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Medication Risk in the Older Adult: A Hidden and Costly Epidemic

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Title: Medication Risk in the Older Adult: A Hidden and Costly Epidemic


1
Medication Risk in the Older Adult A Hidden and
Costly Epidemic
  • Penny Shelton, Pharm.D., CGP, FASCP
  • Director of Experiential Programs
  • Associate Professor, Dept of Pharmacy Practice
  • Campbell University
  • Claudia Schlosberg, J.D.
  • Director of Policy and Advocacy
  • American Society of Consultant Pharmacists

2
Agenda
  • Medication Use in Older Adults
  • Medication Related Problems (MRPS)
  • Costs of MRPs
  • Preventability
  • Inappropriate Prescribing and Non-Adherence
  • MTM and the Role of Pharmacists
  • Policy Implications and Recommendations
  • Case Studies

3
Medication Use in the Elderly
  • Seniors make-up approx. 12 of U.S. population
    but account for 37.2 of total Rx spend
  • Medicare Part D increased prescription
    utilization by almost 5 in 2006
  • 40 OTC medications

Kaufman DW, et al. JAMA 2002287337-44 IMS
1997 Ketcham JK, Simon KI. Am J Managed Care
200814SP14-21 U.S. Census Bureau
4
MRPs are Common among Older Adults
  • Older adults (65 ) are
  • 2.5 txs more likely to visit ERS due to an MRPs
    than younger individuals.
  • 7 txs more likely to be hospitalized for an MRPs
    than younger individuals.
  • Budnitz DS, Pollock, DA, Weidenbach KN, et al,
    National Surveillance of ER Visits for Outpatient
    ADEs, JAMA, 2006 2961858-1866.

5
Outcomes of Medication Related Problems
  • 10 of all hospital admissions
  • 28 of hospitalizations of the elderly
  • ADRs (17)
  • Non-adherence (11)
  • 23 of all nursing home admissions
  • Vermiere E, Hearnshaw H, Van Royen P, Denekens
    J.  Patient adherence to treatment  three
    decades of research  a comprehensive review.  J
    Clin Pharm Ther 200126331-342 Col N, Fanale
    JE, Kronholm P. The role of medication
    noncompliance and adverse drug reactions in
    hospitalizations of the elderly. Arch Intern Med
    19901508415 Lazarou J, Pomeranz BH, Corey PN.
    Incidence of adverse drug reactions in
    hospitalized patients.  JAMA 1998279(15)12005.
    Strandberg LR.  Drugs as a reasons for nursing
    home admissions.  J Am Health Care Assoc
    19841020-3

6
Example Falls
  • Falls- No risk factor for falls is as
    potentially preventable or reversible as
    medication use.
  • Leipzig, Gumming and Tinetti, 1999)
  • 1 in 3 seniors fall each year, 30 of falls
    result in injury
  • Average non-fatal injury costs 7,300
  • 48 million the annual cost of falls from a
    populationof 100,000 seniors

7
Costs of MRPs in 2000
  • 13.8 billion physician visits
  • 121.5 billion hospitalizations
  • 5.8 billion emergency room visits
  • 32.8 billion nursing home care
  • 3.5 billion new prescriptions
  • 177.4 billion direct medical costs of
  • DRPs

Prescription drug costs in 2006 217 billion
Ernst FR, Grizzle AJ. J Am Pharm Assoc
200141192-9
8
Annual Cost of Diseases Affecting People 65 in
the US
9
Older Adults at Highest Risk
  • Older adults are at the highest risk for
  • medication related problems (MRPS) due to
  • age-related physiological changes
  • high-prevalence of multiple chronic diseases
  • large numbers of prescription and OTC
    medications
  • visual and cognitive impairments that interfere
    with
  • proper use and adherence to medications
  • poverty
  • language, literacy, and cultural barriers

10
Potential Medication-Related Problems (MRPs)
  • Untreated indications
  • Improper drug selection
  • Subtherapeutic dose
  • Failure to receive drugs
  • Overdosage
  • Adverse drug reactions
  • Drug interactions
  • Drugs without an indication

Strand, et al. Drug Intell Clin Pharm
1990241093-97
11
The Domino Effect
KCL
HCTZ
ZYLOPRIM
DIABETA
MECLIZINE
12
Common Symptoms of the Elderly Drug or Disease?
  • Fatigue
  • Altered mental status
  • Falling
  • Constipation
  • Blurred vision
  • Depression
  • Dizziness

13
Medication Problem or Aging?
  • Any symptom in an elderly patient should be
    considered a drug side effect until proven
    otherwise.

