) Individual problems relating to their medication/symptoms.
Medication was trialled and optimised for 19 out 24 patients. 5 out of 24 patients did not have medication optimised, this was because it was their choice not to trial the proposed medication change. This is an important point as these patients had opportunity to talk through their concerns regarding medication and ask questions. The discussion between the prescriber and the patient was initiated by the Prescriber after the clinic appointment allowing the patient sufficient time make an informed decision. 9 patients achieved their goals of medication and 10 patients did not tolerate the proposed medication.
Cost and savings
Specific cost saving could not be identified over the period of this project.
The project demonstrated that medicines optimisation was improved via telephone consultation(s) with an Independent Prescriber Physiotherapist. Issues with obtaining or taking the medication were identified and addressed sooner via the telephone consultation in comparison to waiting for their next clinic appointment. Similarly, side effects were identified and addressed sooner. If the medication was problematic or ineffective, alternative medication was considered sooner. Where medication worked well, the goals of treatment were achieved sooner and patient outcomes were achieved sooner in comparison to awaiting for the next face to face clinic appointment.
It is possible that less frequent face to face clinic contact may be required over time if spasticity/ neuropathic pain are the main issues. This is because issues will have already been addressed outside of clinic, via telephone consultation. When medication is not tolerated or does not provide adequate symptom management, the team can sooner consider progressing to other treatment interventions to achieve symptom management. As a result of this work, a business plan to recruit a full time Independent Prescriber Physiotherapist for a 12 month pilot has been agreed. This will enable medicines optimisation to be continued and data to be captured over a longer period.
Top three learning points
Timely medication follow up improves communication with patients about their medication, condition and symptom management. When the patient is educated better on their medications they can be more empowered to manage their health better.
A timely prescriber review aids greatly with medicines optimisation and in turn can help to optimise the patient’s health and manage symptoms.
Physiotherapists Independent Prescribers who have expertise in spasticity management and neuropathic pain management are well placed to take on this role.
This work was unfunded.
For further information about this work, contact Jennifer Curran.