ENSURING EXCELLENCE IN PRESCRIBING FOR OLDER ADULTS

Transcription

1 ENSURING EXCELLENCE IN PRESCRIBING FOR OLDER ADULTS Philip J. Schneider, MS, FASHP The University of Arizona College of Pharmacy Learning Objectives: Describe the medication-use system and all interdependent components that affect the outcome of drug therapy. List three metrics used to evaluate medication-use that comprise a balanced scorecard. List the most common drugs that increase the risk of falls in the elderly. DISCLOSURE OF COMMERCIAL SUPPORT Philip J. Schneider, MS, FASHP does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 ENSURING EXCELLENCE IN PRESCRIBING FOR OLDER ADULTS Philip J. Schneider, MS, FASHP Professor and Associate Dean University of Arizona College of Pharmacy Phoenix Biomedical Campus SUMMARY AND LEARNING OBJECTIVES The prescribing of medications for older adults requires special care. This population of patients not only responds differently to medications, but other factors related to medication-use in older adults can also affect prescribing decisions. At the conclusion of this presentation, the participant will be able to: Describe the medication-use system and al interdependent components that affect the outcome of drug therapy List three metrics to evaluate medication-use that comprise a balanced scorecard List the most common drugs that increase the risk of falls in the elderly EFFICACY V. EFFECTIVENESS Efficacy Treatment effect shown by randomized, controlled trials. Effectiveness Does treatment effect transfer to real world populations? 2

3 THE ANATOMY OF A SYSTEM: MEDICATION-USE MEDICATION-USE SYSTEM Procurement Administration Prescribing Monitoring Transcription Patient education Preparation Wellness Dispensing PATHOLOGY IN A SYSTEM: MEDICATION-USE 3

4 INCIDENCE OF ADVERSE DRUG EVENTS AND POTENTIAL ADVERSE DRUG EVENTS 247 adverse drug events 70 preventable 6.5/per 100 admissions 1900 per year 194 potential adverse drug events 5.5/ 100 admissions 1600 per year Source: Bates DW, DJ Cullen, N Laird, et al. JAMA. 1995;274: INCIDENCE AND PREVENTABILITY OF ADVERSE DRUG EVENTS AMONG OLDER PERSONS IN THE AMBULATORY SETTING 50.1 adverse drug events/1000 person-years (~350/year/7000 pt. practice) 27.6% were preventable 38.8% were serious, life threatening or fatal 58.4% were associated with prescribing 60.8% were associated with monitoring 21% were associated with patient adherence Source: Gurwitz JH, TS Field, LR Harrold, et al. JAMA. 2003;289: PROBLEMS WITH PRESCRIBING Known to be associated with 56% of serious and life threatening injuries resulting from the use of medications. 4

5 FACTORS RELATED TO ERRORS IN MEDICATION PRESCRIBING Frequency errors per 1000 orders ~ 4/day in a typical hospital Source: Lesar TS, L Briceland, DS Stein. JAMA. 1997;277: MEDICATION MISUSE IN OUTPATIENTS 42.5% misuse at least one medication Source: Berry C and CJ Latiolais. Drug Intell Clin Pharm. 1966;6: MEDICATION MISUSE IN OUTPATIENTS Source: Berry C and CJ Latiolais. Drug Intell Clin Pharm. 1966;6:

6 COSTS OF MEDICATION RELATED PROBLEMS (MRP) WHY DO WE CARE? Medication-related problems (MRP) Estimated about 20,000 people die each year from MRP 5 th leading cause of death in this country Costs at least $200 billion annually Most MRP may have been PREVENTABLE! WHAT ARE MEDICATION-RELATED PROBLEMS (MRP)? 6

7 DEFINITION OF MRP: An event or circumstance involving a patient's drug treatment that actually, or potentially, interferes with the achievement of an optimal outcome. ~ Hepler and Strand EXAMPLES OF MRP Untreated indication Lack of indication Wrong drugs Over-dosing Under-dosing Lack of monitoring Poor communications Adverse drug reactions (ADRs) Drug Interactions Non-adherence MRP AS RELATED TO OLDER ADULTS At higher risk of complications from MRP: Age-related physiological changes More chronic disorder that may alter drug response More complicated drug regimen Poorer baseline health Access to health care 7

8 MEDICATION FALL RISK SCORE (AHRQ) Point Value (Risk Level) Drug Class Comments 3 (High) Analgesics,* antipsychotics, anticonvulsants, benzodiazepines 2 (Medium) Antihypertensives, cardiac drugs, antiarrhythmics, antidepressants Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition Induced orthostasis, impaired cerebral perfusion, poor health status 1 (Low) Diuretics Increased ambulation, induced orthostasis Score 6 Higher risk for fall; evaluate patient * Includes opiates. Although not included in the original scoring system, the falls toolkit team recommends that you include nonbenzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this category. POLYPHARMACY The use of a number of different drugs, possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several problems ~ Mosby s Medical Dictionary, 8 th Edition 8