Gurwitz J, Monane M, Monane S, Avorn J. Brown
University Long-term Care Quarterly Letter 1995
14
Risk Factors for MRPs in Elderly Outpatients
  • PATIENT CHARACTERISTCS
  • Polypharmacy
  • Dementia
  • Multiple chronic diseases
  • Impaired kidney function
  • Recent hospitalization
  • Age ? 85 years
  • Multiple prescribers
  • Regular use of alcohol ( 1 fl oz/d)
  • Prior ADR

Hajjar ER, et al. Am J Geriatr Pharmacother
2003182-9)
15
MRPs in Older Ambulatory Patients
  • 1523 ADE identified from records and MD reports
  • 27.6 preventable
  • Prescribing stage
  • wrong drug/wrong therapeutic choice (27.1)
  • wrong dose (24)
  • inadequate patient education (18)
  • drug-drug interactions (13.3)
  • Monitoring stage
  • Failure to respond to lab values or drug
    toxicity(36.6)
  • Inadequate lab monitoring (36.1)

Gurwitz JH, et al. JAMA 20032891107-16.
16
Preventability of MRPs
Of fatal, life-threatening serious events
Of significant events
Preventable 42
Preventable 19
17
Event Rate Issues
  • Rate found may be underestimate
  • Based on chart review - limitations
  • Classifiers required strong evidence
  • Extrapolation to total US Medicare population
    (n38,000,000)
  • 1,900,000 MRPs per year in ambulatory setting
  • 180,000 life threatening or fatal MRPs (50
    preventable)
  • To Err is Human, IOM

18
Estimated Annual Incidence of MRPs Treated in US
Emergency Departments
Red line - general population rate of ADEs
beginning at age 60, ADE rate begins to exceed
general population
Budnitz, D. S. et al. JAMA 20062961858-1866.
19
Factors Associated with Medication Errors
  • The most common groups of factors associated with
    errors were those related to
  • Knowledge and the application of knowledge
    regarding drug therapy (30 percent)
  • Knowledge and use of knowledge regarding patient
    factors that affect drug therapy (29.2)
  • Use of calculations, decimal points, or unit and
    rate of expression factors (17.5 percent) and
  • Nomenclature (13.4 percent).
  • Lesar et al., Factors related to errors in
    medication prescribing, JAMA. 277(4)312-317,
    1997, from To Err is Human, IOM 2000.

20
Inappropriate Prescribing
  • 25 percent of prescriptions written for older
    people living the community are for potentially
    inappropriate medications
  • Failure to routinely screen for potential drug
    interactions, even when medication history
    information is readily available.
  • Computerized alerts and clinical decision support
    tools while helpful, are limited
  • Alert burden
  • Non-geriatric focus
  • Need to fully integrate clinical and lab
    information
  • Not a substitute for clinical judgment

21
Inappropriate Prescribing in Various Ambulatory
Settings
22
Noncompliance
  • Lack of understanding
  • Barriers to communications
  • Complex regimen
  • Differing doses
  • Inconvenient scheduling
  • Lack of perceived need
  • Adverse events
  • Cost
  • Social isolation

23
Rx During 1 Year Following Fracture in Previously
Untreated Women
Andrade SE, et al. Arch Intern Med
20031632052-7
24
State Example A Utilization and Cost Summary for
Uncoordinated Care Patients
Uncoordinated Care Utilization and Cost
Percentages
45
\\46
36
32
1.8 B
10
Percent Patients
Percent Prescription Costs
Percent Prescriptions
Percent Medical Costs
Percent All Costs (drug medical)
25
State Example B Utilization and Cost Summary for
Uncoordinated Care Patients
Coordinated Care Patients
Uncoordinated Care Patients
366M
4.3M rxs
539M
40,000 pts
39
41
27
32
905M
7
Percent Patients
Percent Prescription Costs
Percent Prescriptions
Percent Medical Costs
Percent All Costs (drug medical)
26
State Example C Utilization and Cost Summary for
Uncoordinated Care Patients
Coordinated Care Patients
Uncoordinated Care Patients
75 M
45
48
160.7 M
235.6 M
34
30
8
Percent of Prescription Costs
Percent of Total Prescriptions
Percent of Medical Costs plus Prescription Costs
Percent of Patients
Percent of Medical Costs
27
State Example Percent Total Dollars By Cost
Groups
Comparison of Uncoordinated Care vs. Coordinated
Care Patients by Cost Groups (Percentage and
Amount of Total Costs)
130 M
123 M
97 M
82 M
87 M
58
74 M
90
58
61 M
47
69
59
57
19 M
42
53
42
41
31
43
97
3
10

