Tuesday, October 20, :15 p.m. to 4:45 p.m. Continental Ballroom 5

Size: px

Start display at page:

Download "Tuesday, October 20, :15 p.m. to 4:45 p.m. Continental Ballroom 5"

Sophia Horton
5 years ago
Views:

1 Geriatrics PRN Focus Session The Beers Criteria: A Focus on the 2015 Update Activity Number: L01-P, 1.50 hours of CPE credit; Activity Type: A Knowledge-Based Activity Tuesday, October 20, :15 p.m. to 4:45 p.m. Continental Ballroom 5 Note: This session is being recorded for future playback. A complimentary copy of these recordings will be available to all 2015 ACCP Global Conference on Clinical Pharmacy registrants approximately two weeks after the conclusion of the conference. Moderator: Amber N. McLendon, Pharm.D., BCPS Assistant Professor, Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences; Geriatrics Clinical Pharmacy Specialist, Glenaire, Inc., Cary, North Carolina Agenda 3:15 p.m. Evolution of the Beers Criteria from 2003 to 2015 Todd P. Semla, Pharm.D., FCCP, BCPS National PBM Clinical Pharmacy Program Manager, Department of Veterans Affairs; Associate Professor, Departments of Medicine and Psychiatry, Northwestern University, Chicago, Illinois, USA 4:00 p.m. The Impact of the Updated Beers Criteria on Quality Measures and the Applicability to Clinical Practice Zachary A. Marcum, Pharm.D., Ph.D., BCPS Assistant Professor, University of Washington School of Pharmacy, Seattle, Washington Conflict of Interest Disclosures Zachary A. Marcum: no conflicts to disclose. Amber N. McLendon: no conflicts to disclose. Todd P. Semla: Spouse the employee of AbbVie; Consultant/member of advisory board for Omnicare, Inc., P&T Committee, AARP Caregiver Expert Advisory Panel, Lexicomp Inc.; Stock holder of AbbVie (spouse), Abbott, and Hospira, Other: American Geriatrics Society Honorarium for editor services for the Journal of American Geriatrics Society, authorship for Geriatrics at Your Fingertips (GAYF), travel support for Beers Criteria and GAYF). Learning Objectives 1. Describe the evolution of the Beers criteria from 1991 to 2015 with emphasis on changes in the 2012 to 2015 version 2. Navigate the process of updating guidelines and what new data lead to revisions. 3. Describe and apply the impact of the Beers Criteria on the 2014 CMS Clinical Quality Measures include Use of High-Risk Medications (HRM) in the elderly. 4. Demonstrate through a patient case the application and future applicability of the Beers criteria. Global Conference American College of Clinical Pharmacy 1

2 5. Discuss the applicability of the Beers criteria for members of a multidisciplinary geriatric team (i.e., nursing, social work, therapy). Self-Assessment Questions Self-assessment questions are available online at Global Conference American College of Clinical Pharmacy 2

THE BEERS CRITERIA: A FOCUS ON THE 2015 UPDATE 2015 American College of Clinical Pharmacy Global Conference on Pharmacy: Geriatric PRN Symposium October 20, 2015 San Francisco, CA Todd P.

3 THE BEERS CRITERIA: A FOCUS ON THE 2015 UPDATE 2015 American College of Clinical Pharmacy Global Conference on Pharmacy: Geriatric PRN Symposium October 20, 2015 San Francisco, CA Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF Co chair AGS Beers Criteria Panel Zach A. Marcum, PharmD, PhD, BCPS Assistant Professor, School of Pharmacy University of Washington Symposium Goals 1. Provide an update on the newly released 2015 AGS Beers Criteria 2. Provide a review of the more recent literature that support the 2015 update 3. Discuss how the AGS Beers Criteria can be evaluated as part of CMS health metrics, application and use in the clinic and research, and how the AGS Beers Criteria can be used to educate other members of the healthcare team. EVOLUTION OF THE BEERS CRITERIA FROM 2003 TO 2015 Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF Co chair AGS Beers Criteria Panel Financial Disclosures LexiComp, Inc. Omnicare Pharmacy & Therapeutics Committee American Geriatrics Society Journal of the American Geriatrics Society, Geriatrics At Your Fingertips AARP Caregivers Advisory Panel (through 2014) Spouse: Employee of AbbVie and owns stock in AbbVie, Abbott and Hospira Learning Objectives Describe the evolution of the Beers criteria from 1991 to 2015 with emphasis on changes in the 2012 to 2015 version Navigate the process of updating guidelines and what new data lead to revisions A ballet-dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs MD, Univ of Vermont First med student to do a geriatrics elective at Harvard s new Division on Aging Geriatric Fellowship, Harvard Faculty, UCLA/RAND Co-editor, Merck Manual of Geriatrics Editor in Chief, Merck Manuals Originator of the Beers Criteria Mark Beers: American College of Clinical Pharmacy 3

