Medication Safety: Deprescribing Jessica Visco, PharmD ... · August 24, 2016 Deprescribing Jessica...
Transcript of Medication Safety: Deprescribing Jessica Visco, PharmD ... · August 24, 2016 Deprescribing Jessica...
DeprescribingJessica Visco, PharmD, CGP
SeniorPharmAssist
August 24, 2016
Deprescribing
Jessica Visco, PharmD, CGPSeniorPharmAssist
Webinar #1Webinar #6
Medication Safety: Preventing Adverse Drug Events and Improving Transitions of Care
Michael Crooks, PharmDJessica Visco, PharmD, CGP
Disclosures
Verification of participation will be noted by signing in
via the chat box.
No influential financial relationships have been disclosed
by planners or presenters which would influence the
planning of the activity. If any arise, an announcement
will be made at the beginning of the session.
No commercial support has influenced the planning of
the educational objectives and content of the activity.
Any commercial support will be used for events that are
not CE related.
Objectives
Define and classify medication errors and preventable
medication-related harms
Identify medication-related quality measures for various
care providers and settings
Identify opportunities to engage community pharmacists
in health care improvement
Explain the difference between medication therapy
management and medication management
List at least 3 community resources for medication
management
Case Mr. J is a 72 year old AA gentleman who comes in
today for his follow up medication review. His chief
complaint is pain and swelling in his left hand and arm.
He also reports no appetite and a general feeling of
malaise.
PMH
Arthritis and gout
Diabetes
Hypertension
Elevated lipids
Reflux
Case Current Medications
Hydrochlorothiazide 25mg daily
Carvedilol 25mg twice daily
Amlodipine 5mg daily
Aspirin 81mg daily
Simvastatin 40mg daily
Glipizide ER 10mg 2 daily
Vitals
BP 102/46 P 60 BG 579 (random)
“A medication error is any preventable event
that may cause or lead to inappropriate
medication use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer.”
-National Coordinating Council on Medication
Error Reporting and Prevention (NCC-MERP)
Medication Errors Defined
“A medication error is any preventable event
that may cause or lead to inappropriate
medication use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer.”
-National Coordinating Council on Medication
Error Reporting and Prevention (NCC-MERP)
Medication Errors Defined
Term Definition Example
Medication Error
An inappropriate use of a
drug that may or may not
cause harm (all are
considered preventable)
Incorrect dose selection, dosing at
wrong time of day, dose omission,
duplicate therapy, insufficient
monitoring, etc.
Potential Adverse
Drug Event
(pADE)
A medication error with the
potential to result in an ADE
which is detected before
reaching a patient
Long-acting sulfonylurea
(glyburide) ordered for patient
over 65 years old, or possible
drug interaction (warfarin and
antibiotic)
Adverse Drug
Event (ADE)
Harm resulting from medical
intervention related to a drug
(May be preventable or not preventable)
Hypoglycemia resulting from
glyburide use
Adverse Drug
Reaction (ADR)
Harm directly caused by a
drug at usual doses
(May be preventable or not preventable)
Allergic reaction to glyburide in
patient with ‘sulfa’ allergy
The Medication Error Continuum
Inappropriate
Use
May Cause
Harm
Potential Adverse Drug Event
(pADE)
Patient Injury
Adverse Drug Event (ADE)
Or
Adverse Drug Reaction
(ADR)
pADE
ADE
Medical Errors and Medication Errors:
Prevalence in the US Health System
1999 Institute of Medicine (IOM) report:
To Err is Human: 44,000–98,000 people/year die as a
direct result of medical errors
2016 Journal of Patient Safety
Deaths from Preventable Harms in Hospitals: New
estimate of 210,000 to >400,000 deaths per year
2006 Institute of Medicine report
Preventing Medication Errors: 1.5 million preventable
ADEs annually in the US. Average costs ~$8,750
Community and Post-Acute Care
Adverse Drug Events and Older Adults
2011 New England Journal of Medicine Emergency Hospitalizations for Adverse Drug
