Medicines Stewardship

The health system inherently has limited resources. So if we're going to use those resources and bandwidth wisely, we need to really think about every step before we implement. And I think that's often where things go wrong.

[Music] Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed, and free.

I'm Dhineli Perera, your host for this episode, and it's a pleasure to be speaking to Dr David Liew and Elizabeth Su about medicines stewardship. For the dedicated podcast listeners, David doesn't really need an introduction, he's usually sitting in my seat asking the questions. However, in his other life, David is the Project lead for the Medicines Optimisation Service at Austin Health in Melbourne, as well as a Clinical pharmacologist and rheumatologist. Elizabeth, known as Liz, is the Senior project officer for the Medicines Optimisation Service at Austin Health, as well as a Senior clinical pharmacist and someone I'd consider to be an esteemed colleague. So Liz and David and their team have written a bigger picture article in Australian Prescriber about medicines stewardship and the broad strategies that are used for these services. Liz and David, a warm welcome to the program.

DL: Thanks so much. It's great to be here with the reboot of the podcast and the journal.

ES: Thanks, Dhineli. Just such a pleasure to speak to you today.

Likewise. So Liz, maybe you can get us started. Starting with the obvious, what exactly is medicines stewardship?

ES: Medicines stewardship is basically a continuous improvement approach that sits within the quality use of medicines. So when we talk about medicines stewardship, what we're usually referring to is a structured program of strategies and interventions that are used to address particular challenges within a specific therapeutic area to help to ensure appropriate and efficient use of medicines.

So the word stewardship gets thrown around a bit. What exactly does it mean by the stewarding part?

ES: So basically what stewarding means or how it's a bit different from just normal practice is that stewards are responsible for managing activities in a quite structured way. So it's not just something that you do differently each time. It's around building systems within an organisation or a group to help ensure the quality use of medicines is ongoing or consistent throughout time.

Right. So David, do all clinical areas need medicines stewardship?

DL: Well, I think it’s really important that when we design medicines stewardship programs, we design them with a specific need in mind, and while there are needs across prescribing, it’s partially also about making sure that we tackle problems which are real and are achievable. Because if we don’t do that, if we don’t have that strong clinical imperative as to why such a service needs to exist, we not only will struggle to get it started, we’ll struggle to maintain the momentum and we’ll struggle to see that sustainable in the long term.

Liz, can you tell us a little bit more about some of the stewardship programs that David’s touched on? I think antimicrobial stewardship has been well covered, but maybe some of the other programs that you’ve mentioned in your article are possibly less well known.

ES: So I might start off with opioid analgesic stewardship. Sometimes the things that help to trigger hospitals or other organisations in considering a particular stewardship program is through clinical care standards being released to help highlight and address particular variations in clinical practice for how certain medicines are prescribed or used. Very recently there was a release of the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, which helps to address potential areas where there are variations in how people manage opioid use. In the case of opioid analgesic stewardship, these programs aim to prevent excessive or inappropriate opioid prescribing to help reduce the risk of opioid-related harm. So potential side effects such as overdose or persistent use, trying to make sure that the opioids or other analgesics are being used appropriately so that patients actually have a good quality of pain management.

Another area where stewardship is starting to emerge is anticoagulant stewardship. There is a risk with anticoagulants of patient harm due to either over-anticoagulation where patients might be at a risk of bleeding and also under-anticoagulation causing VTEs. Anticoagulant stewardship programs can provide oversight on the appropriate use of anticoagulants while patients are in hospital and also help to provide ongoing management with community providers as well when patients are discharged.

Finally, there's also psychotropic stewardship programs that are emerging and these help to target inappropriate psychotropic prescribing and administration to help reduce the risk of psychotropic-related adverse effects and persistent use. And this is also very pertinent given that there is likely to be the release of a new clinical care standard around psychotropic prescribing.

It really is highlighting the fact that as much as these are medications prescribed frequently and broadly, they're definitely coming with their own risks that have now been identified, particularly in the hospital setting. Your article, Liz and David also really touches on the importance of transitions of care, for the Australian prescriber listeners, this is something that's particularly relevant.

ES: So I might touch on that Dhineli. When we talk about medicines stewardship, what we are trying to achieve is ongoing sustainable improvements. So medication use and safety doesn't occur only within the hospital walls, it occurs in the community as well. So it's really important when a patient is transitioning from community to hospital and back, that there is continuity in what we do to help promote quality use of medicines. So what we would be aiming to do for medicines stewardship is to ensure that any stewardship improvements that we instigate in hospital does get communicated and transitioned for the patient when they go back home.