Why is inappropriate medication use important in older adults? TOO MANY DRUGS IS RESTRAINT NEEDED? Increases mortality, morbidity & risk of adverse drug events (Lau et al.

, Lancet, 2007) Is increasing in use in the oldest and most vulnerable adults (Olfson et al., 2014, Davidson et. al., 2015) Is highly common but preventable (Tannenbaum et al., 2014, Gurwitz, et al.

4 Why is inappropriate medication use important in older adults? TOO MANY DRUGS IS RESTRAINT NEEDED? Increases mortality, morbidity & risk of adverse drug events (Lau et al., Arch Intern Med, 2005) Increases healthcare costs and utilization (Fick et al,. Res in Nurs & Health, 2008; Spinewine et al., Lancet, 2007) Is increasing in use in the oldest and most vulnerable adults (Olfson et al., 2014, Davidson et. al., 2015) Is highly common but preventable (Tannenbaum et al., 2014, Gurwitz, et al., Am J Med, 2000) PIMS Way to eliminate bad drugs The Biggest independent predictor of ADEs is the number of drugs the older adult is taking Less is More To do nothing is sometimes a good remedy (Hippocrates (circa BC) What is the purpose of the Beers Criteria? Beers Criteria: History and Utilization To identify drugs to avoid in older adults: 1) Independent of diagnosis 2) Considering diagnosis To reduce adverse drug events and drug related problems and improve medication selection and medication use in older adults Designed for use in any clinical setting, also used as an educational, quality and research tool Original 1991 Nursing home pts Updates 1997 All elderly; adopted by CMS in 1999 for nursing home regulation 2003 Era of generalization to Med D, NCQA, HEDIS 2012 Further adoption into quality measures 2015 Introduction DDI, Renal Dosage Tables, How to Use and Alternatives Papers Specific Aims 2015 AGS Beers Criteria Intent of the AGS 2015 Beers Criteria Specific aim: Update 2012 Beers Criteria using a comprehensive, systematic review and grading of evidence Strategy: Incorporate new evidence Grade the new evidence Use an interdisciplinary panel with consensus Incorporate exceptions Goals: Improve care by exposure to PIMS Educational tool Quality measure Research tool American College of Clinical Pharmacy 4

5 Method Panel Members Framework Expert panel 13 members + 3 ad hoc members IOM 2011 report on guideline development Includes a period for public comment Extensive Literature Search Co chairs Donna Fick, PhD Todd Semla, MS, PharmD Panelists (voting) Judith Beizer, PharmD Nicole Brandt, PharmD Catherine DuBeau, MD Jerome Epplin, MD, AGSF Nina Flanagan, CRNP,CS BC Joseph Hanlon, PharmD, MS Peter Hollmann, MD Rosemary Laird, MD Sunny Linnebur, PharmD Stinderpal Sandhu, MD Michael Steinman, MD Nonvoting Panelists Robert Dombrowski, PharmD (CMS) Woody Eisenberg (PQA) Erin Giovannetti (NCQA) AGS Staff Elvy Ickowicz, MPH Mary Jordan Samuel Others Sue Radcliff (research) Susan Aiello, DVM (editing) Assembling the Evidence SEARCH TERMS: ADE, inappropriate drug use, med errors, polypharmacy x age/human/english Initial Search (8/1/2001 7/1 2014) n=25,549 citations Records reviewed by co chairs n=3,387 Records Screened by Full Panel (n=1,188 citations) Records excluded due to duplication or did not meet the inclusion criteria (n=5,531) METHODOLOGY & PROCESS Use of Beers SWAT team In person meeting: review of 2012 Criteria, SWAT Team report and lit search 4 groups reviewed lit, selected citations Evidence tables prepared, rated quality of evidence and strength of recommendation Final group consensus multiple meetings Studies Used to create Evidence Tables (n=335) Designations of Quality and Strength of Evidence: ACP Guideline Grading System, GRADE QUALITY OF EVIDENCE GRADING USING GRADE High Evidence Moderate Evidence Low Evidence Designations of Quality and Strength of Evidence: ACP Guideline Grading System, GRADE STRENGTH OF RECOMMENDATION HOW DID WE DO THIS? Benefits clearly outweigh harms, adverse events, and risks or harms, adverse events, and risks clearly outweigh benefits. Weak Benefits finely balanced with harms, adverse events, and risks. Insufficient Evidence inadequate to determine net harms, adverse events, and risks. American College of Clinical Pharmacy 5

