Adverse Drug Events Impact on Hospital Readmissions

Adverse Drug Events Impact on Hospital Readmissions Co hosted by FHA HIIN and HSAG Facilitators Edna Clifton HSAG, Florida QIN QIO Phyllis Byles FHA Scott King, PharmD Orlando Health Dr. P. Phillips Hospital March 7, 2017

Agenda Overview Mission to Care FHA HIIN goals Data year to date for high risk medications (HRMs) Overview hospital specific reports analysis of claims data for HRMs and hospital readmissions Open Discussion Q/A Conclusions Next steps

HIIN Overview Mission to Care HIIN Accomplishments of HEN 1.0 & 2.0 Core Topics and Data for HIIN Resources HRET HIIN & FHA HIIN Hospital Process and Expectations Questions/Open Discussion

HIINs: Where are they? 32 states 1600+ hospitals (largest HIIN collaborative nationally) FHA HEN: 94 Hospitals

HIINs: How are they related? CMS Partnership for Patients (PfP) 15 Other HIIN Entities across the Nation AHA/HRET 31 other state organizations across the nation 1600+ FHA Mission to Care 94 member hospitals

FHA HEN Results: 2012 2016 Prevented 31,342 cases of harm Avoided $198 million in healthcare costs

Where We are Going HIIN GOALS: 20% Overall Reduction in Hospital Acquired Conditions (baseline 2014) 12% Reduction in 30 Day Readmissions (baseline 2014) America s hospitals embrace the ambitious new goals CMS has proposed, said Rick Pollack, president and CEO of the American Hospital Association (AHA). The vast majority of the nation s 5,000 hospitals were involved in the successful pursuit of the initial Partnership for Patients aims. Our goal is to get to zero incidents. AHA and our members intend to keep an unrelenting focus on providing better, safer care to our patients working in close partnership with the federal government and with each other. 2010 2011 2012 2013 2014 New Goal 2019 145 Harms/1,000 Discharges 142 Harms/1,000 Discharges 132 Harms/1,000 Discharges 121 Harms/1,000 Discharges 121 Harms/1,000 Discharges 97 Harms/1,000 Discharges partnershipforpatients.cms.gov

Historical Comparison Original HEN HEN 2.0 HIIN Funding Source Affordable Care Act Affordable Care Act Medicare Trust Fund Project Timeline 2 base years; 1 optional 1 base year; no optional 2 base years; 1 optional year year year Project Aim 40% reduction in preventable harm; 20% reduction in readmissions 40% reduction in preventable harm; 20% reduction in readmissions 20% reduction in all cause harm; 12% reduction in readmissions Number of hospitals 1,378 1,497 ~1710 Number/Types of Topics 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAP/VAE, VTE 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAE, VTE Number of Primes 26 17 16 Data Submission 2010 2010 2014 Baseline Data Measures Mix of national, state, and organizationally defined measures Nationally defined (standardized) outcome measures 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, C diff, Falls, Pressure Ulcers, Sepsis, SSI, VAE, VTE Nationally defined (standardized) outcome measures

Financial Incentives for Strong Quality Processes 0% PERCENT PAYMENT REDUCTION 1% 2% 3% 4% 5% 6% 7% 8% 9% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 1.00% 1.25% 1.50% 1.75% 2.00% 2.00% 1.00% 2.00% 3.00% 3.00% 3.00% 3.00% 1.00% 1.00% 1.00% 1.00% 2011 2012 2013 2014 2015 2016 2017 2018 IQR VBP Readmission Reduction HACS National health expenditures=$3.4 Trillion in hospitals=$1.1 Trillion (2016)

Readmissions 12.0 10.0 Florida HEN 2.0 Baseline: 10.0 (74 hospitals) Florida HEN 2.0 Apr June 2016: 9.5 (73 hospitals) Rate per 100 8.0 6.0 4.0 2.0 0.0 Baseline Oct 16 Nov 16 Dec 16 FL Rate 10.8 10.1 10.3 8.4 HRET HIIN Rate 9.0 8.4 8.6 7.4 # FL Reporting 76 56 46 22 #HRET HIIN Reporting 1,274 591 551 439 Source: HRET Comprehensive Data System, February 21, 2017

Readmissions Medicare 15.0 12.0 Rate per 100 9.0 6.0 3.0 0.0 Baseline Oct 16 Nov 16 Dec 16 FL Rate 13.7 12.5 12.4 7.6 HRET HIIN Rate 11.9 10.5 10.8 9.0 # FL Reporting 40 40 36 20 #HRET HIIN Reporting 838 447 423 350 Source: HRET Comprehensive Data System, February 21, 2017

