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The PILL Clinic: Pharmacologic Intervention in Late Life

The PILL Clinic: Pharmacologic Intervention in Late Life. Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC. Objectives. Discuss PILL clinic concept and development Provide overview of patient selection and assessment strategies Review short-term outcomes .

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The PILL Clinic: Pharmacologic Intervention in Late Life

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  1. The PILL Clinic:Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC

  2. Objectives • Discuss PILL clinic concept and development • Provide overview of patient selection and assessment strategies • Review short-term outcomes

  3. PILL Clinic Concept: • Focused & multidisciplinary approach to: • Reducing polypharmacy • Assessing for inappropriate prescribing • Reduce risk of ADRs • Providing patient and provider education • Assessing patient perceptions about medications • Medication reconciliation

  4. Multi-disciplinary Team Geriatrician Geriatric Fellow Pharmacist Pharmacy resident

  5. Why a PILL clinic? • Gaps in current system • Potential inappropriate medication use

  6. Why a PILL clinic? • Non-adherence • Polypharmacy • Increase risk of adverse drug reactions (ADRs) • ADRs ~12% of elderly hospital admissions

  7. Why a PILL clinic? Medication Use in the Elderly • ~12% of the US population is ≥65 years • 3 out of 4 are taking prescription medication • 2-6 prescription drugs • 1-3 over-the-counter products • 50% of all drugs used in US

  8. Complex Medication Management:Contributing Factors

  9. Patient Selection 3 criteria for patient selection • ≥65 years • ≥ 14 medications • ≥ 1 Beers criteria drug

  10. Patient Selection 992 veterans identified by electronic medication record audit *Age range65 – 95 *Prescribed medications14 – 31

  11. Patientselection • 661 patients • 1+ medications from Beers criteria • 66 providers contacted • 22 responses • 11 agreed to have their patients contacted

  12. PatientSelection Of the 661 patients: • 41% - using 2 or more Beers criteria medications • Top Drugs

  13. PatientSelection • Phone calls to identified patients • Clinic schedule • 4 hours / week

  14. PatientAssessment • Pt seen by pharmacist, geriatrician, pharmacy resident • Survey completed by patient • Brown bag review of meds

  15. Patient Assessment • Medication reconciliation • Patient education • Medication optimization • Changes to therapy

  16. PatientSurvey How many medications do you take? How do you take your medications? The medications I take include: Only prescriptions from VA OTC products Herbals/vitamins other

  17. Patientsurvey • Which of the following statements apply? True/False • I take too many meds • I take meds too many times during the day • I am taking medication that doesn’t work for me • I am having side effects.

  18. PatientSurvey • I don’t understand the purpose of my meds. • I have a problem getting medication from the pharmacy • I forget to take medication. • I don’t know what meds I should be taking. • When I feel better/worse, I sometimes stop my meds.

  19. Medication Reconciliation • Compare • Clarify • Communicate • Reconcile

  20. Medication Reconciliation • Compare • Brown Bag Review • Discussion with patient and Caregiver • Electronic medication record

  21. MedicationReconciliation 2. Clarify • Actual medication patient is taking • Including OTC/herbals/ vitamins • Non-VA meds

  22. CrucialSteps 3. Communicate & Reconcile • Omissions, inconsistencies, discrepancies • Involve other practitioners

  23. What was that again? “Medication reconciliation is something that at first glance seems like it should be an easy thing to do……It turns out it’s not all that easy.” R. Croteau MD, JCAHO Executive Director for Strategic Initiatives

  24. PatientAssessment AnticholinergicRiskAssessment • More susceptible to anticholinergic effects • Central cognitive changes memory impairment confusion • Peripheral dry mouth blurred vision constipation • Increased risk of falls

  25. Medication Assessment • Medications • Indication • Duplication • Side effects? • ARS score • Optimizing therapy • Can any medications be discontinued? • Can any medications be switched? • Risk / benefit analysis

  26. ClinicPatients • 39 patient uniques • Age range 64-92 • Average age 75 • Male

  27. Interventions • 95 total including education, reconciliation, medication changes • 14 involving BEERs criteria medications • ~ 3.4 interventions per patient

  28. Interventions • Patient education • Medication chart • Expiration dating • Disease state education • Medication counseling • Example: Inhaler use, max dose acetaminophen, NTG use

  29. PatientSurveyResults • 8% identified number of medications correctly • 78% use a pillbox • 21% believe they take too many meds • 92% believe they take meds too many times during the day

  30. Whatwe’velearnedsofar… • High numbers of patients do not know what medications they take and why. • Frequency of dosing is of concern to patients and pill burden is less of a concern.