Total Cost Groups (Medical and Drug Costs)
Unpublished data, Southeastern Consultants Mary
Kay Owen, R.Ph., C.Ph., 2008
28
Improving the Quality of Medication Use in
Elderly Patients
  • Putting the pieces of the puzzle together to
    create a solution remains a formidable, but not
    insurmountable task….All the pieces of the puzzle
    lie before us it remains for us to find a way to
    fit them together
  • Jerry H. Gurwitz, M.D.

Gurwitz JH, Arch Intern Med 2002 1621670-3
29
Role of the Pharmacist
Because of the immense variety and complexity of
medications now available, it is impossible for
nurses and doctors to keep up with all of the
information required for safe medication use.
The pharmacist has become an essential resource .
. . And thus access to his/her expertise must be
possible at all times. Institute of
Medicine To Err is Human Building a
Safer Health System - 2000
30
What is MTM?
  • Defined by the American Medical Associations
    2008 Current Procedural Terminology (CPT) as
  • Medication Therapy Management service(s) (MTMS)
    describe face-to-face patient assessment and
    intervention as appropriate, by a pharmacist. 
    MTMS is provided to optimize the response to
    medications or to manage treatment-related
    medication interactions or complications.

31
What is MTM?
  • Distinct from dispensing and related activities,
    e.g., counseling
  • Patient-centered, not product-centered
  • Focus on the whole patient, not a drug product
  • Requires collaboration with treatment team

32
MTM Goals
  • Promote appropriate, safe and effective
    medication use.
  • Improve quality of life and quality of care
  • Empower patients/caregivers to be active
    participants in medication and health care
    management
  • Be cost effective
  • Decrease overall health care costs
  • Others

33
Examples of MTM Services
  • Patient assessment for MRPs
  • Formulating a medication treatment plan
  • Selecting, initiating, modifying, administering
    medication within the scope of license
  • Monitoring drug therapy outcomes safety and
    effectiveness
  • Comprehensive medication review to identify and
    resolve drug-related problems
  • Providing patient education to enhance adherence
  • Documenting and communicating recommendations to
    other providers

34
Settings for Delivering MTM Services
  • All settings of patient care
  • Community pharmacies
  • Hospitals
  • Nursing facilities
  • Office practices
  • Home visits
  • Anywhere that involves patients and/or caregivers
    and managing the patients medications
  • Empowerment model
  • Work collaboratively with other providers

35
Self-insured Employer The Diabetes 10 City
Challenge
  • Outcomes
  • Decrease in A1C (5.2), LDL (32), SBP (15.7),
    DBP (9.2)
  • Increase in nutrition, exercise, and weight loss
    goals
  • Employer savings of 918 per employee in total
    health care costs
  • ROI of at least 41 beginning in the second year
  • 50 reduction in absenteeism and fewer workers
    compensation claims
  • 97.5 of patients reported being satisfied or
    very satisfied with their diabetes care

36
Private Sector Minnesota Collaborative
  • BlueCross BlueShield of Minnesota, Fairview
    Health Services of Minneapolis, and the
    University of Minnesota one year prospective
    study
  • 637 drug therapy problems resolved (285 patients)
  • 78 without direct involvement with physician
  • 22 through collaboration with a physician
  • Patients receiving MTM services demonstrated
    significant improvement in
  • Drug problems resolved
  • Drug therapy goals achieved
  • Improved HEDIS measures

37
Private Sector Minnesota Collaborative
  • Drug expenditures increased by 19.7
  • Total health expenditures decreased from 11,965
    to 8,197 per person
  • Expenditures decreased by 57.9 for facilities
    and 11 for professional claims
  • Return on Investment (ROI) was 121 (dollars
    saved for each dollar invested)
  • Now a benefit option to employer health plans
    across the U.S. as ClearScript

38
Medicaid MTM Programs
  • Missouri - Pharmacists and primary care providers
    working collaboratively have reduced per capita
    annual program expenditures by 6,804 - total
    savings 2.4 million annually.
  • Minnesota - Pharmacists identified 3.1 drug
    therapy problems per recipient. Inadequate
    therapy represented 73 of resolved problems.
  • Other states with Medicaid MTM programs Florida,
    Maryland, Mississippi, Ohio, Virginia, Vermont .
    . . .

