4/26/2016 DISCLOSURES BACKGROUND OBJECTIVES BACKGROUND BACKGROUND

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1 DEVELOPMENT OF A PHARMACIST DRIVEN MEDICATION REVIEW PROCESS TO ADDRESS POLYPHARMACY WITHIN A NEUROLOGY CLINIC Lindsey Firman, PharmD PGY-1 Pharmacy Resident Bozeman Health Deaconess Hospital Bozeman, Montana April 30, 016 DISCLOSURES IRB Status: Exempt Co-investigators: Kristal Barker, PharmD Betsy Biggerstaff, PharmD Natalie Cooper, PharmD Jennifer Schultz, PharmD, FASHP Amanda Woloszyn, PharmD, BCPS Conflicts of interest: None Project Sponsorship: None OBJECTIVES 1. Identify patients at risk for polypharmacy mediated adverse effects. Integrate medication review into the daily process and employ different methods of communication with other healthcare providers Polypharmacy is generally defined as a high number of, but more specifically can mean greater than a threshold number of or unnecessary use of Examples: Five or more regardless of necessity Greater than 9 or any unnecessary Any incidence of unnecessary, regardless of number Polypharmacy affects all stages of healthcare and has significant consequences Healthcare costs Adverse drugs reactions Drug interactions Medication non-adherence Functional decline, including cognitive impairment and falls Prescribing cycle Polypharmacy is prevalent and incidence will increase as the population continues to age Table 1. Reported prevalence of polypharmacy in literature Setting Definition of polypharmacy Prevalence of polypharmacy Ambulatory care Greater than 5 37% Hospital discharge Greater than 9 37% Long term care facilities 5 or more 38-91% 10 or more 10-65% 1

2 Mean Number inner/contrevercis_inner_pictures_18.jpg AND OBJECTIVE Interdisciplinary teams have addressed polypharmacy in various settings Neurology clinic is an ideal setting for review as side effects can have a significant impact on this patient population Objective: Develop a process for identifying high risk polypharmacy patients and communicating potential interventions to providers METHODS- CHART REVIEW PHASE randomly selected patients of Bozeman Health Neuroscience Center. Diagnosis of Parkinson s disease, Alzheimer s disease, dementia or other memory loss 3. The data gathered included: a. Age b. Sex c. Primary diagnosis d. comorbidities e. Creatinine clearance f. Potential interventions g. in the following categories: 1. Meeting Beer s list criteria. Meeting START criteria 3. Drug interactions category D or X. Dose adjustments needed 5. No indication 6. Monitoring needed 7. Therapeutic duplication 8. Inappropriate OTCs 9. Potential adverse reactions DATA AND RESULTS- CHART REVIEW Table 3. Chart review results Medication Regimen Data Mean Range Table. Patient characteristics Graph 1. Data By Age Group Patient Characteristics n=50 (%) Medications Comorbidities Vitamins or Herbals Male 1 (%) METHODS- ACTIVE Weekly review of upcoming appointments in the neurology clinic Over 65 years of age 0 (80%) Parkinson s Diagnosis 7 (5%) Alzheimer s or 3 (6%) Dementia Diagnosis Greater than 3 (6%) comorbidities Greater than 5 31 (6%) Medications meeting Beer s List criteria Medications meeting STOPP criteria Medications that meet START criteria Drug interactions rating D or higher Potential Interventions < >85 Age Group Medications Potential Interventions Figure 1. Screen shot of provider schedule with medication list METHODS- ACTIVE Identified patients with extensive drug lists, high risk, and certain high risk disease states for further review ed provider with recommendations or clarifications as appropriate based on review Data was collected similar to the chart review, with an emphasis on intervention outcomes Figure. Example medication list and interventions METHODS- ACTIVE INTERVENTION PHASE Extensive drug lists Generally looking at patients who had long medication lists Included blatant drug interactions that were found on brief review High risk Benzodiazepines Anticholinergics Sleeps aids, including z-drugs and diphenhydramine Opioids High risk disease states- for sensitivity to side effects or difficulty in treating Parkinson s disease Alzheimer s disease Peripheral neuropathy