Events in Older Americans:
ADEs result in 265,000+ ED visits per year among adults 65 an older
100,000 of these required hospitalization
ADE rate 3.5x higher for 85+ vs 65-69 year old regardless of # of meds taken
265,000 ADE – ED Visits
100,000 result in
Hospital-ization
Community & Post-Acute Care ADEs:
Highest Risk Drugs in Older Adults
ADEs result in 265,000+ ED visits per year, 100,000 requiring hospitalization(2007-2009)
Warfarin 33.3% 46.2%
Insulins 13.9% 40.6%
Anti-platelet 13.3% 41.5%
Oral Hypoglycemics 10.7% 51.8%
Opioids 4.8% 32.4%
Beers List Meds* 3.2% 27.6%
% of Hospitalizations
% of ED Visits resulting in Hospitalizations
*Excludes digoxin, as 0.125mg dose is not considered a Potentially Inappropriate Medicine
The National Action Plan for Adverse Drug Event Prevention
U.S. Department of Health and Human
Services, Office of Disease Prevention and
Health Promotion , July 2014
Modeled after National Action Plan to Prevent
Healthcare-Associated Infections
Defines a framework for government and
non-government agencies to coordinate
efforts to reduce the health burden of ADEs
Significant ADEs for the Big 3
Anticoagulants: Bleeding Events
Diabetes Agents: Hypoglycemia
Opioids: Respiratory Depression and
Excessive Sedation
This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. [11SOW-QINNCC-00362-07/31/15]
This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. [11SOW-QINNCC-00362-07/31/15]
Medicine: Help and Harm“At least 80% of the way we prevent and control
disease is through the use of medications”
Drug-related harm costs >$200 Billion annually. More
than the cost of the drugs themselves
Medicare beneficiaries with chronic diseases:
See 13 physicians; Fill 50 different Rxs per year
76% of admissions; 100x rate vs no chronic disease
Only 33% to 50% of chronic condition patients adhere
to prescribed medication therapies
Medication Reconciliation in
Patient Care Settings
Inpatient (Hospitalization, Nursing Facility, Surgical Care)
Mandatory/Regulated/Best Practice
Many available systems or toolkits
Varying standardization and quality
Outpatient (Community Dwelling ± Care Assistance)
Not mandatory, not widely recognized as best practice
Few/minimally developed systems or toolkits
Varying standardization and quality (if it even occurs)
“Brown Bag” Medicine Reviews
Physical review of patient
medication supply
For Medication Reconciliation
and/or to identify medication
related problems
Possible strategy to perform
medication management services
Do Your PART: My Meds Bags
Order Bags for FREE at
www.alliantquality.org/content/orders
Why Pharmacists?
Specialized training in the properties and
management of medications
Interface between prescribing and
dispensing to resolve potential conflicts of
interest
Community pharmacists are the health
professionals most accessible to the public
Pharmacy Care Process
Describes the elements
of Pharmacy Care
Promotes consistency
across the profession
Create a framework for
care in any setting
Medication Error Prevention: Engaging the Community Pharmacist
Improving Medication Safety
Preventing Drug Interactions
Preventing Adverse Drug Events
Identifying Duplications of Therapy and Unnecessary Medications
Improving Medication Efficacy:
Reducing Medication Non-Adherence
Identifying Medication Omissions
Improving Patient Medication and Monitoring Self-Management
Hospital Readmission Reduction Program:30 Day Readmission Rate
All Patients
Discharged Medicare FFS Beneficiaries
Select Conditions
Select Condition DRG as 1
oDiagnosis
Readmission to Any Hospital for
Any Cause
Outcome Measure Denominator
Outcome MeasureNumerator
Population of Focus
Select Condition Diagnosis-Related Groups (DRGs) 2017:AMI, HF, pneumonia, COPD, CABG, THA/TKA
Hospital Readmission Reduction Program:30 Day Readmission Rate
All Patients
Discharged Medicare FFS Beneficiaries
Select Conditions
Select Condition DRG as 1
oDiagnosis
Readmissions
Medication Adherence
Discharge Medication
Confusion
Adverse Drug Events
Quality Improvement Opportunities
What factors increase risk of readmission?