6 Use of Caveats Amiodarone is to be avoided as first line therapy for atrial fibrillation unless the patient has heart failure or substantial left ventricular hypertrophy. WHAT IS DIFFERENT IN THE 2015 UPDATE? (COMPARED TO THE 2012 CRITERIA) TABLE 2 Patients enrolled in palliative or hospice care excluded. Nitrofurantoin 1,2 Change: Changed recommendation to avoid in CrCl <60 ml/min to < 30 ml/min Quality of evidence ed to low Reason: New evidence that nitrofurantoin can be used safely and be effective in patients with CrCl >30 and <60 ml/min However: Still avoid long term use due to potential pulmonary toxicity, hepatotoxicity, and peripheral neuropathy Antiarrhythmics in Atrial Fibrillation 3 5 (Class Ia, Ic, III) Change: Removed from Table 2 Amiodarone listed separately Reason: New evidence & ACC/AHA guidelines suggest that rhythm control can have equal or even favorable outcomes compared to rate control However: Amiodarone avoid as 1 st line unless patient also has heart failure or significant left ventricular hypertrophy Dronadarone avoid in permanent atrial fibrillation or with severe or recently decompensated heart failure Digoxin 6 13 Change: Avoid as first line in atrial fibrillation. Avoid as first line in heart failure. Reason: AF more effective alternatives; possible association with mortality HF questionable effects on risks of hospitalizations; possible mortality However: If using digoxin, still avoid doses >0.125 mg/day Nonbenzodiazepine Hypnotics 14,15 Change: Changed avoid chronic use (>90 days) to avoid regardless of duration Reason: Increase in the evidence of harm with minimal efficacy in treating insomnia Increased risk of hip fracture in nursing home residents, particularly new users 14 American College of Clinical Pharmacy 6

7 Additions to Table 2 Other Modifications of Note Desmopressin (moved from Table 4) High risk of hyponatremia Avoid for treatment of nocturia and/or nocturnal polyuria Proton pump inhibitors Increased risk of C difficile, bone loss and fractures Avoid for >8 weeks duration unless high risk patients Spironolactone and Triamterene moved to Table 6 Sliding scale insulin definition clarified Trimethobenzamide removed Meperidine avoid especially in those with chronic kidney disease Medications to Avoid in Delirium and Dementia/Cognitive Impairment WHAT IS DIFFERENT IN THE 2015 UPDATE? (COMPARED TO THE 2012 CRITERIA) TABLE 3 Changes: Added antipsychotics to drugs to avoid in delirium Updated the language about avoiding the use of antipsychotics for behavioral problems of dementia and/or delirium. Only use if nonpharmacologic options have failed or are not possible AND patient is a harm to self or others. Medications to Avoid in Chronic Constipation Change: Removed from Table 3 Reason: Not specific to the elderly. Considered common knowledge. Medications to Avoid in Incontinence / BPH Change: Reorganized this section to 2 categories: Urinary incontinence (all types) in women Lower urinary tract symptoms, benign prostatic hyperplasia Medications are the same American College of Clinical Pharmacy 7