39
Who Will Benefit from MTM?
  • All patients, but most benefit will be realized
    by patients who are at highest risk
  • Uses prescription or non-prescription medication
  • Uses herbal products or dietary supplements
  • Has an actual or potential drug-related problem
  • Physicians and other prescribers
  • Health care system

40
What the Research Shows
  • Pharmacists can
  • Help patients manage and monitor their drug
    therapy
  • Improve overall medication use
  • Improve clinical outcomes
  • Decrease adverse drug events
  • Improve quality of life
  • Reduce overall health care costs

41
Return on Investment
  • Ashville Project - Pharmacist MTM program for
    diabetics saved 1200/pt/yr with improved
    outcomes
  • Minnesota MTM program resolved 3.1 drug therapy
    problems per recipient generating average cost
    savings of approx. 403/pt/yr
  • Bussey, On average, 16.70 saved for every 1
    invested in clinical pharmacy services (review of
    104 studies)
  • Schumock, benefit cost ratio ranged from 1.71 -
    17.01 (literature review).

42
Medicare Part D MTM - A misplaced opportunity
  • Inconsistent and overly restrictive inclusion
    criteria - focus on total drug spend, not risk
    factors
  • Poorly defined service criteria resulting in
    great variability and intensity of services
  • In PDPs,
  • Poor integration with health care providers
  • Antithetical business model
  • No outcomes criteria or monitoring
  • Lack of adequate payment mechanism for
    provider/pharmacists

43
Improving Drug Therapy Outcomes
  • Patients must be educated about the medication,
    including potential ADRs
  • Records must contain all current medications,
    including OTC and herbals (HIT wil help!)
  • Therapeutic end points and ADEs must be monitored
  • Medication therapy should be systematically
    review at least annually (or whenever there is a
    significant change)
  • Improve care coordination between primary care
    and others treating the patient including
    pharmacists
  • Increase access to pharmacist-provided MTM for
    patients at highest risk

Knight EL, Avorn J. Ann Intern Med
2001135703-10.
44
How?
  • Create new payment models to enhance
    collaborations between physicians and pharmacists
    (i.e. patient-centered medical home separate
    payment for clinical services from payment for
    product
  • Establish Part B benefit for high risk
    beneficiaries
  • Revamp physician incentives and performance
    measures to promote effective medication
    assessment and management
  • Increase number of pharmacists with training and
    expertise in geriatrics

45
Why is MTM a Policy Imperative?
  • The aging of the Baby Boom population, combined
    with an increase in life expectancy and a
    decrease in the relative number of younger
    persons, will create a surge in the elderly
    population that will severely strain the
    healthcare system.

46
Strain on the System
  • As the baby boomers come of age, more money will
    be spent on pharmaceutical care.

47
Controlling Drug Spending
  • Drug Re-importation
  • Promotion of restrictive formularies and
    formulary management tools
  • Promoting generic and therapeutic substitution
  • Mandating comparative effectiveness research
  • Limiting DTC
  • Registration of drug reps
  • Academic detailing
  • The rapid growth of prescription drug
    expenditures is prompting consumers, policymakers
    and public and private payors to look for new
    ways to control drug spending.

48
Product Cost v. Appropriateness
  • Sound medication therapy management principles
  • Focus on more than the cost of the pill
  • Require collaboration between prescriber and
    pharmacist
  • Benefit from data exchange
  • Appropriate prescribing
  • Safety and effectiveness
  • Persistence and adherence

49
  • CASE STUDIES

50
QUESTIONS?
51
CONTACT INFORMATION
  • Penny Shelton, Pharm.D., CGP, FASCP
  • Director of Experiential Programs
  • Associate Professor, Department of Pharmacy
    Practice
  • Campbell University
  • PO Box 1090
  • Buies Creek, NC 27506
  • 800-760-9697 ext. 1716
  • sheltonp_at_campbell.edu
  • Claudia Schlosberg, J.D.
  • American Society of Consultant Pharmacists
  • 1321 Duke Street
  • Alexandria, VA 22314
  • 703-739-1316, ext 128
  • Cschlosberg_at_ascp.com
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