Many people aged 75 or older, including those in nursing and care homes and hospitals, receive inappropriate treatment. This is the research subject of Prof. Anne Spinewine, who on 12 December 2017 received the AstraZeneca Foundation’s Healthy Ageing Award.
Prof. Anne Spinewine is the head of the Clinical Pharmacy Department at CHU UCL Namur (Godinne branch), a researcher at UCL’s Louvain Drug Research Institute (Clinical Pharmacy Research Group) and a UCL professor. For several years she has focused on prescription treatments for the elderly and treatment continuity when a patient changes location, for example between home, hospital, nursing home and care home. ‘I work on the overall quality of medication use by the elderly’, Prof. Spinewine explains. ‘We’ve observed that medications aren’t used to their optimal effect, which has a negative impact on quality of life, particularly because of side effects, and on morbidity and mortality. My work focuses on, among other things, inappropriate prescriptions. This covers overprescription,incorrect prescription and underprescription.’
Identify and calculate
To learn about the current situation, Prof. Spinewine’s team took several steps. ‘First of all, we had to have the right means for assessing prescription quality. We therefore developed, based on existing methods, prescription quality measurement tools. They were validated and are of great help to clinicians. Next, we had to determine the prevalence of inappropriate prescriptions and their consequences for patients. We conducted research on nursing and care homes, hospitals and outpatient treatments. This revealed that, in any given environment, about half of the elderly did not receive appropriate treatment. In our last large project, this proportion increased to 80% for residents of nursing and/or care homes. It also emerged that in one out of four cases, the hospitalisation of an elderly person was due to a potentially inappropriate prescription.’
Why do inappropriate prescriptions occur? How can improvements be made?
To know why inappropriate prescriptions occur, it’s important to understand their context. Doctors are trained to prescribe the right treatment, but doing so for an elderly polymedicated patient is often a great challenge. ‘We tried to learn more, particularly by interviewing health care providers. Sometimes, the doctor knows full well that the treatment is inappropriate but adheres to it anyway because he assumes the patient will refuse to change, or because a more appropriate treatment isn’t covered, etc. From there, we can try to find solutions.’
This search for solutions is in progress, including clinical studies in collaborating hospitals and multidisciplinary approaches to improving geriatric care. ‘We’ve been able to demonstrate that when the hospital pharmacist is involved with care units, for example in geriatrics, prescriptions improve’, Prof. Spinewine says. This scientifically solid clinical proof motivated the Belgian Federal Public Health Department to budget for the further development of clinical pharmacy activity. Convincing doctors to get involved could have proven difficult, but those who were sceptical often simply lacked clear information. ‘Those who see no interest in this approach often change their minds when they see that the framework is in place, actors are properly trained, and working and collaboration conditions are clearly defined.’
Situation in nursing and care homes
The interdisciplinary approach also works well in nursing and care homes, where more than one in three residents take at least ten chronic medications, as Prof. Spinewine’s team has shown. ‘Just issuing good practice recommendations isn’t enough. You have to establish a collaborative approach among everyone involved, including doctors, nursing and care staff and pharmacists. So we carried out a project in that direction. It’s imperative that every player is correctly trained and informed. We’ve thus offered all of them training concerning medication, especially in interdisciplinary medication review. Next, discussions were held for each resident, involving all stakeholders. The results were very encouraging: prescription quality improved, some drug classes were reduced, health professionals were very satisfied with the teamwork even in light of the organisational constraints. This involvement of all parties can be difficult to implement, especially owing to differing working environments.’
Political developments
In view of these encouraging results, the team of Prof. Spinewine is completing draft recommendations that will be sent in the near future to the Minister of Health in order to promote a legal and financial framework adapted to interdisciplinary care, which in the end also achieves economies of scale.
These research projects are supported not only by national authorities (INAMI, Ministry of Health) but also by authorities at other levels, such as the European Union and the Walloon Region. ‘To take one example, the European Union (H2020 programme) contributes funds for evaluating a computer program that helps inform treatment decisions concerning the elderly. It takes into account data entered by the doctor concerning the patient’s medical history, prior treatments, drug tolerability and pathology, then proposes administering, stopping, reducing or increasing treatment. The doctor, in collaboration with the pharmacist, considers this input and decides on treatment.’
Continuity of care
Another subject Prof. Spinewine is working on and that attracted the AstraZeneca jury’s attention is continuity of care. The elderly pass quite frequently from one care environment to another, between home, hospital, nursing home and care home. This can pose a challenge to communicating current and chronic treatment information. ‘These are risky situations, particularly rehospitalisation when the treatment to administer (or stop administering) isn’t correctly communicated. When elderly persons come to the emergency room, nine times out of ten information on treatments taken at home is lacking. So clear communication from one department to another, one environment to another, is crucial to continuity of care. The Walloon Region’s E-Santé project aims to improve this information transfer. A pilot phase involved an application accessible by the general practitioner and other care providers, which optimised the communication of information on treatments taken by the patient, who can also add treatment information via a specific application.’
Here we encounter a third research subject: involving patients in their health. ‘Doctors and pharmacists should consider the patient’s perspective. It’s particularly important in deprescribing. It’s a question of involving the patient in a way that increases the chances that he or she will adhere to the doctor’s decision.’
Carine Maillard
A glance at Anne Spinewine's bio
© CHU UCL Namur asbl
1976 : Born
1994-1996 : Bachelor’s Degree in Pharmaceutical Sciences, Facultés Universitaires Notre-Dame de la Paix (FUNDP), Namur
1996-1999 : Master's Degree in Pharmaceutical Sciences, UCL.
2000-2001 : MSc, Clinical Pharmacy, International practice and Policy, School of Pharmacy, University of London.
2002-2006 : PhD Pharmaceutical Sciences, clinical pharmacy track, UCL.
2002-2006 : FRS-FNRS Research Candidate
2005-2007 : Master's Degree in Hospital Pharmacy, UCL.
2007 : National Award, Belgian Society of Pharmaceutical Sciences
2009-present : Researcher, Clinical Pharmacy Research Group (UCL Louvain Drug Research Institute); Professor, Faculty of Pharmacy and Biomedical Sciences, UCL; Head, Clinical Pharmacy Department, CHU UCL Namur, Godinne branch.