9 POLYPHARMACY Factors that may contribute to polypharmacy: Multiple providers Multiple pharmacies Multiple disease states Over-the-counter (OTC) medications Herbal/vitamins/supplements POTENTIAL MRP ASSOCIATED WITH POLYPHARMACY Therapeutic duplications Medications without indication Drug interactions Inappropriate dosing Inappropriate prescribing Prescribing cascade PRESCRIBING CASCADE 9

10 THE BALANCING ACT OF PRESCRIBING What are some potential benefits? What are some potential risks? OVERUSING MEDICATIONS Older adults usually have multiple disease states, resulting in complex medication regimens For example: 68-year old woman with history of recent MI, CHF, HTN, post-menopausal osteoporosis, atrial fibrillation, and persistent asthma will likely need at least the following: UNDERUSING MEDICATION May happen for several reasons: Improve adherence to essential medications Limit drug interactions Treating priority health conditions May lead to unintentional underuse of medications at times: Unrecognized benefits for patient s condition Ageism Fear of adverse drug events Unrecognized barriers to access Lack of patient adherence 10

11 UNDERUSING MEDICATIONS ADHERENCE Vital component to medication use Medication adherences rates has been shown to be as low as 50% for chronic disease Multifactorial ADHERENCE Cost/Financial Barriers Medicare Part D plans Prescription assistance programs Generics Combination products 11

12 ADHERENCE Physical and Cognitive Barriers Easy-access containers Large fonts for labels and instructions Setting alarms Pill box selection Device/formulation selection IMPROVING MEDICATION SAFETY IN OUTPATIENTS THROUGH IMPROVED PACKAGING COMPLIANCE PACKAGING Blister package Childproof 28 day supply Marked with day of week Patient information name of drug special instructions ( e.g. first and missed doses) 12

13 FRONT, BACK - PRINIVIL R CARD ENROLLMENT CRITERIA Patients 65 years or older Diagnosis of essential hypertension Being treated with lisinopril (5, 10, 20, or 40 mg) Read and sign informed consents Do not have severe concomitant disease(s) (e.g.. terminal cancer) STUDY DESIGN Random assignment to one of 2 groups compliance package traditional prescription bottle Seen every six months by physician blood pressure, serum creatinine, morbidity, medical services utilization Seen monthly by pharmacist obtain medication, refill interval, pill count 13

14 COMPLIANCE DATA Study Control P value Missed 6.1 (10.5) 7.4 (10.5) dose % taken 96.8% 97.1% % refill 55.2% 37.3% * on time MPR BASELINE BLOOD PRESSURE CONTROL DBP 79.0 (13.9) SBP (22.4) Study Control p-value 77.3 (10.9) (19.7) BP CONTROL - SECOND VISIT DBP 74.3 (11.1) SBP (17.8) Study Control p-value 78.7 (12.0) (24.4)

15 CHANGE IN BP (1ST - 2ND VISIT) DBP -5.7 (12.0) SBP -5.3 (21.5) Study Control p-value +0.9 (10.7) -0.2 (20.5) * SUMMARY FINDINGS # meds missed is lower but not significant % refills on time is significantly higher MPR is higher, but not significant Diastolic blood pressure is lower but not significant Reduction in diastolic blood pressure is significant OTHER LESSONS LEARNED Balancing real world and scientific control is difficult Multi-center studies are difficult to control rigorous proof of efficacy is neither necessary nor sufficient. Leape, et al. What practices will most improve patient safety. JAMA. 2002;288:

16 ADHERENCE Complex drug regimen Simplifying therapy Medication education Visual aids Caregiver involvement ADHERENCE Health Literacy Barriers Assess degree of health literacy Patient counseling/education Motivational interviewing Address misconceptions Connect therapy to health outcomes Assess understanding EFFECTIVE USE OF MEDICATIONS Does it work? Effectiveness Did it unnecessarily harm the patient? Safety Did it make good use of limited resources? Cost considerations economic stewardship Cost of the drug itself Patient co-pay Cost of administering the drug if appropriate Cost of preventable adverse drug events Benefits of investing in pharmacotherapy 16

17 BALANCED SCORECARD Effectiveness Treatment outcomes (HbA1C, BP, INR, etc.) Safety Preventable adverse drug events (falls, bleeds, hypoglycemia, etc.) Cost responsibility Cost/patient/month Health care utilization (hospital, ED, office visits, etc.) SUMMARY AND LEARNING OBJECTIVES The prescribing of medications for older adults requires special care. This population of patients not only responds differently to medications, but other factors related to medication-use in older adults can also affect prescribing decisions. At the conclusion of this presentation, the participant will be able to: Describe the medication-use system and al interdependent components that affect the outcome of drug therapy List three metrics to evaluate medication-use that comprise a balanced scorecard List the most common drugs that increase the risk of falls in the elderly 17