N O’Kane1, M O’Neill2, K King1, F Ahern1, A Doherty1, M Donnelly1, C Cassidy1, D Quinn1
1Federation of Family Practices Mid Ulster Federation CIC, Cookstown, N. Ireland
2Screen Clinical Ltd, Tobermore Road, Draperstown, N. Ireland
Introduction and Aims
Combined hormonal contraceptives (CHCs) are the most widely prescribed contraceptives in Northern Ireland. The publication of the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) in 2006 and April 2016, gives clear categories for the prescribing of CHCs, with Category 3 and 4 patients being most at risk of a serious cardiovascular event and therefore unsuitable for CHCs.
In 2012 a cross-sectional study was conducted using the General Practice Research Database to analyse UK women aged 15–49 years who were prescribed CHCs during the period 2004–2010. This study highlighted that in 2010, the numbers of higher risk CHC users was 7.3% of all CHC users.
Aims
In January 2017, the Mid Ulster GP Pharmacists and Screen Clinical team worked together to focus on identifying patients at risk of serious events, potentially caused by their oral contraceptive medication while also aligning suitable patients to the NI drug formulary choices.
- Identify at risk patients (UKMEC 3 and UKMEC 4)
- Align to NI formulary and implement prescribing cost savings
- Pilot a Quality Improvement project across two practices to evaluate the long-term impact of screening and implementing practice protocols had on reducing the number of women prescribed CHCs with UKMEC 3 and 4 risk profiles.
- Due to the pressures on GP pharmacist time in relation to day to day clinical activity, the GP pharmacist group utilised a service to medicine funded by Consilient Health and delivered by Screen Clinical Pharmacists. This ensured no additional spend by the Mid Ulster GP Federation to deliver the clinical and cost-effective outcomes.
Method
The practice clinical systems were interrogated to:
- Assess the risk of venous and arterial thrombotic/thromboembolic events and or cerebrovascular accident for individual patients.
- Ensure that prescribing of combined oral contraceptives was in line with UKMEC guidelines and current expert opinion.
- Reduce prescribing costs by aligning the practices prescribing to the Northern Ireland formulary
Interventions
- Patients with UKMEC category 3 or 4 contacted to discuss medication and associated risks and possible change of contraceptive
- Patients prescribed drug interactions with potential to significantly affect contraceptive effectiveness called to clinic to review
- Patients suitable for transition onto NI Formulary brand choices changed
Quality Improvement project
In addition to this, the Mid Ulster GP Pharmacist lead, implemented a Quality Improvement (QI) project across 2 GP sites to ensure safer prescribing of CHCs, to flag patients falling into the UKMEC 3 or 4 category and reduce the numbers of higher risk CHC users within the GP practices.
- Practice protocol for annual review of CHC patients
- Annual UKMEC scoring as per criteria
Results
Federation Wide:
- 9% of patients were identified with multiple UKMEC 2, UKMEC 3 or UKMEC 4 risk factors
- 2, 336 patients aligned to NI oral contraceptive pill (OCP) formulary choices
- Prescribing costs for OCPs halved across the federation
- Projected annual cost savings: £28,110
Quality Improvement project outcomes
- Reduction in patients falling into UKMEC 3 or UKMEC 4 category from 7.8% to 1.4%
- Maintained alignment to NI Formulary
Conclusions
The aims for the project were met and led to:
- Reduced prescribing risk across the federation
- Roll out across all sites of the QI improvement project with practice protocol and UKMEC scoring
- Sustained improvements in alignment to NI OCP prescribing choices