Medications and Readmissions
Don’t fill or don’t take prescribed meds
10
and 20
Non-Adherence
Don’t stop taking discontinued meds
Duplication of therapy and drug interactions
Adverse Drug Events/Adverse Drug
Reactions
Dose confusion, improper monitoring
Pharmacy Solutions
Involve Pharmacist in Discharge Process
Perform medication reconciliation
Drug selection for generic/formulary coverage
Resolve duplicate/omitted medications
Patient counseling and education
Provide Medications at Discharge
Delivery to Bedside or Home, Ready Pick-Up
Care Coordination and Follow-up
Appointment reminders
Regular contact for adherence, side-effects,
self-monitoring
NQF #0092(a & b): Use of High-Risk Medications in the Elderly
All Patients
Medicare FFS Beneficiaries
Age 66+
Medicare, 66+ with any visit in past year
Rx claim for
(a) One HRM
(b) Two or more HRM
Outcome Measure Denominator
Outcome MeasureNumerator
Population of Focus
High-Risk Medications (HRM) from Beer’s Criteria List
NQF #0092(a & b): Use of High-Risk Medications in the Elderly
All Patients
Medicare FFS Beneficiaries
Age 66+
Medicare, 66+ with any visit in past year
HRM Use
Uncoordinated Care
Lack of Medication Reconciliation
Lack of Comprehensive Medication Review
Quality Improvement Opportunities
What factors increase risk of inappropriate medication use?
Potentially Inappropriate
Medications
High-Risk Medications in the Elderly (>65)
Beer’s Criteria List, START/STOPP Criteria
Increased ADE risk for certain medication
classes, extended duration or above
threshold doses
Includes prescription and OTC medications
Pharmacy Solutions
Medication Reconciliation and Coordination
of Care
Complete and accurate record of all Rx and OTC meds
Communicate medication list to all prescribers
Identify Potentially Inappropriate Medications
Comprehensive Medication Review
Medication Therapy Management (Medicare Part D
Benefit, self-pay or contracted service)
Review all medications and conditions to identify
medication-related problems
Develop Medication Care Plan with patient and MDs
How to Engage Pharmacy
Services
Identify the Pharmacies that serve your patients
Identify pharmacies offering enhanced services
Comprehensive Medication Review/MTM, Medication
Synchronization, Compliance Packaging, Delivery
Consider value proposal
Increased Referrals, Mutual benefits of Quality
Measure Improvement, contracted fee
Plan for sharing patient health information
With the pharmacy
With the patient
Medication Therapy
Management (MTM) Core elements of MTM
Comprehensive Medication Review
Personal Medication Record
Medication related Action Plan
Intervention and/or referral
Documentation and follow up
Senior PharmAssist (SPA) SPA provides four primary services to support the well-
being of Durham residents 60 and older:
1. Direct financial assistance
2. Medication therapy management
3. Tailored community referral and care management
4. Medicare insurance counseling (SHIIP Coordinating
site for Durham County)
919-688-4772
Duke Connected Care
Care Management Services Transitional care management
Chronic disease management
Connection to community
resources
Access to disability benefits and
social services
Home visits
In-clinic consultations
Medication adherence and
management
Transportation assistance
Medical home / primary care
physician (PCP) selection
Specialist e-consults
How To Refer:
1) Ambulatory Referral to DukeWELL in Maestro Care
2) In Basket Message to “DUKE WELL GENERAL” pool
3) Call (919) 660-9355
Who To Refer:
1) Eligibility for services depends on insurance
2) Refer patients with a PCP in DCC Network and screening will be completed to determine eligibility
Interagency Care Team (ICT) Target audience
GRTs
ICT members
Eligibility Criteria
60 and older
Dementia or other cognitive disorder
Recent or recurrent hospitalizations
Medication related problems
Referral – email [email protected]
Community Pharmacies MTM
Adherence packaging
Health education
Immunizations
Health screening
Delivery
Revisiting Mr. J Diabetes
Contacted his provider
Sent to the emergency room
Patient Assistance applications
Left arm pain
Gout
Urinary Tract Infection
Antibiotics
Summary
It is important to understand and identify medication errors and
adverse drug events, including the drug classes most frequently
associated with serious, preventable harm.
