Appendix E: Case Finding Indicators to prioritise patients for review

Polypharmacy guidance
Scottish Government Effective Prescribing & Therapeutics Division
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This section is to support prioritising patients for review. The following case finding criteria provide a high level strategic classification:

  1. Aged 50 years and older and resident in a care home, regardless of the number of medicines prescribed
  2. Prescribed 10 or more medicines (this will identify those from deprived communities where the average age is lower when taking 10 or more medications)
  3. On high-risk medication (as defined by the Case Finding indicators (see below), regardless of the number of medicines taken
  4. Approaching the end of their lives: Adults of any age, approaching the end of their life due to any cause, are likely to have different medication needs, and risk versus benefit discussions will often differ from healthy adults with longer expected life spans

If is not realistic to review all of these patients immediately  the above criteria can be further stratified by:

  • Age (e.g. 75 years and over, then 65 years and over as resource allows)
  • Frailty (e.g. HIS Frailty / SPARRA score) – use the score which has been agreed by your organisation
  • Dominant condition (e.g. dementia) – certain conditions dominate patient care as they impact and inform decisions for all other conditions

There has been further development of using high-risk medication measures to develop a suite of 69 Case Finding prescribing and monitoring indicators. Many of these measures can be also used as Clinical Outcomes indicators, where a fall in the number of patients affected may be seen following intervention (Appendix F). In addition, where the Case Finding indicators (27 indicators) utilise patient level prescribing data (PIS) the measures can be used to identify prevalence figures (Table E1).

Table E1: Prevalence from Validated Case Finding indicators (PIS Data)

Composite Indicator

Measure

Denominator

2017 Q1

% of Denominator

1. Cardiac decompensation and/or bradycardia

d. Patient prescribed nitrate and phosphodiesterase type-5 inhib.

Of all people prescribed a nitrate

1332

1.58

h. Patient prescribed beta-blocker and verapamil/diltiazem

Of all people prescribed a beta-blocker

2889

0.72

2. Bleeding

c. Patient prescribed aspirin and another antiplatelet without gastroprotection

Of all people prescribed aspirin

6167

2.25

d. Patient prescribed oral anticoagulant and antiplatelet

Of all people prescribed an oral anticoagulant

6334

6.51

i. Patient  ≥75 years prescribed an NSAID without gastroprotection

Of all people ≥ 75 years

5421

1.28

k. Patient prescribed antiplatelet and NSAID

Of all people prescribed an antiplatelet

18992

5.22

l. Patient prescribed oral anticoagulant and NSAID

Of all people prescribed an anticoagulant

1559

1.60

m. Patient prescribed oral corticosteroids and NSAID

Of all people prescribed an oral corticosteroid

9577

8.62

3. Bone Marrow Suppression

a. Patient prescribed methotrexate without folic acid

Of all people prescribed methotrexate

2689

11.14

b. Patient prescribed two different strengths of methotrexate tablets

Of all people prescribed methotrexate

266

1.10

c. Patient prescribed methotrexate with long-term trimethoprim

Of all people prescribed methotrexate

12

0.05

4 – Acute Kidney Injury

a. Patient prescribed ACEI/ARB and diuretic and NSAID

Of all people prescribed an ACEI or an ARB and a diuretic

11499

5.97

b. Patient ≥65 years  prescribed metformin  and ACEI/ARB and NSAID

Of all people prescribed metformin and an ACEI/ARB

2417

4.67

5 - Hyperkalaemia

b. Patient prescribed  ACEI or ARB and potassium supplement

Of all people prescribed an ACEI or an ARB

709

0.12

c. Patient prescribed  ACEI and ARB

Of all people prescribed an ACEI or an ARB

4764

0.81

d. Patient prescribed all of: (ACEI or ARB) and (spironolactone or eplerenone) and (aliskiren or potassium supplement)