8 Additions to Table 3 Dementia and cognitive impairment Eszopiclone and zaleplon History of falls or fractures Ability to impair psychomotor function; if needed consider reducing us of other CNS meds that increase risk Avoid unless safer alternatives are not available Table 5: Drug Drug Interactions Table 5. Potentially Clinically Important Non infective Drug Drug Interactions That Should Be Avoided in Older Adults Object Drug/Class Peripheral alpha 1 blockers ACEIs Anticholinergic Antidepressant Interacting Drug/Class Loop diuretics Amiloride or triamterene Anticholinergic *Two or more other CNS active drugs Rationale risk of urinary incontinence in older women risk of hyperkalemia risk of cognitive decline risk of falls Recommendation Avoid in older women, unless conditions warrant both drugs Avoid routine use; reserve for patients with demonstrated hypokalemia while on an ACEI Avoid, minimize the number of anticholinergic drugs (see Table 8). Avoid 3 or more CNS active drugs, minimize the number of CNS drugs. Quality of Evidence Moderate Moderate Moderate Moderate Strength of Recommen dation Hines LE, Murphy JE. Potentially harmful drug drug interactions in the elderly: a review. Am J Geriatr 372 Pharmacother. 2011;9: Table 5: Drug Drug Interactions continued Table 5. Potentially Clinically Important Non infective Drug Drug Interactions That Should Be Avoided in Older Adults Object Drug/Class Antipsychotic Benzodiazepines and benzodiazepinereceptor agonists Corticosteroids Lithium Lithium Interacting Drug/Class *Two or more other CNS active drugs *Two or more other CNS active drugs NSAIDs ACEIs Loop diuretic Rationale risk of falls risk of falls/fracture s risk of peptic ulcer disease/gi bleed risk of lithium toxicity risk of lithium toxicity Recommendation Avoid 3 or more CNS drugs, minimize the number of CNS drugs. Avoid 3 or more CNS active drugs, minimize the number of CNS drugs. Avoid; if not possible, provide GI protection. Avoid, monitor lithium conc. Avoid, monitor lithium conc. Quality of Evidence Moderate High Moderate Moderate Moderate Strength of Recommendation Table 6: Renal Dosing Table 6. Non infective Medications That Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Function in Older Adults Medication/ Class Creatinine Clearance (ml/min) Threshold Rationale Recommendation Quality of Evidence Strength of Recommendation Cardiovascular/Hemostasis Amiloride <30 potassium and sodium Avoid Moderate Apixaban <15 bleeding Avoid Moderate Dabigatran <30 bleeding Avoid High Edoxaban bleeding Reduce dose Moderate <30 Avoid Enoxaparin <30 bleeding Reduce dose Moderate Fondaparinux <30 bleeding Avoid Moderate Rivaroxaban Reduce dose bleeding <30 Avoid Moderate Hanlon JT, Aspinall SL, Semla TP, et al. Consensus guidelines for oral dosing of primarily renally cleared 375 medications in older adults. J Am Geriatr Soc. 2009;57: Table 6: Renal Dosing Table 6. Non infective Medications That Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Function in Older Adults Creatinine Strength of Medication/ Clearance Quality of Rationale Recommendation Recommendatio Class (ml/min) Evidence n Threshold Cardiovascular/Hemostasis Spironolactone <30 Hyperkalemia Avoid Moderate Triamterene <30 Increased risk of kidney injury; potassium and sodium Avoid Moderate Central Nervous System/ Analgesics Duloxetine <30 GI adverse effects (nausea, diarrhea) Avoid Moderate Weak Gabapentin <60 CNS adverse effects Reduce dose Moderate Levetiracetam 80 CNS adverse effects Reduce dose Moderate Pregabalin 60 CNS adverse effects Reduce dose Moderate Tramadol <30 CNS adverse effects Immediate release: reduce dose Extended release: avoid Weak Weak Other Modifications of Note Table 4 Medications to be Used with Caution Dabigatran modified the wording to specify increased risk of GI bleeding. Table 7 Drugs with Anticholinergic Properties A few additions and deletions based on various lists and review articles. American College of Clinical Pharmacy 8