ADEs opioids 0.8 0.6 Florida HEN 2.0 Baseline: 0.6 (54 hospitals) Rate per 100 0.4 0.2 Florida HEN 2.0 Apr June 2016: 0.4 (54 hospitals) 0.0 Baseline Oct 16 Nov 16 Dec 16 FL Rate 0.6 0.5 0.5 0.4 HRET HIIN Rate 0.5 0.4 0.4 0.4 # FL Reporting 57 46 45 37 #HRET HIIN Reporting 1,040 627 608 555 Source: HRET Comprehensive Data System, February 21, 2017

ADEs hypoglycemia 8.0 Florida HEN 2.0 Baseline: 7.5 (53 hospitals) 7.0 6.0 Florida HEN 2.0 Apr June 2016: 5.7 (54 hospitals) Rate per 100 5.0 4.0 3.0 2.0 1.0 0.0 Baseline Oct 16 Nov 16 Dec 16 FL Rate 6.8 3.6 3.5 3.0 HRET HIIN Rate 3.9 4.3 4.5 4.5 # FL Reporting 48 35 31 31 #HRET HIIN Reporting 1,010 626 605 567 Source: HRET Comprehensive Data System, February 21, 2017

ADEs excessive anticoagulation 4.0 3.5 Florida HEN 2.0 Baseline: 3.4 (48 hospitals) Rate per 100 3.0 2.5 2.0 1.5 1.0 0.5 Florida HEN 2.0 Apr June 2016: 1.8 (59 hospitals) 0.0 Baseline Oct 16 Nov 16 Dec 16 FL Rate 2.5 2.0 2.3 2.2 HRET HIIN Rate 3.4 3.3 3.1 3.1 # FL Reporting 52 46 45 43 #HRET HIIN Reporting 1,066 659 636 590 Source: HRET Comprehensive Data System, February 21, 2017

Reducing Adverse Drug Events Edna Clifton Associate Director Care Coordination Health Services Advisory Group (HSAG) March 7, 2017

Overview HSAG is contracted by the Centers for Medicare & Medicaid Services (CMS) to work with healthcare providers to: Improve coordination of care Reduce hospital readmissions Improve medication safety by reducing adverse drug events (ADEs) for patients in the community 17

Readmissions and Medication Safety HSAG works with hospitals to reduce ADEs. ADEs contribute to readmissions and are the leading cause of preventable patient harm. 1 The Department of Health and Human Services (HHS) identified the following medication classes as high priority medication targets for the National Action Plan for Adverse Drug Event Prevention 2 (common, preventable, and measurable ADEs): Anticoagulants Diabetic agents Opioids 18 1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107 16. 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC: Author.

ADEs Contribute to Increased Costs and Negatively Impact Patient Care ADEs $3.5 BILLION Add an additional $3.5 billion in healthcare costs; of this, up to $5.6 million per U.S. hospital. 3 Prolong hospital stays by 1.7 to 4.6 days. 2 Account for 1/3 of adverse events encountered in hospitals. 4 19 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC: Author. 3. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006. 4. U.S. Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC. 2010 November. Report No.: OEI-06-09-00090.

Emergency Department (ED) Visits for ADEs Associated with anticoagulants 17.6% of the visits, with 48.8% of cases resulting in hospitalization. 5 Associated with diabetic agents 13.3% of the visits, with 38.5% resulting in hospitalization. 5 Associated with opioids 6.8% of the visits, with 24.6% resulting in hospitalization. 5 20 5. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

Engaging With Hospitals to Create and Implement ADE Interventions Data reveal that many facilities rank above the state average for high risk readmission rates related to one or more of the three high risk medication (HRM) classes: anticoagulants diabetic agents opioids A hospital s ADE rate is measured by counting the number of hospital admissions and ED visits related to an ADE from one of the three HRMs. 21

Florida Medicare Readmissions Within 30 Days Calendar Year 2015 148,154 Readmissions Within 30 Days 54,512 Readmissions Within 7 Days 16,246 7 Day Readmissions Were on HRMs 22

Florida Medicare Readmissions Within 30 Days 2015 (cont.) Of the 54,512 readmissions within 7 days, 16,246 (29.8%) readmissions were for beneficiaries who were on HRMs. That is almost 3 out of every 10 readmissions! 23

