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Safe Prescribing in the Oklahoma Elderly (SPOkE) Better Options. Better Outcomes.


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Title: Safe Prescribing in the Oklahoma Elderly (SPOkE) Better Options. Better Outcomes.

Safe Prescribing in the Oklahoma Elderly
(SPOkE)Better Options. Better Outcomes.
Medicare Part D
  • Benefit added for Medicare beneficiaries in 2006
  • New QIO task for the 8th SOW (August 2005 to July
  • Developmental in nature
  • Less structured than tasks in other settings
  • National clinical measures still being developed
  • QIO latitude in developing project QIO projects
    across the nation will be diverse
  • Experiences during this SOW will influence
    program structure for the 9th SOW

Americas Other Drug Problem
The Problem
  • The elderly, with multiple co-morbidities,
  • chronic conditions, and, often, on
  • are at increased risk for Adverse Drug Events
  • ADEs have been linked to preventable problems in
  • elderly patients
  • Depression, constipation, falls, immobility,
  • and hip fractures

The Magnitude of the Problem
  • 30 of hospital admissions in elderly patients
    can be
  • linked to drug-related problems or toxic
    effects from drugs
  • 35 of ambulatory older patients have ADEs
  • 29 of ADEs require health care services
  • Up to 66 of NH Residents, over time, have ADEs,
  • with 1/7 requiring hospitalization

The Magnitude of the Problem
Estimate of 106,000 medication related deaths
annually Cost estimates are 76.6 billion for
ambulatory care. 20 billion for hospitals, and
4 billion for nursing homes
The Magnitude of the Problem
If ranked as a disease, medication related
problems would be the 5th Leading Cause of
Death in the US !
The Solution
  • Different methods for defining medication-related
    problems in the elderly
  • Use of lists containing specific drugs to avoid
    or appropriateness indexes by clinicians
  • Systematic review of literature
  • Limited number of controlled studies in elderly
  • Develop consensus criteria
  • Beers Criteria and Canadian Criteria
  • Beers Criteria adopted by CMS in 1999 for nursing
    home regulation

Beers Criteria
  • Based on expert consensus developed through an
    extensive literature review
  • Most recent update includes 48 individual
    medications or classes to generally avoid
  • amitryptiline (Elavil)
  • muscle relaxants and antispasmodics including
    cyclobenzaprine (Flexeril)
  • diphenhydramine (Benadryl)
  • 20 diseases or conditions and meds that should
    be avoided in those conditions
  • Depression avoid long-term benzo use

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Historical Context
PIM Studies
  • Most studies on Beers Criteria or PIM are
  • Findings can only show an association or
    relationship between inappropriate medication use
    and healthcare outcomesnot a cause
  • Need well-designed prospective studies to better
    evaluate health outcomes of inappropriate
    medication use
  • Can assist in strengthening predictive validity
    of Beers Criteria

Potentially Inappropriate Medications (PIM)
  • One study found PIM rate of 23 in Medicare
    managed care population (gt65 yo)
  • of patients with at least 1 PIM based on Beers
  • Those receiving a PIM had higher total costs,
    higher provider and facility costs, and higher
    mean number of inpatient, outpatient, and ED
  • Majority of PIM used
  • Antihistamines, skeletal muscle relaxants,
    opiates (propoxyphene), and psychotropic meds
  • HHS Secretary Thompson called for national action
    plan to ensure appropriate use of therapeutic
    agents in elderly (2002)

Impact on Care
  • Regardless of existing discussions, Beers
    Criteria is being used in measures of quality
  • 2006 HEDIS measure assessing quality of care in
    managed healthcare plans
  • PDPs not required to cover benzodiazepines and
    barbiturates (both on Beers list) under Medicare
    Part D
  • CMS requesting QIOs assess PIM use in Medicare

The SPOkE Project Safe Prescribing in the
Oklahoma Elderly
SPOkE Objectives
  • Rationale Many seniors ( 65 yo) are on
    medications deemed inappropriate, predisposing
    them to risks of adverse drug events with
    consequential hospitalizations
  • Quality Indicator Decrease the use of
    medications on the Beers List
  • Accomplish through interventions with physicians,
    pharmacists, and prescription drug plans (PDPs)
    to improve prescribing

Selected Medications
  • A different list of 33 drugs was used in the
    quality measure for CMS
  • Utilized Zhans Always Avoid and Rarely
    Appropriate categories as well as other
    medications on the Beers Criteria
  • 12 drug classes
  • 33 individual medications
  • OFMQ and the OU College of Pharmacy chose 12
    meds to specifically target in OK
  • Based on Beers list, frequency ofuse, and
    practice experience