9 Disclaimer from the Panel The changes in the 2015 update are not as significant as those of the previous update, but two major components have been added: 1. drugs for which dose adjustment is required based on renal impairment and 2. drug drug interactions. Neither of these new additions is intended to be comprehensive, because such lists would be too extensive; instead, an interdisciplinary expert panel focused on those drugs and drug drug interactions when there is evidence that older adults are at risk of serious harm if the dose is not adjusted or the drug interaction is overlooked. APPLICATION AND INTENT OF THE AGS 2015 BEERS CRITERIA Michael A. Steinman, MD Judith L. Beizer, PharmD Catherine E. DuBeau, MD Rosemary D. Laird, MD, MHSA Nancy E. Lundebjerg, MPA Paul Mulhausen, MD, MHS Improve How Beers Criteria Are Interpreted and Used Application to Clinicians Workgroup Beers panel members and AGS leaders Provide guidance on how to optimally use Beers Criteria Key principles for how Beers Criteria should (and should not) be used Articulate how these principles can be used by patients, clinicians, health systems, payors Obtained feedback from internal and external reviewers representing different stakeholder groups Maximize benefits, minimize unintended harms Publication in JAGS Other dissemination materials Think of Beers Criteria as a warning light Why is patient taking the drug; is it truly needed? Safer and/or more effective alternatives? Does patient have particular characteristics that increase or mitigate risk of this medication? At time of initial Rx and at follow up Actively assess for symptoms, and assess whether these could be related to meds Don t automatically defer to colleagues ALTERNATIVES TO HIGH RISK MEDICATIONS IN THE ELDERLY AND POTENTIALLY HARMFUL DRUG DRUG INTERACTIONS IN THE ELDERLY Methods Authors: Joe T. Hanlon, PharmD, MS Todd P. Semla, MS, PharmD Ken E. Schmader, MD Reviewed by: AGS Beers Criteria Panel Representatives of NCQA and PQA AGS Executive Board American College of Clinical Pharmacy 9

10 Methods cont d Recommendations Literature search PubMed Cochrane Library Google Scholar Other articles from personal files Two tables & three appendices Table 1 Alternatives to High Risk Medications Table 2 Alternatives to Potentially Harmful Drug Disease Interactions Appendix I References for Table 1 Appendix II References for Table 2 Appendix III Resources for Non Pharmacological Alternatives for Tables 1 & 2 Alternatives for High Risk Medications in the Elderly (Table 1) Anticholinergics 1 st generation antihistamines AVOID e.g., chlorpheniramine, diphenhydramine (po) ALT intranasal NS, 2 nd gen. antihistamine, intranasal steroids Parkinson Disease AVOID benzotropine, trihexyphenindyl ALT Carbidopa/levodpa Alternatives for High Risk Medications in the Elderly CNS Tertiary TCAs AVOID amitriptyline, clomipramine, imipramine, etc. ALT Depression: SSRI (except paroxetine), SNRI, bupropion, psychotherapy ALT Neuropathic pain: SNRI, gabapentin, capsaicin, pregabalin, lidocaine patch Nonbenzodiazepine hypnotics AVOID Z drugs ALT doxepin </= 6mg, nonpharmacologic txs. Alternatives for Potentially Harmful Drug Disease Interactions (Table 2) Falls AVOID anticonvulsants ALT New onset epilepsy newer agents, eg, lamotrigine or levetiracetam; vit. D and calcium +/ bisphosphonate ALT Neuropathic pain SNRI, gabapentin, pregabalin, capsaicin, lidocaine patch AVOID benzodiazepines & nonbzd hypnotics ALT Anxiety buspirone, SNRI ALT Sleep doxepin </= 6 mg, nonpharm txs. Alternatives for Potentially Harmful Drug Disease Interactions (Table 2) Dementia AVOID antipsychotics ALT Nonpharm. Interventions; if these fail and is psychosis and danger to self or others low dose non anticholinergic antipsychotics (risperidone, quetiapine) for shortest duration possible CKD/Chronic renal failure AVOID all NSAIDs ALT Pain APAP, SNRI, capsaicin, lidocaine patch American College of Clinical Pharmacy 10