Medicare Fee For Service (FFS) Beneficiaries on HRMs in Florida 2015 Diabetic agents are the most common drug type used, closely followed by opioids agents. Fewer beneficiaries use anticoagulants. Anticoagulants 5.59% Diabetic Agents 8.07% Opioids 7.75% Represents beneficiaries with at least 30 days supply of drug type. Patients may be included in more than one drug type category. 24

ADE Rates Among Medicare FFS Beneficiaries Discharged on HRMs in Florida 2015 (ADEs per 1,000 Discharges) Anticoagulant ADEs 48.42 Diabetic Agent ADEs 28.72 Opioid ADEs 5.53 Despite lower frequency of use, patients taking anticoagulants have the highest rate of ADEs per 1,000 discharges among Medicare beneficiaries on HRMs, followed by diabetic agents. Opioids have much lower ADE rates based on claims data. 25

30 Day Readmissions Among Medicare FFS Beneficiaries on HRMs in Florida 2015 30 Day All Cause Readmission Rate 19.6% 30 Day HRM Readmission Rate 23.7% Readmissions among beneficiaries on HRMs are much more frequent than the general population, suggesting ample opportunity for improvement. Percent of 30 day readmits with an anticoagulant or diabetes agent ADE are much higher than the percent of readmits with an opioid ADE. 26

Factors That Contribute to ADEs Sub optimal medication reconciliation Failure to confirm patient s understanding of their medication regimen Inappropriate medication use by the patient and inappropriate prescribing Failure to monitor patient s therapeutic lab values, drug treatment outcomes, and patient s adherence Poor multidisciplinary communication and polypharmacy 27

What You Can Do to Reduce the Incidence of ADEs Target patients who are receiving HRMs Medicare claims data is used to focus on medication safety improvement efforts Goal Improve medication safety and reduce the incidence of ADEs related to hospital readmissions 28

Best Practices to Reduce the Risk of ADEs Best Practice Pharmacist led medication reconciliation and medication therapy review Bedside delivery of medications prior to discharge Pharmacist led discharge medication counseling Post discharge follow up Medication therapy management (MTM) Comprehensive medication history 29 Description Compares active medication orders to all of the current medications that the patient has been taking, identifies and addresses medication related problems (i.e., duplication of therapy, unnecessary medications, inappropriate dosing, drug drug interactions) Prevents delay or interruption in medication therapy following discharge, verifies insurance coverage, manages prior authorizations or drug substitutions (i.e., therapeutic equivalent substitutions based on cost, availability, formulary, insurance) Provides information on proper medication administration, side effects, disease state education Reinforces the discharge plan, assesses patient retention of information, addresses patient questions and concerns, assesses medication therapy adherence Improves medication use, enhances health care professionals collaboration, enhances communication between patients and their health care team, encourages patient involvement Assists with obtaining high quality, complete, and accurate medication history

Hospital ADE Report

High Risk Medication (HRM) Categories Data sources are Medicare FFS Part A and Part D claims. Beneficiaries are considered on an HRM if they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest. Beneficiaries may qualify as being on a HRM for more than one drug class. 31

High Risk Medication (HRM) Categories (cont.) Adverse Drug Events (ADEs) are evaluated based on the beneficiary s HRM drug classification. If a beneficiary is on an opioid and has a claim identified as an ADE related to opioid, this is counted in the numerator. If a beneficiary is on an opioid and has a claim identified as an ADE related to anticoagulants, this is not counted in the numerator. Missing data points or figures indicate there were no applicable data for your hospital during the specified time period. 32

Readmissions 33

Readmissions (cont.) 34

Readmissions for HRM Beneficiaries on an Anticoagulant 35

Readmissions for HRM Beneficiaries on a Diabetic Agent 36

Readmissions for HRM Beneficiaries on an Opioid 37

Readmissions by Drug Category 38

Overall ED Utilization within 30 Days of Discharge from an IP Visit 39

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Anticoagulant 40

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on a Diabetic Agent 41

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Opioid 42

General Utilization by HRM Beneficiaries 43

General Utilization by HRM Beneficiaries on Anticoagulants 44

General Utilization by HRM Beneficiaries on Diabetic Agents 45

General Utilization by HRM Beneficiaries on Opioids 46

Anticoagulant ADEs by Prescription Drug Class Number of ADEs Warfarin 838 Direct Factor Xa Inhibitors (New Oral Anticoagulants) 107 Direct Thrombin Inhibitors 42 Heparins and Heparinoid Like Agents 27 47