Learning medication-related quality measures and tips for
improving safe and effective medication use will improve patient
care.
Coordinating care with community pharmacist/pharmacies that
serve your patients will help decrease medication errors and
adverse drug events.
References:Slide #
4-7 National Coordinating Council for Medication Error Reporting and Prevention.
http://www.nccmerp.org/about-medication-errors. Web. 7/14/16
9 National Coordinating Council for Medication Error Reporting and Prevention.
http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf Web. July
14, 2016
10 Kohn, Linda T, Janet Corrigan, and Molla S. Donaldson. To Err Is Human:
Building a Safer Health System. Washington, D.C: National Academy Press,
2000. Print.
10 James, John T. A New, Evidence-based Estimate of Patient Harms Associated
with Hospital Care. Journal of Patient Safety 9.3 (2013): 122-28. Web.
10 Aspden, Philip. Preventing Medication Errors. Washington, DC: National
Academies, 2007. Print.
10,11 Budnitz, DS, et al. Emergency Hospitalizations for Adverse Drug Events in Older
14 Americans. N Engl J Med 2011;365:2002-12. Print.
References:Slide #
15,16 U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion. (2014). National Action Plan for Adverse
Drug Event Prevention. Washington, DC: Author.
17,18 High Risk Medication Classes: Hospital Admission and Readmission Rates.
Alliant Quality. Medicare Quality Innovation – Quality Improvement
Organization. North Carolina. 2017.
19 "The Patient-Centered Medical Home: Integrating Comprehensive
Medication Management to Optimize Patient Outcomes. 2nd Ed." Patient-
Centered Primary Care Collaborative, June 2012. Web. 12 Aug. 2016.
19 National Council on Patient Information and Education. Enhancing
Prescription Medicine Adherence: A National Action Plan. National Council
on Patient Information and Education. Rockville (MD).; 2007 Aug.
References:Slide #
22,23 The Role of the Pharmacist in the Health Care System. World Health
Organization. http://apps.who.int/medicinedocs/en/d/Jh2995e/, 1994. Web.
12 Aug. 201621 Pharmacists’ Patient care Process. Joint Commission of
Pharmacy Practitioners. http://jcpp.net/patient-care-process/; May 29, 2014.
Web. 15 Aug 2016.
25,26 Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/
medicare -fee-for-service-payment/acuteinpatientpps/readmissions-
reduction-program.html. Center for Medicare and Medicaid Services, 18
April 2016. Web. 15 Aug. 2016.
29,30 Measure #238 (NQF 0022): Use of High-Risk Medications in the Elderly –
National Quality Strategy Domain: Patient Safety. Center for Medicare and
Medicaid Services. https://pqrs.cms.gov/dataset/2016-PQRS-Measure-238-
11-17-2015/c2h5-33fn/data. 17 Nov. 2015. Web. 15 Aug. 2016.
Continuing Education Credits• 1 hour of CE credit is being offered for this
webinar.
• For the live webinar, to obtain the credit you
must:• Add your name to the chat box (to verify
attendance)
• Complete the survey. The survey will open
automatically at the end of the webinar and the
link will be sent in a follow-up email.
• If you did not register for this webinar and
would like CE credit, contact