11 Conclusions Beers Criteria should be used with clinical judgment and common sense Keep in mind key principles to help you best use Beers Criteria in practice Warning light Use resources (and direct your patients to them too) AGS Beers Criteria Resources Criteria AGS Updated Beers Criteria How-to-Use Article Alternative Medications List Coming Soon! Updated Beers Criteria Pocket Card Updated Beers Criteria App Public Education Resources for Patients & Caregivers AGS Beers Criteria Summary 10 Medications Older Adults Should Avoid Avoiding Overmedication and Harmful Drug Reactions What to Do and What to Ask Your Healthcare Provider if a Medication You Take is Listed in the Beers Criteria My Medication Diary - Printable Download Eldercare at Home: Using Medicines Safely - Illustrated PowerPoint Presentation Thank you for your time! Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatricssociety Selected References 1. Bains A et al. A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment. Can Pharm J. 2009;142(5): Geerts AF et al. Ineffectiveness and adverse events of nitrofurantoin in women with urinary tract infection and renal impairment in primary care. Eur J Clin Pharmacol. 2013;69(9): Al Khatib SM et al. Treatment of atrial fibrillation. Comparative Effectiveness Review 119. AHRQ Publication No. 13 EHC095 EF. 2013: 1 348;KQ Ionescu Ittu R et al. Comparative effectiveness of rhythm control vs. rate control drug treatment effect on mortality in patients with atrial fibrillation. Arch Intern Med. 2012;172(13): Tsadok MA et al. Rhythm versus rate control therapy and subsequent stroke or transient ischemic attack in patients with atrial firbrillation. Circulation. 2012;126(23): Selected References, cont d. Selected References, cont d. 6. Al Khatib SM et al. Treatment of atrial fibrillation. Comparative Effectiveness Review 119. AHRQ Publication No. 13 EHC095 EF. 2013:1 348; KQ Turakhia MP et al. Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: Findings from the TREAT AF Study. J Am Coll Cardiol. 2014;64(7): Whitbeck MG et al. Increased mortality among patients taking digoxin analysis from the AFFIRM study. Eur Heart J. 2013;34(20): Gheorghiade M et al. Lack of evidence of increased mortality among patients with atrial fibrillation taking digoxin: Findings from post hoc propensity matched analysis of the AFFIRM trial. Eur Heart J. 2013;34(20): Gheorghiade M et al. Effect of oral digoxin on high risk heart failure patients: A pre specified subgroup analysis of the DIG trial. Eur J Heart Fail. 2013;15(5): Friberg L et al. Digoxin in atrial fibrillation: report from the Stockholm Cohort Study of Atrial Fibrillation (SCAF). Heart. 2010;96(4): Mulder BA et al. Digoxin in patients with permanent atrial fibrillation: Data from the RACE II study. Heart Rhythm. 2014;11(9): Freeman JV et al. Effectiveness and safety of digoxin among contemporary adults with indident systolic heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(9): Berry SD et al. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med. 2013;173(9): Hampton LM et al. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71(9): Pandya N et al. Burden of sliding scale insulin use in elderly long term care residents with type 2 diabetes mellitus. J Am Geriatr Soc. 2013;61(12): American College of Clinical Pharmacy 11

12 Selected References, cont d. 17. Aparasu RR et al. Risk of death in dual eligible nursing home residents using typical or atypical antipsychotic agents. Med Care. 2012;50(11): Rigler SK et al. Fracture risk in nursing home residents initiating antipsychotic medications. J Am Geriatr Soc. 2013;61(5): American College of Clinical Pharmacy 12

13 The Impact of the Updated AGS Beers Criteria on Quality Measures and the Applicability to Clinical Practice Financial Disclosures Grant funding from NIH Consultant for Purdue Pharma No conflicts of interest Zachary A. Marcum, PharmD, PhD, BCPS Assistant Professor School of Pharmacy University of Washington October 20, 2015 Learning Objectives Describe the impact of the AGS Beers Criteria on the 2014 CMS Clinical Quality Measures including Use of High-Risk Medications in the elderly Demonstrate through a patient case the application and future applicability of the AGS Beers Criteria Discuss the applicability of the AGS Beers Criteria for members of a multidisciplinary geriatric team (i.e., nursing, social work, therapy) 2014 CMS Clinical Quality Measures (CQM) Tools to measure and track the quality of health care services provided To participate in Medicare and Medicaid Electronic Health Record Incentive Programs and receive incentive payment, providers required to submit CQM data National Quality Strategy (NQS) Eligible professionals needed to report 9 measures in 2014, covering at least 3 of the 6 NQS domains Represent the DHHS priorities for health care quality improvement 6 domains: 1) Patient and Family Engagement, 2) Patient Safety, 3) Care Coordination, 4) Population/Public Health, 5) Efficient Use of Healthcare Resources, 6) Clinical Process/Effectiveness Patient Safety Domain Use of High-Risk Medications (HRM) in the Elderly % of patients 66 years ordered high-risk medications 1) % of patients ordered 1 high-risk medication 2) % of patients ordered 2 different high-risk medications 1/9 Adult Recommended Core Measures Measure Stewards: NCQA & PQA Avoid selecting most criteria with caveats Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_AdultRecommend_CoreSetTable.pdf American College of Clinical Pharmacy 13