Anticoagulant ADEs by Diagnosis Code 1 ICD 9 Diagnosis Code Description Count ICD 10 Diagnosis Code Description Count 79092 Abnormal coagulation profile 472 E9342 5789 Anticoagulants causing adverse effect in therapeutic use Hemorrhage of gastrointestinal tract, unspecified 255 59970 Hematuria, unspecified 64 7847 Epistaxis 59 59971 Gross hematuria 44 5693 Hemorrhage of rectum and anus 28 56212 Diverticulosis of colon with hemorrhage 20 4590 Unspecified hemorrhage 20 5781 Blood in stool 19 68 R791 Abnormal coagulation profile 66 T45515A Adverse effect of anticoagulants, initial encounter K922 Gastrointestinal hemorrhage, unspecified 22 R319 Hematuria, unspecified 17 T45511A Poisoning by anticoagulants, accidental (unintentional), initial encounter R040 Epistaxis 12 R310 Gross hematuria 11 K921 Melena 9 R042 Hemoptysis 6 K5521 Angiodysplasia of colon with hemorrhage 4 50 13 1 Only the top 10 diagnosis codes are shown 48

Diabetic Agent ADEs by Prescription Drug Class Number of ADEs Insulin 341 Sulfonylureas 104 Dipeptidyl Peptidase 4 (DPP 4) Inhibitors 26 Thiazolidinediones 11 Antidiabetic Combination Agents 8 Glucagon Like Polypeptide 1 (GLP 1) Receptor Agonists 4 Meglitinides 3 Biguanides 2 Alpha Glucosidase Inhibitors 1 49

Diabetic Agent ADEs by Diagnosis Code 2 ICD 9 Diagnosis Code 25080 25082 E9323 25081 Description Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Insulins and antidiabetic agents causing adverse effect in therapeutic use Diabetes with other specified manifestations, type I (juvenile type), not stated as uncontrolled Count 284 79029 Other abnormal glucose 17 2512 Hypoglycemia, unspecified 17 63 24 19 ICD 10 Diagnosis Code E11649 E1169 E10649 T38X1A T38X5A Description Type 2 diabetes mellitus with hypoglycemia without coma Type 2 diabetes mellitus with other specified complication Type 1 diabetes mellitus with hypoglycemia without coma Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter Count R7309 Other abnormal glucose 1 62 15 7 3 2 25083 Diabetes with other specified manifestations, type I (juvenile type), uncontrolled 12 2 Only the top 10 diagnosis codes are shown 9623 Poisoning by insulins and antidiabetic agents 4 2511 Other specified hypoglycemia 1 50

Opioid ADEs by Prescription Drug Class Number of ADEs Oxycodone 22 Hydrocodone Combinations 14 Morphine 7 Codeine and Codeine Combinations 5 Fentanyl 5 Hydromorphone 5 Methadone 2 51

Opioid ADEs by Diagnosis Code 3,4 ICD 9 Diagnosis Code Description Count ICD 10 Diagnosis Code Description Count 96509 Poisoning by opiates and related narcotics, other 16 T40601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter 2 96500 Poisoning by opium (alkaloids), unspecified 14 F1123 Opioid dependence with withdrawal 2 E9352 Other opiates and related narcotics causing adverse effect in therapeutic use 11 T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter 2 E8502 Accidental poisoning by other opiates and related narcotics 11 T40605A Adverse effect of unspecified narcotics, initial encounter 2 E9500 Suicide and self inflicted poisoning by analgesics, antipyretics, and antirheumatics 11 T40602A Poisoning by unspecified narcotics, intentional self harm, initial encounter 1 496 Chronic airway obstruction, not elsewhere classified 4 T400X1A Poisoning by opium, accidental (unintentional), initial encounter 1 78009 Other alteration of consciousness 3 96502 Poisoning by methadone 3 29281 Drug induced delirium 3 E9800 Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted 3 F1193 Opioid use, unspecified with withdrawal 1 T404X1A T402X5A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Adverse effect of other opioids, initial encounter R0681 Apnea, not elsewhere classified 1 3 Only the top 10 diagnosis codes are shown 4 Some opioid ADEs require two diagnosis codes used in combination 1 1 52

Contact to Obtain Your Hospital Report Email Nina Rose nrose@hsag.com 53

Questions? 54

Thank you! Edna Clifton 813.865.3579 Cell 813.753.5379 eclifton@hsag.com

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No FL 11SOW C.3.6 02172017 01