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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.


1
Safe Prescribing in the Oklahoma Elderly
(SPOkE)Better Options. Better Outcomes.
2
Medicare Part D
  • Benefit added for Medicare beneficiaries in 2006
  • New QIO task for the 8th SOW (August 2005 to July
    2008)
  • 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

3
Americas Other Drug Problem
4
The Problem
  • The elderly, with multiple co-morbidities,
    complex
  • chronic conditions, and, often, on
    poly-pharmacy,
  • are at increased risk for Adverse Drug Events
    (ADEs)
  • ADEs have been linked to preventable problems in
  • elderly patients
  • Depression, constipation, falls, immobility,
    confusion,
  • and hip fractures


5
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

6
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
7
The Magnitude of the Problem
If ranked as a disease, medication related
problems would be the 5th Leading Cause of
Death in the US !
Lazarou,
JAMA 98
8
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

9
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

10
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11
Historical Context
12
PIM Studies
  • Most studies on Beers Criteria or PIM are
    retrospective
  • 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

13
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
    Criteria
  • Those receiving a PIM had higher total costs,
    higher provider and facility costs, and higher
    mean number of inpatient, outpatient, and ED
    visits
  • 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)

14
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
    population

15
The SPOkE Project Safe Prescribing in the
Oklahoma Elderly
16
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

17
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

18
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19
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

20
Interventions
  • 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
    Project
  • Educational tools for providers and patients
  • Collaboration with SPOkE partners in raising
    awareness about Beers criteria

21
Interventions
  • Recruitment of Prescription Drug Plan
    Partners
  • National, Oklahoma, Individual PDP PIM Rates
    shared with PDPs
  • SPOkE brochure, prescribing principles, Physician
    Patient sample letters, PT info, article for
    PDP newsletters distributed

22
Interventions
  • Stakeholder / Partnership Development
  • OPhA
  • Pharmacy Providers of Oklahoma
  • OU College of Pharmacy
  • RHAO
  • OSMA OSMA Geriatrics Subcommittee
  • Oklahoma Geriatrics Society
  • OAFP
  • OOA

23
Interventions
  • 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

24
Interventions
  • 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
    Mtg
  • Publications
  • SPOkE article in Ok County Med Society Bulletin,
    June,07

25
Interventions
  • 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
    www.ofmq.com/spoke-cme
  • ( Walgreens, the nations largest retail pharmacy
    chain, has integrated the OFMQs CME program in
    its Continuing Education Web Site, reaching
    pharmacists nationwide. )

26
Interventions
  • 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
    tools
  • Stage C Reassessment of PI Efforts
  • ( 20 Hours AMA Category 1 CME Credit )

27
What You Can Do
  • Read the journal article on the updated Beers
    Criteria (refer to the SPOkE web site for related
    articles)
  • 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
    alternatives
  • Tell a colleague about the SPOkE project
  • Encourage them to take this one hour web-based
    CME at www.ofmq.com

28
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
    medication
  • Must remove PIMs from more than 7,000 Medicare
    beneficiaries to reach this goal

29
To obtain education or resources about SPOkE,
contactLesley Maloney, Pharm.D.Medications
Systems Management SpecialistOklahoma Foundation
for Medical Quality405.840.2891
x104lmaloney_at_okqio.sdps.org
www.ofmq.com
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