Recommended Core Measures Conditions that contribute to the morbidity and mortality of the most Medicare and Medicaid beneficiaries Conditions that represent national public health priorities

and the provider community to measure quality of care in new dimensions, with a stronger focus on parsimonious measurement Measures that include patient and/or caregiver engagement 2014 Adult

14 Recommended Core Measures Conditions that contribute to the morbidity and mortality of the most Medicare and Medicaid beneficiaries Conditions that represent national public health priorities Conditions that are common to health disparities Conditions that disproportionately drive health care costs and could improve with better quality measurement Measures that would enable CMS, States, and the provider community to measure quality of care in new dimensions, with a stronger focus on parsimonious measurement Measures that include patient and/or caregiver engagement 2014 Adult Recommended Core Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Documentation of Current Medications in the Medical Record Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Closing the Referral Loop: Receipt of Specialist Report Functional Status Assessment for Complex Chronic Conditions Other Quality Measures Medicare Star Ratings Medicare Star Ratings CMS expanding its value-based purchasing to Medicare Parts C/D Part C = Medicare Advantage Part D = PDPs Medicare plans receive plan ratings on safety and quality (stars) 1. Consumer choice (Plan Finder) 2. Regulatory oversight 3. Payment modifications Final Thoughts AGS Beers Criteria contain clinical information PDP vs. HMO Integrated health system full list (e.g., renal dosing) What does a quality metric mean for a pharmacy? Triumphed historically in dispensing quality Easy quality issues have been solved Time to move the needle for prescribing quality American College of Clinical Pharmacy 14

Learning Objectives Describe the impact of the AGS Beers Criteria on the 2014 CMS Clinical Quality Measures including Use of High-Risk Medications in the elderly Demonstrate through a patient case

15 Learning Objectives Describe the impact of the AGS Beers Criteria on the 2014 CMS Clinical Quality Measures including Use of High-Risk Medications in the elderly Demonstrate through a patient case the application and future applicability of the AGS Beers Criteria Discuss the applicability of the AGS Beers Criteria for members of a multidisciplinary geriatric team (i.e., nursing, social work, therapy) Patient Case HK, an 88 year old male reports to the ED due to falling at home Admitted to the medical floor PMH: dementia, anxiety, hypertension Current meds: donepezil, paroxetine, zolpidem Sticky note from RN Uses of the AGS Beers Criteria in Clinical Care Quality Prescribing Patient-centered Patient-specific goals Tolerance for deviation from EBM care guidelines Requires system-level approaches Quality Performance Measurement Population-centered Benchmark goals Less tolerance for deviation from EBM care guidelines Requires system-level approaches AGS Beers Criteria Only Part of Quality Prescribing Quality prescribing includes Correct drug for correct diagnosis Appropriate dose (dose adjustments for comorbidity, drug-drug interactions) Avoiding underuse of potentially important medications (e.g., bisphosphonates for osteoporosis) Avoiding overuse (e.g., antibiotics) Avoiding potentially inappropriate drugs Avoiding withdrawal effects with discontinuation Consideration of cost What are the Challenges of Using the AGS Beers Criteria in Clinical Care? RN/Family Request Lack of Tested Non-pharm Alternatives Non-pharm alternatives not covered by Part D, but may be by Part B Multiple prescribers/pharmacies Risk of drug is less than risk of condition Palliative Care and other special cases and populations HK AGS Beers Criteria: Paroxetine AVOID Non-BZD hypnotics AVOID Drug-disease interactions: Dementia + non-bzd hypnotics History of falls + non-bzd hypnotics & SSRIs Drug-drug interaction: Non-BZD hypnotics + 2 or more other CNS agents American College of Clinical Pharmacy 15