DL: A lot of the changes happen in hospitals, and I look at the Council of Australian Therapeutic Advisory Groups, CATAG, which is an organisation that mainly works with medicines governance within hospitals. They've released guiding principles on medicines stewardship, and I think a lot of the successful programs have really been based in hospitals. But if these programs are really to have the impact that we hope, we have to see these things continue across into the community space and across transitions of care.

Absolutely. Now moving to this amazing table that you have in your article, Liz and David, there's fundamental elements of successful medicines stewardship. What I really love about it is that it's taking a step back and looking at system-wide elements that would be needed to implement a stewardship program regardless of the area.

DL: Yeah. And I think what we hope is clear from this table is that really planning every element of a stewardship program is what sets you up for success. I think it's very easy to go in with a lot of good intentions and the momentum from outside and to take it to people, but we only really get one shot at capturing people's bandwidth. The health system inherently has limited resources. So if we're going to use those resources and bandwidth wisely, we need to really think about every step before we implement. And I think that's often where things go wrong.

So the first thing is about who is in the team, and this is critical because often stewardships are driven by maybe one craft group, one discipline, but really very few therapeutic areas are completely cordoned off to just one area. And we need to be able to work across different groups. That's potentially involving doctors, pharmacists, nurses, other healthcare practitioners, as well as our patient partners who are critical in understanding where the problems really lie. And healthcare administrators are critical in this as well. Because if we don't bring along the right governance to this, we can have a short little burst of good intention and potentially benefit, but without the sustained, ongoing benefit that we'll see from a program that's truly long-lasting. And bringing in other disciplines within healthcare sciences on top of that, things like health economics and what we've seen in antimicrobial stewardship. Of course, the other bit as well is that we need to make sure that the right skill set is involved and that we have people with skills within strategic healthcare interventions, implementation science, but also people with understanding of the therapeutic area. And then I think really when you bring the right people in, you set yourself up for the rest of things in terms of the right engagement over the course of time.

Absolutely. What about you, Liz? In terms of stakeholder engagement, I would say from my own experience, this would have to be one of the trickiest parts. It can really make or break a stewardship attempt or intervention.

ES: So stakeholder engagement is really all around trying to get the right people involved to understand the problems that are facing clinicians and also in planning solutions. So for a stewardship program, the stakeholders that are involved are obviously the leadership team, but also the clinicians on the ground who are providing patient care. It is sometimes very tricky to get people to be engaged in your stewardship messages. The way to reach out to people is really trying to understand what is important to them. So for example, in the area of opioid stewardship, it may be that the clinicians might not be as interested or understanding of why you are trying to get them to practise in a certain way or do things in a certain way. However, if they do have things that they are particularly passionate about, so for example, the pain management of the patient, when you are delivering your stewardship information, it does need to be part of a holistic message about the patient as a whole. So you can address stakeholders’ concerns around pain management and alternatives to things like opioids if you are trying to encourage wiser use.

Then that sort of goes hand in hand with your next point, which is around the communication strategy.

DL: Oh, absolutely. And I think that once again, it's about using that bandwidth wisely. So I think with the communication strategy, whenever we build a communication strategy, we think about what kind of messages are needed to what audience and what is that seeking to achieve. So knowing that we can't just broadcast everything to everyone, otherwise we'll start to have people tune out, I think trying to segment out your audience into not just doctors, nurses, pharmacists, but actually which doctors and when do we want to reach them? Of course, the other thing is that using multiple modalities is something which is incredibly powerful. Because people start to triangulate messages when they hear things from more than one space. That's how people start to believe things when they hear it from more than one source.

So David, moving from communication strategy, the methodologies behind the science, so that's like the behavioural change science and the implementation science, is kind of the backbone of what you're doing in medicines stewardship. Can you tell us a bit more about this?

DL: Yeah, absolutely. Now, I'm not going to try and teach implementation science in 30 seconds, but I think what all of the strategies have in common is a rational and planned approach to how you go about trying to achieve the goals that you seek. And I think that's often overlooked and a lot of it might seem like common sense, but it's frustrating how often common sense doesn't come into the way that a lot of our healthcare systems are designed. So this is kind of an opportunity really to make sure that we do things which are going to have true impact. A lot of implementation science strategies really depend on effective communication like we've talked about. And also depend on a progressive, gradated approach where we take incremental changes, test them in certain environments, and that's the kind of thing that can really lead to that broader behavioural change. It really makes sense that we think about this because, if you think about the world outside of medicine, and you think about all the behaviour change that happens in the corporate world, all the effort that goes in, all the psychological science that goes into getting us to change our behaviour in the broader world, why shouldn't we have those advantages within healthcare to do good for our patients?

You're right. Why can it not be trialled and used and tailored to the healthcare setting?

DL: I mean, I think we used to think we were above that, right? I think we used to think we were too good for that, but we're not, we are humans in a system. Everyone comes to work trying to do the best they can, but fundamentally there's a lot of competing priorities and it's not easy to change the way we do things. We need all of those things on our side.

And then finally, Liz, the ongoing monitoring, evaluation and reporting, I guess that's really critical to see the impact, good or bad of your stewardship program, as well as the reporting of the impact that perhaps it's having for the stakeholder that you've tried to engage in the first place. So the engagement and reporting back from all parties is critical here.

ES: I will say that ongoing monitoring of your stewardship programs really is key to their successes. So we mentioned earlier that medicines stewardship is all about continuous improvement. And if you don't actually measure how you're going, you don't know whether what you are doing is effective or where areas for further improvement are. So when it comes to setting up your stewardship programs, an important part is really thinking about how you're going to be measuring or defining that success in your intervention. The sorts of things that you'd be monitoring whether your intervention processes are being followed. So for example, are people following your prescribing guidelines.

It's also really useful to look at things like outcome measures as well so that clinicians can see what they're doing is making a difference for patients. So for example, patients reporting better experience now that you've got a change in place. And as well as looking at the objectives of the stewardship itself, we also need to consider balancing measures as well. So is there any chance that there are some adverse effects that are occurring because of the stewardship intervention? Because that's a really important part of, again, making sure that we're not inadvertently causing any harm as well.

You think you're doing really well and then all of a sudden if you don't look out for those adverse effects, this presumption that you are improving things can really take you astray. David, you touched earlier on the importance of sustainability. What would be important to sustain a stewardship program?

DL: Really the design is critical. So basically thinking at the beginning, and it might seem premature, but you need to have a plan as to what this is going to do in not just the next 6 months, not just the next year, but what this looks like in a couple of years as part of business as usual. Because ultimately people invest in stewardship programs to see long-term change. If you're going to try and build that kind of legacy, you need to actually map out how this is going to be justifiable in the long term, how this can be done in as lean a way as possible, in as efficient a way as possible, and in a way that maintains the momentum that occurred at the beginning. To me, that's a first critical bit of sustainability. The second bit is really about trying to make sure you take those plans and that you articulate them to the right stakeholders, to the clinicians, to the administrators, and to the funders. So embedding these kind of changes into normal practice really requires that level of forethought.

So Liz, do you think you could give us a few pointers on how we would go about setting up such a program in the community setting?

ES: So when it comes to looking at medicines stewardship in the community setting, you are less likely to be in a large organisation where you have a lot of resources into developing things yourself. So it's very useful to be able to tap into things that have been created elsewhere and then to adapt them to your local setting so that again, you are not having to spend a lot of time trying to develop things from scratch and reinventing the wheel.

DL: And I guess as well, that's where organisations like CATAG come in to provide these communities of practice to distribute type of information that's going to lead to effective medicines stewardship programs. And then to take the learnings that happen in one place or at one level, either at a local or state level, and try and distribute them more broadly across different areas, across different systems. That's how we're going to make the health system better in Australia, not by trying to do things in our own little silos, but actually trying to build things which are applicable and then replicate them elsewhere.

Wonderful. Well, that's unfortunately all the time we've got for this episode. Thank you so much, Liz and David, for joining us today.

DL: It's a pleasure.

LS: Thanks Dhineli.

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Liz and David's full article is available on the Australian Prescriber website. The views of the hosts and the guests on the podcasts are their own and may not represent Australian Prescriber or Therapeutic Guidelines. Dr David Liew is a member of the Drug Utilisation Subcommittee of the Pharmaceutical Benefits Advisory Committee. I'm Dhineli Perera, and thanks for joining us on the Australian Prescriber Podcast.