Medication Regimen Complexity in Home Health Care

1. Medication Regimen Complexity in Home Health Care June 10, 2010 CTA site visit

2. Why should regimen complexity matter? • Number of medications, dosage frequency, administration, instructions & prescribed dose all have been linked individually to: • Medication adherence • Adverse drug events • Nurses typically use the number of medications as an approximation of complexity • The “whole may be greater than the sum of the parts” – complexity may have an “additive” effect on patient outcomes

3. VNSNY Analysis: Research Questions • Does the MRCI add to what we already know? • Is it any different from the count of medications? • Is the MRCI related to patient outcomes? • Emergency Department use • Hospitalizations

4. Analysis: Population Studied • All new admissions to VNSNY’s Adult Acute Care program in 2008 • Does not include patient episodes in Lombardi or Congregate programs • Includes all payers • At least one medication at admission • Median = 7 medications • Medication regimen at admission • Total patient episodes (N) studied = 89,645

5. Distribution of MRCI at VNSNY Scores range from 1.5 to 88.5 Median score is 14.5 Source: 89,645 new admissions to ADU in 2008. MRCI calculated as of admission entry date.

6. MRCI vs. Count of Medications • MRCI scores are correlated to medication count, as expected • At any given number of medications, MRCI scores vary widely • For example, among patients on 7 medications MRCI scores range from 6.5 to 42.0 • Average MRCI score is about 15.0

7. MRCI Ranges Widely at any Given Med Count MRCI is related to medication count, but is not the same

8. Analysis: MRCI and Emergency Dept Use Patients with higher MRCI scores are at greater risk for ED use

9. Analysis: MRCI and 60-day Hospitalization Patients with higher MRCI scores are at greater risk for hospitalization

10. Analysis: Does MRCI Predict Hospitalization? • Dependent variable is count of OBQI hospitalizations within 60 days of admission to VNSNY • Compare how MRCI performs vs. medication count • Event count modeled using poisson regression controlling for patient case-mix Expected count of OBQI hospitalizations within 60 days of admission MRCI, medication count, and other patient characteristics at start of care =

11. Constructed a priori based on prior work Case-mix at start of care includes: Integumentary status Diagnosis of chronic disease Diabetes, CHF, COPD, CVA, PVD, AMI, cancer, arrhythmia, hepatic / renal disease, HTN, Alzheimer’s, organic brain disease, HIV, osteoarthritis, dementia Admission from inpatient hospital stay Presence of anti-coagulant in regimen Hospitalization Model Case-mix Adjustment • Demographics • (age, sex, region) • Functional status • (ADL/IADL dependencies) • Clinical status • Dyspnea, intravenous or oxygen therapy, sensory status, pain, cognitive status, depression • Elimination status

12. Results: MRCI Predicts Hospitalizations • Both MRCI score and medication count are highly significant predictors of OBQI hospitalizations within 60 days of home health admission • Models are fully case-mix adjusted • MRCI is a significant predictor after controlling for medication count • MRCI is more strongly predictive of hospitalizations than medication count Together, MRCI & medication count are better predictors of hospitalizations than either one alone

13. Predicted Effect of Changing MRCI Score Modest reduction in medication complexity has the potential to lower the number of hospitalizations experienced by home health patients

14. Summary of Analyses • Medication Regimen Complexity can be measured by adapting the MRCI for a home care population • MRCI score is related to, but not the same as, medication count • Higher regimen complexity is related to higher risk of hospitalizations • Reduction of regimen complexity, holding medication count constant, has the potential to reduce hospitalization events