Of all people prescribed an ACEI or an ARB

78

0.01

e. Patient prescribed all of: (ACEI or ARA) and (triamterene or amiloride) and (aliskiren or potassium supplement)

Of all people prescribed an ACEI or an ARA

9

0.00

10 – Hypoglycaemia

a. Patient prescribed insulin without glucose test strips

Of all people prescribed insulin

7410

12.69

14 – Falls, Fractures and Delirium

b. Patient ≥65 years  prescribed THREE or more drugs with sedating or anticholinergic effects (excluding antiepileptics)

Of all people ≥ 65 years

25802

2.85

d. Patient prescribed steroid long term without co-prescription of a bone protecting agent

Of all people prescribed a steroid long term

16092

54.90

15 – Opioids and gabapentinoid dependency

a. Patient prescribed  opioid at dose equivalent to >180 mg morphine per day over last 6 months

Of all people prescribed an opioid

6016

1.11

b. Patient prescribed gabapentin at dose of >4800 mg per day over last 6 months (or equivalent dose of pregabalin)

Of all people prescribed a gabapentanoid

964

0.65

16 – Seizures and neurotoxicity

a. Patient on lithium prescribed an NSAID

Of all people prescribed lithium

262

4.17

b. Patient on lithium recently prescribed a thiazide

Of all people prescribed lithium

6

0.10

17 - Extrapyramidal symptoms

a. Patient prescribed levodopa and metoclopramide long term

Of all people prescribed levodopa

16

0.17

b. Patient ≥65 years prescribed metoclopramide long termA

Of all people ≥ 65 years

3802

0.42

b.(alt) ≥65 years prescribed metoclopramide long termB

Of all people ≥ 65 years

2532

0.28

Notes:

A - Long term metoclopramide defined as ≥ 2 dispensings in the 6 month period

B - Long term metoclopramide defined as ≥ 1 dispensings in the most recent 3 month period and ≥ 1 dispensing’s in the 3 month period immediately preceding this.

Indicators

The remaining 42 Case Finding indicators utilise diagnosis, examination signs and laboratory data and so cannot be straightforwardly used to identify prevalence figures. They have been grouped as Composite indicators to help linkage with other clinical diagnosis data sets such as hospital admission data:

  1. Cardiac decompensation and/or bradycardia
  2. Bleeding
  3. Bone Marrow Suppression
  4. Acute Kidney Injury
  5. Hyperkalaemia
  6. Hypokalaemia
  7. Hyponatraemia
  8. Hypercalcaemia
  9. Hypocalcaemia
  10. Hypoglycaemia and Lactic Acidosis
  11. Hypotension
  12. Stroke / Vascular Events
  13. Respiratory Exacerbation
  14. Falls, fractures and delirium
  15. Opioid and gabapentinoid dependency
  16. Seizures and neurotoxicity
  17. Extrapyramidal Symptoms
  18. Gynaecological Cancer

All 69 Case Finding indicators have been developed within the Scottish Therapeutics Utility (STU) and will enable practices to run searches to identify patients for review. A full list of the case finding indicators can be accessed online.

Indicator selection through a consensus process

The consensus process to define the case finding criteria was conducted in 5 steps: 

  1. A list of candidate indicators was compiled based on previously published indicator sets
  2. In the first round, panel members rated each candidate indicator on a 5 point scale (1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, 5=strongly agree) reflecting their level of agreement with the statement ‘It is necessary that a patient triggering on the respective indicator receives a medication review as soon as possible and it would be inappropriate to wait until the next routine medication review’
  3. Panel members met in person for a discussion of first round ratings, informed by a presentation of current evidence and guidance, subsequent to which all candidate indicators were rerated
  4. Candidate indicators, for which there was disagreement in the second rating round (defined as >30% of panellists agreeing or strongly agreeing and >30% of panellists disagreeing or strongly disagreeing with the statement) were rerated
  5. Indicators that achieved a median rating of 4 or higher without disagreement after three rating rounds were accepted as case finding criteria