3 Mean Number Table. Patient characteristics during intervention phase Patient Characteristics n=9 (%) Male 11 (38%) Table 5. Results of intervention phase Medication Regimen Data Mean Range Medications Vitamins or Herbals interventions on a total of 9 patientsaverage of 1.3 accepted interventions per patient What constitutes a successful intervention? Over 65 years of age 16 (55%) Parkinson s, Alzheimer s, 13 (5%) or Dementia Diagnoses Greater than 9 8 (97%) Drug interactions rating D or higher Potential Interventions Interventions to attempt potential interventions to attempt led to 39 interventions- 1% success rate Successful interventions What constitutes a successful intervention? Any action on or change to a patient s chart or medication list that follows a given recommendation DATA AND RESULTS- COMPARISON Random selection of patients with specific diagnoses versus Deliberate selection of patients with high numbers of and varying diagnoses Mean age was 73 during chart review and 63 during active intervention phase Graph. Comparison of Chart Review and Active Intervention Phase Findings vitamins/herbals Findings interactions category D or X 3.3 Potential Interventions Chart Review Active Intervention Phase Polypharmacy was clearly present in patients of the neurology clinic Rates were higher than that generally reported in literature- 6% in chart review phase had nine or more Could be attributed to higher risk population The mean number of potential interventions increased from 1.9 to 3. when population was selected based on high number of There was a % success rate on attempted interventions On further review, only 18 of the 9 patients had successful interventionsproviding an average rate of.1 interventions per patient if any were accepted 3

4 On further review, only 18 of the 9 patients had successful interventionsproviding an average rate of.1 interventions per patient if any were accepted interventions were more likely to be successfully made Communication is KEY!! 1. Certain visit types do not allow time for medication discussion Example: Procedure visits for Botox injections or electromyography (EMG) 1. Certain visit types do not allow time for medication discussion Example: Procedure visits for Botox injections or electromyography (EMG). Provider forgets to bring the printed medication list and interventions Especially common if notification was sent too many days before the appointment and was lost in an inbox or if provider was seeing multiple patients without returning to his office in between LIMITATIONS Methods changed between phases Communication with neurologist Time consuming work up of patients Primary care versus specialty care

5 CONCLUSION FUTURE DIRECTIONS There is a need for pharmacist intervention with polypharmacy Pharmacists can have a direct impact on patient care Identification of patients and work up take time Efficient and effective communication with busy providers is key Primary care is the setting where a majority of interventions need to be made Work within the EMR to communicate with providers Work within the primary care clinic to make interventions Use polypharmacy as a trigger for comprehensive medication reviews Continue to track interventions and follow patients QUESTIONS? Lindsey Firman, PharmD Bozeman Health Deaconess Hospital lfirman@bozemanhealth.org REFERENCES 1. Jokanovic N, Ran EC, Dooley MJ, et al. Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 015; 16:535.e1-1.. Maher RL, Hanlon, JT, Hajjar ER. Clinical Consequences of Polypharmacy in Elderly. Expert Opin Dug Saf.01; 13: Hajjar E, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 005; 53: Akazawa M, Imai H, Igarashi A, Tsutani K. Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother. 010; 8: Bourgeois FT, Shannon MW, Valim C, et al. Adverse drug events in the outpatient setting: an 11- year national analysis. Pharmacoepidemiol Drug Saf. 010; 19: Hohl CM, Dankoff J, Colacone A, et al. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 001; 38: Simpson SH, Majumdar SR, Tsuyuki RT, et al. Effect of adding pharmacists to primary care teams on blood pressure control in patients with type diabetes: a randomized controlled trial. Diabetes Care. 011; 3: Wubben DP, Vivian EM. Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review. Pharmacotherapy. 008; 8: Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: A systematic review of randomized trials. Arch Intern Med. 008; 168: Machado M, Nassor N, Bajcar JM, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part III: systematic review and meta-analysis in hyperlipidemia management. Ann Pharmacother. 008; : Massey AJ, Ghazvini P. Involvement of neuropsychiatric pharmacists in a memory clinic. Consult Pharm. 005; 0: Fried T, O Leary J, Towle V, et al. Health Outcomes Associated with Polypharmacy in Community-Dwelling Older Adults: A Systematic Review. J Am Geriatr Soc. 01; 6: Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 01, Issue Patterson SM, Cadogan CA, Kerse N, Cardwell CR, et al. Intervention to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews. 01; Hanlon JT, Weinberger, M, Samsa G, et al. A Randomized, Controlled Trial of a Clinical Pharmacist Intervention to Improve Inappropriate Prescribing in Elderly Outpatients with Polypharmacy. Am J Med. 1996; 100: