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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 8 th SOW (August 2005 to July 2008) “Developmental” in nature Less structured than tasks in other settings
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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 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
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
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 ! Lazarou, JAMA 98
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
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 outcomes…not 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 (>65 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)
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
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 Zhan’s “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
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
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
Interventions Recruitment of Prescription Drug Plan Partners • National, Oklahoma, & Individual PDP PIM Rates shared with PDPs • SPOkE brochure, prescribing principles, Physician & Patient sample letters, P&T info, & article for PDP newsletters distributed
Interventions Stakeholder / Partnership Development • OPhA • Pharmacy Providers of Oklahoma • OU College of Pharmacy • RHAO • OSMA & OSMA Geriatrics Subcommittee • Oklahoma Geriatrics Society • OAFP • OOA
Interventions Physician Recruitment • Environmental Scan sent to 1250 PCPs - 183, or 14.6% response with >67% unfamiliar with Beers • Pain, Psych, & CV meds of most concern • Needs cited : Current Guidelines, More Geriatric Prescribing Education, & Automated Systems with Alerts, EHRs
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
Interventions Physician & Pharmacist Education Free 1.5 hours of web-based CME on prescribing in geriatric patients : Dr. Mark Stratton’s presentation, “Optimizing Medication Use in the Elderly” is available at www.ofmq.com/spoke-cme ( Walgreens, the nation’s largest retail pharmacy chain, has integrated the OFMQ’s CME program in its Continuing Education Web Site, reaching pharmacists nationwide. )
Interventions OFMQ’s spOke Performance Improvement Project Voluntary participation in the office setting to reduce the use of PIMs in one’s practice. Stage A: Practice Assessment of PIMS in patients > 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 )
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, don’t start new patients over age 65 on any of the twelve meds…choose safer alternatives • Tell a colleague about the SPOkE project • Encourage them to take this one hour web-based CME at www.ofmq.com
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
To obtain education or resources about SPOkE, contact:Lesley Maloney, Pharm.D.Medications Systems Management SpecialistOklahoma Foundation for Medical Quality405.840.2891 x104lmaloney@okqio.sdps.org www.ofmq.com