Assess areas for improvement on a routine basis Learning Objectives Describe the impact of the AGS Beers Criteria on the 2014 CMS Clinical Quality Measures including Use of High-Risk Medications in

16 What Do We Do Now? Prioritize patient goals of care in order to identify first steps Coordinate close follow up to ensure treatment plan is enacted Communicate plan to patient, caregiver, and rest of the medical team Assess areas for improvement on a routine basis Learning Objectives Describe the impact of the AGS Beers Criteria on the 2014 CMS Clinical Quality Measures including Use of High-Risk Medications in the elderly Demonstrate through a patient case the application and future applicability of the AGS Beers Criteria Discuss the applicability of the AGS Beers Criteria for members of a multidisciplinary geriatric team (i.e., nursing, social work, therapy) What Can Nurses Do? Initiate non-pharm approaches Admission and discharge teaching with family and patient about risks of and alternatives to AGS Beers Criteria medications Review scheduled and non-scheduled meds when the older adult has a change in function Observe/communicate medication responses For behavioral issues, pharm as last resort Involve family & caregivers in care and nonpharm approach, consider patient values/preferences What Can Nurses & Other Multidisciplinary Team Members Do? Lead multidisciplinary practice rounds with other team members/disciplines using AGS Beers Criteria pocket cards HK Nursing interventions: Pt asking for sleeping pill Admitted for falls Communicate alternatives to team Non-pharm Sleep Protocol PT/OT interventions: Pt falling asleep during therapy Social Work interventions: Contact with family/caregiver Agostini JV, et al. J Am Geriatr Soc 2007;55: McDowell JA, et al. J Am Geriatr Soc 1998; 46: American College of Clinical Pharmacy 16

17 Non-pharm Alternatives Sleep protocol (Agostini et al, 2007) Bright Light Therapy for delirium, sleep, depression (Taguchi et al, 2007) Physical Activity/Exercise Diet Cognitive Stimulation, Music Olfactory Stimulation (Sakamoto et al, 2012) Interventions to Decrease Use of Potentially Inappropriate Medications Education Geriatric Medicine services Pharmacist interventions Computerized support systems Regulation AGS Beers Criteria: Key Principle #1 Medications in the AGS Beers Criteria are potentially inappropriate, not definitely inappropriate. AGS Beers Criteria: Key Principle #2 Read the rationale and recommendation statements for each criterion. The caveats and guidance listed there are important. AGS Beers Criteria: Key Principle #3 Understand why medications are included in the AGS Beers Criteria, and adjust your approach to those medications accordingly. AGS Beers Criteria: Key Principle #4 Optimal application of the AGS Beers Criteria involves offering safer nonpharmacologic and pharmacologic therapies. American College of Clinical Pharmacy 17

18 AGS Beers Criteria: Key Principle #5 The AGS Beers Criteria should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety. AGS Beers Criteria: Key Principle #6 Access to medications in the AGS Beers Criteria should not be excessively restricted by prior authorization and/or health plan coverage policies. AGS Beers Criteria: Key Principle #7 The AGS Beers Criteria are not equally applicable to all countries. Application to Clinicians Think of AGS Beers Criteria as warning light Why is patient taking the drug; is it truly needed? Safer and/or more effective alternatives? Does patient have particular characteristics that increase or mitigate risk of this medication? At time of initial prescription and at follow-up Actively assess for symptoms, and assess whether these could be related to meds Conclusions AGS Beers Criteria should be used with clinical judgment and common sense Keep in mind key principles to help you best use AGS Beers Criteria in practice Warning light Use resources (and direct your colleagues and patients to them, too) American College of Clinical Pharmacy 18

Objectives. What are the Beers Criteria? Mark H Beers, MD Beers Criteria: History and Utilization 5/24/2016

Objectives. What are the Beers Criteria? Mark H Beers, MD Beers Criteria: History and Utilization 5/24/2016 @agilis Objectives Understand what the AGS Beer s list is and the methods used for the AGS Beer s Update HOW TO USE THE BEERS CRITERIA IN PERSONS WITH DEMENTIA & IN YOUR HEALTHCARE SYSTEM DONNA FICK, RN,