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Oklahoma Rates
  • Quality measure of patients 65 years of age
    on at least 1 potentially inappropriate
    medication (PIM)
  • National rate (based on Part D claims)
  • First quarter 2006 10.2
  • Second quarter 2006 10.4
  • Oklahoma rate
  • First quarter 2006 14.7
  • Second quarter 2006 15.0
  • Rates are based on the list of 33 drugs for CMS
    and not for the 12 SPOkE meds
  • Subsequent analysis has shown that the list of 12
    SPOkE meds accounts for a PIM rate almost double
    that of CMS

  • Involve physicians, pharmacists, and PDPs in
    efforts to decrease use of 12 medications on the
    Beers list
  • Provision of resources and tools
  • Free 1.5 hours of web-based CME on prescribing in
    geriatric patients
  • Free 20 hours of CME for select physicians
    through the SPOkE Performance Improvement
  • Educational tools for providers and patients
  • Collaboration with SPOkE partners in raising
    awareness about Beers criteria

  • Recruitment of Prescription Drug Plan
  • National, Oklahoma, Individual PDP PIM Rates
    shared with PDPs
  • SPOkE brochure, prescribing principles, Physician
    Patient sample letters, PT info, article for
    PDP newsletters distributed

  • Stakeholder / Partnership Development
  • OPhA
  • Pharmacy Providers of Oklahoma
  • OU College of Pharmacy
  • RHAO
  • OSMA OSMA Geriatrics Subcommittee
  • Oklahoma Geriatrics Society
  • OAFP
  • OOA

  • Physician Recruitment
  • Environmental Scan sent to 1250 PCPs - 183, or
    14.6 response with gt67 unfamiliar with Beers
  • Pain, Psych, CV meds of most concern
  • Needs cited Current Guidelines, More Geriatric
    Prescribing Education, Automated Systems with
    Alerts, EHRs

  • Statewide Outreach
  • Presentations
  • OSU Rural Managers,
  • Community Care/Comp Med,
  • RHAO Roundtable,
  • OUTMC Grand Rounds,
  • OSMA Leadership, OSMA Geriatrics Committee
  • MWC Hospital, Edmond Regional Hospital,
    Stillwater Medical Center
  • OKPRN Convocation ( planned 8/18/07 )
  • Exhibitions
  • OKASHA Annual Mtg, OSMA Annual Mtg, OAFP Annual
  • Publications
  • SPOkE article in Ok County Med Society Bulletin,

  • Physician Pharmacist Education
  • Free 1.5 hours of web-based CME on prescribing in
    geriatric patients
  • Dr. Mark Strattons presentation, Optimizing
    Medication Use in the Elderly is available at
  • ( Walgreens, the nations largest retail pharmacy
    chain, has integrated the OFMQs CME program in
    its Continuing Education Web Site, reaching
    pharmacists nationwide. )

  • OFMQs spOke Performance Improvement Project
  • Voluntary participation in the office setting to
    reduce the use of PIMs in ones practice.
  • Stage A Practice Assessment of PIMS in patients
    gt 65 (EHR or claims)
  • Stage B Application of PI with evidence based
  • Stage C Reassessment of PI Efforts
  • ( 20 Hours AMA Category 1 CME Credit )

What You Can Do
  • Read the journal article on the updated Beers
    Criteria (refer to the SPOkE web site for related
  • Commit to decreasing use of the 12 SPOkE meds in
    your senior patients, especially those at higher
    risk for ADEs
  • For older patients already on these meds,
    consider tapering them off and starting a med
    with fewer adverse effects
  • At the least, dont start new patients over age
    65 on any of the twelve medschoose safer
  • Tell a colleague about the SPOkE project
  • Encourage them to take this one hour web-based
    CME at

At The End Of The Day
  • Our goal
  • To reduce the number of Oklahoma elderly on
    potentially inappropriatemedication
  • First target
  • To have less than 10 of Oklahoma Medicare
    beneficiaries on a potentially inappropriate
  • Must remove PIMs from more than 7,000 Medicare
    beneficiaries to reach this goal

To obtain education or resources about SPOkE,
contactLesley Maloney, Pharm.D.Medications
Systems Management SpecialistOklahoma Foundation
for Medical Quality405.840.2891