Case Study 10: NHS Harrogate & Rural District CCG – Using the SystmOne STOPP protocol to support deprescribing among care home residents

In a nutshell: ‘STOPP’ stands for Screening Tool of Older People’s potentially inappropriate Prescriptions.  Frailty is currently a ‘hot topic’ with the British Geriatric Society in conjunction with the RCGP having published their ‘Fit for Frailty’  Best Practice Guidance for the care of older people living with frailty in community and outpatient settings in 2014. Conducting a personalised, evidence based medication review is one of the key recommendations of the guidance.  HaRD CCG tested the role of the SystmOne STOPP protocol as a decision support tool for primary care clinicians to help improve deprescribing in older adults with frailty, specifically care home residents.


Background

‘STOPP’ stands for Screening Tool of Older People’s potentially inappropriate Prescriptions. This was originally devised in 2008, and has been thoroughly reviewed and updated in 2014: http://ageing.oxfordjournals.org/content/early/2014/10/16/ageing.afu145

The medications included in the STOPP criteria are significantly associated with adverse drug reactions.  Applying STOPP criteria during acute hospital admission has been shown to significantly improve medication appropriateness 6 months post intervention and reduce adverse drug reactions.  The tool is validated for patients over 65, but is specifically recommended in patients considered to be ‘frail’.  The tool identifies markers of frailty and reviews medications, giving recommendations on reviewing these for interactions, and side effects and drugs to consider stopping or dose reduction. There is a second tool used in conjunction with ‘STOPP’ called ‘START’ which gives recommendations on suitable drugs that should be considered.  This does not form part of the STOPP tool kit on SystmOne.

People with frailty should be offered a personalised, evidence based medication review is line with the British Geriatric Society and  RCGP ‘Fit for Frailty’  Best Practice Guidance for the care of older people living with frailty in community and outpatient settings in 2014: http://www.bgs.org.uk/index.php/resources-6/bgscampaigns/fit-for-frailty . The STOPP/START tool is recommended as one way to assist with this. Therefore, Harrogate and Rural Districts CCG decided to explore the clinical utility of the SystmOne STOPP protocol when offering medication reviews to older people, specifically those residing in care homes. 22 residents of a local nursing home registered with East Parade GP Practice were chosen for the initial trial of the tool.  This group was picked because they all fulfil the criteria for frailty. 

Results

STOPP Alerts were generated in 15 of the 22 patients.  No concerns were identified in the remaining 7 patients.

Single alerts (12 patients)

Alert

Number of patients

Action Taken

Review use of PPI for uncomplicated peptic ulcer disease or erosive peptic oesophagitis at full therapeutic dosage for > 8 weeks (dose reduction or earlier discontinuation indicated)  4 patients

Stopped completely for one patient as no clear indication.
Dose reduced to maintenance level for the 3 other patients who were all on concurrent anti-coagulation (NICE CKS recommends low dose PPI in patients at high risk of GI side effects http://cks.nice.org.uk/antiplatelet-treatment#!scenariorecommendation )

Review drugs likely to cause constipation in patients with chronic constipation.  2 patients No changes made as little scope to do so (one patient required current level of opiate pain relief, and the other had iron deficiency anaemia so iron therapy was appropriate)
Review hypnotics  1 patient Attempt made to tackle this again
Review use of acetylcholinesterase inhibitors is a patient with known heart block OR on concurrent treatment with drugs that reduce heart rate  1 patient Betablocker stopped as this patient had ongoing hypotension and falls.
Review antimuscarinics for OAB in patients with concurrent dementia / cognitive impairment / narrow angle glaucoma or chronic prostatism  1 patient Stopped, with review of symptoms planned.
Review loop diuretic in patient without heart failure diagnosis  1 patient Stopped as no obvious indication to remain on this
Review loop diuretic in patient with urinary incontinence  1 patient Continued as required diuretics for symptomatic treatment for heart failure.
Review use of vasodilating drugs in patient with persistent postural hypotension  1 patient Continued because her BP had recently been monitored on and off treatment on ongoing use considered appropriate

 Multiple alerts (3 patients)

Alerts Number of patients Action Taken

3 Alerts:

Long term use of PPI.

Use of first generation antihistamine.

Constipating agents. 
 1 patient  

Reduce lansoprazole to 15mg (on warfarin).

Regular use of cyclizine reviewed, but continued as still needed and appears to be effective.

Stop repeat of codeine as rarely using.
5 Alerts:

Loop diuretics and incontinence

Constipating agents

Tricyclics – avoid first line for depression

Long term PPI

Vasodilators / postural hypotension
 1 patient

 

Continue furosemide 40mg as HF symptoms better with this dose.

Continue prn codeine as cannot tolerate other pain relief.

Try lower dose amitriptyline with a view to stopping.

Reduce lansoprazole to 30 mg od initially, with a view to cutting down to 15mg.

Reduce dose bisoprolol as BP tends to be low
3 Alerts:

Tricyclics in patient with dementia

Hypnotics

Constipating agents
 1 patient

 

Reduce amitriptyline back to 25mgwith a view to further reductions.

Discuss lower dose zopiclone once amitriptyline tackled.

Quantities of tramadol on repeat reduced.

Overall, 5 drugs were stopped completely and dose reductions were made for another 8 drugs, with plans to review further for 3 of these.  7 drugs were reviewed and continued use felt justified.

Follow up Audit

A further follow up audit was undertaken 2 months after the initial review to understand if there were any adverse outcomes of cessation of medication, and any items that have been recommenced.

Two months after the implementation of the changes recommended by the STOPP protocol, all relevant patients were reviewed.  No adverse outcomes have been reported on the reduced medication regimes. None of the agents stopped have been restarted, nor returned to original dose.  In at least 3 cases, a further dose reduction was made, or the medicine stopped.  At least 2 patients report symptom improvement since stopping medication (less dizziness with lower dose of night sedation, and better overall functioning e.g. since stopping Solifenacin).

In Summary

The overall view from East Parade GP Practice is that the STOPP protocol it is an easy tool to use and useful in helping to identify inappropriate prescribing that might otherwise have been overlooked. The plan is to continue to use it in their care homes at the annual medication review and also the to use the tool when developing care plans with patients.

Contact: Dr Robert Penman, GP, Harrogate & Rural District CCG

Email: rob.penman@nhs.net