  31. Whatwe’velearnedsofar…. • Providers need more education • ? Reluctant to refer • Patients need more education • Patients eager to talk about their meds and make changes

  32. FutureDirections • Aggressive recruitment of patients • Further data analysis • Correlations or patterns? • Follow-up review of patients at 1 year • Patient satisfaction survey

  33. Questions??

  34. References 1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-11. 2. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. JAMA. 1997;277:301-6. 3. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA.1998; 279: 1200-5. 4. Physicians Insurers Association of America. Medication Error Study. June 1993. 5. Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-4. 6. Rochon PA, Gurwitz JH. Drug therapy. Lancet. 1995;346:32-6. 7. Inga Klarin, Anders Wimo, Johan Fastbom The Association of Inappropriate Drug Use with Hospitalisation and Mortality Drugs Aging 2005; 22(1):69-82 8. Mannesse CK Derkx FH de Ridder MA, Man in’t Veld A, van der Cammen TJ. Adverse drug reactions in elderly patients as contributing factor for hospital admission: cross sectional study Br Med J 1997;315:1057-8 9. Mannesse CK Derkx FH de Ridder MA, Man in’t Veld A, van der Cammen TJ. Contribution of adverse drug reactions to hospital admissions of older patients. Age Ageing 2000; 29:35-9 10. Cunningham G, Dodd TRP, Grant DJ, Murdo MET, Richards RME. Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassesement. Age Ageing 1997; 26: 375-82 11. Schneeweiss S, Hasford J, Gottler M, Hoffmann A, Riethling AK, Avorn J. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study.Eur J Clin Pharmacol. 2002 Jul;58(4):285-91. Epub 2002 Jun 12. 12. Hugh McGavock Prescription-related illness –a scandalous pandemic. Journal of Evaluation in Clinical Practice, 10, 4, 491-497 13. Gandhi TK, Weingart SN, Borus J et al. Adverse drug events in ambulatory care. N Eng J Med 2003; 348:1556-1564 14. Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004; 164:305-3312 15. Simon SR, Chan KA, Soumerai SB et al. Potentially Inappropriate Medication Use by Elderly Persons in U.S. Health Maintenance Organizations, 2000 2001 JAGS 2005 53:227-232 16. Higashi T, Shekelle PG, Solomon DH, Knight EL, et al. The quality of pharmacologic care for vulnerable older patients. Division of General Internal Medicine, University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California 90095, USA. 17. Hanlon JT, Schmader KE, Ruby CM Weinberger M Suboptimal Prescribing in Older Inpatients and Outpatients. JAGS 2001 49:200-209 18. Beers, MH, Baran RW, Frenia K. Drugs and the Elderly, Part I: The problems Facing Managed Care. The American Journal of Managed Care. 2000; Vol No 12 1313-1320 19. D’Arcy PF. Adverse drug reactions and interactions with herbal medicines. Part 1. Adverse reactions. Advers Drug React Toxicol Rev. 1991;10:189-208 20. D’Arcy PF. Adverse drug reactions and interactions with herbal medicines. Part 2. Adverse reactions. Advers Drug React Toxicol Rev. 1993;12:147-62 21. Chan TY. Monitoring the safety of herbal medicines. Drug Saf. 1997;17:209-15 22. Jaski, ME, Schwartzberg JG, Guttman RA, Noorani M. Medication review and documentation in physi31. Hughes, CM Medication Non-Adherence in the Elderly How Big is the Problem? Drugs Aging 2004; 21(12):793-811 23. Frank E. Enhancing patient outcomes: treatment adherence. J Clin Psychiatry 1997;58 Suppl. 1:11-4

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