Second Opinion Medication Audit

A post-Winterbourne audit of second opinion requests and certificates for learning disability patients detained under

the Mental Health Act

Method• Collected data between Oct 12 – Aug 13

• Identify patients with learning disabilities.

– Analysing diagnosis and ward location– Data included both inpatient and community based (CTO)

• Audit the medication of every case.

– Antipsychotics– Antidepressants– Polypharmacy– High Dosage

• Analyse qualitative data in the form of the treatment rationale.

Definitions

• Polypharmacy– Use of any drug class which has more than one member authorised.– Considered both regular and potential.

• Polytherapy– Use of multiple category medicines within a treatment plan.– E.g. 4.2.1, 4.3.3, 4.1.2, 4.9.2

• High Dosage– Medication (either by itself or combination of ≥2 of same category)

which exceeded 100% of the BNF maximum for a single medicine.– Considered both regular and potential.

Audit Tool

• Key Themes Identified.1. Treatment link with disorder2. Risks/Benefits of treatment3. Evidence for diagnosis4. Consideration of previous medication5. Use of alternative therapies

• Applied to 2 parts of data set:– Section 58 proposed treatment rationale– SOAD certificates

Quantitative Demographics• 796 individuals required a SOAD in the period of Oct

12 to Aug 13. 672 (84%) assessed once.

• Majority of cases were male, totalling 532 (66%).

• 590 (74%) of cases were White British. Second largest group was not specified 101 cases (12%).

• Large age range of 12-89 though average age was 34.

Provider Prescribing Data

Medication % Prescribed % Polypharmacy

Antipsychotic 858 (91%) 379(44%)

Anxiolytic 776 (82%) 220 (28%)

Mood Stabiliser 449 (48%) 106 (24%)

Antidepressant 318 (34%) 14 (4%)

• Number of cases prescribed polypharmacy = 534 (57%)

Regular Prescribing Data

Medication % Regularly Prescribed % Regular Polypharmacy

Antipsychotic 814 (86%) 132(16%)

Anxiolytic 284 (30%) 8 (3%)

Mood Stabiliser 444 (47%) 106 (24%)

Antidepressant 316 (33%) 14 (4%)

• Number of cases prescribed regular polypharmacy = 250 (24%)

Prescribing Comparisons

Provider Data

– Polypharmacy• 51% (NHS) vs. 63% (Independent)

– ≥5 medications• 31% (NHS) vs. 49% (Independent)

Ward Data

– Polypharmacy• 58% (LD) vs. 55% (Non-LD)

– ≥5 medications• 40% (LD) vs. 40% (Non-LD)

High Secure Hospitals Prescribing

• Only 10 cases analysed.• On average fewer medications in a treatment plan.• 4 cases prescribed a depot.• 1 case prescribed treatment featuring polypharmacy.

• Why?– High proportion primarily diagnosed with personality disorder

(Thompson 2000)– Staff training specialised in de-escalation (Thompson 2000)– Longer length of stay possibly allows for rationalisation of

medication.

Community Prescribing

• 52 community treatment order (CTO) cases analysed.

• Fewer medications per treatment plan with only 6 (11%) treatment plans containing ≥5 medications.

• 10 (21%) cases were prescribed treatment plans featuring polypharmacy.

• Deb et al. (2013) similar number of cases though proportionately smaller.

Adolescent Prescribing

• 43 adolescent cases analysed.

• Higher average of number of medications per treatment plan.– 42% prescribed ≥5 medications.

• 51% were prescribed treatment plans featuring polypharmacy.

• Rates of polypharmacy rising in adolescents (Spencer et al., 2013)

Qualitative: Provider

• Detail focused on treatment as opposed to context for

which it was needed.

• Benefits of treatment were presented as preventing

deterioration (in behaviour).

• Evidence for diagnosis was sparse.

• Previous treatments, effective or not, rarely referred to.

• Alternative therapies were not recorded.

Summary

• Analysed 945 cases.

• 24-57% of cases prescribed polypharmacy.

• Independent providers prescribing greatly differed from NHS.

• Variance between subpopulations within sample.

• Rationalisation were better for smaller treatment plans.