Prescribing practices
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Prescribing Practices. Andrew M. Peterson, PharmD, PhD Dean, Mayes College of Healthcare Business and Policy University of the Sciences. Presentation Format . Case-based approach Topics Medication Compliance Medication Errors Underlying theme

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Prescribing practices

Prescribing Practices

Andrew M. Peterson, PharmD, PhD

Dean, Mayes College of Healthcare Business and Policy

University of the Sciences


Presentation format

Presentation Format

  • Case-based approach

  • Topics

    • Medication Compliance

    • Medication Errors

    • Underlying theme

      • Identify trends in laws and regulations that can impact your prescribing practice

      • Describe emerging technologies and how they are influencing the medication use process


Medication compliance objectives

Medication Compliance Objectives

  • Differentiate among the concepts of medication adherence, compliance and persistence

  • Identify four predictors of medication compliance

  • Articulate three reasons for medication non-compliance specific to the elderly

  • Given a specific case, identify at least two strategies to improve medication compliance


Medication compliance

Medication Compliance

  • Non- compliance to medical therapy is a major threat to public health in the United States

    • Non- compliance to prescribed medication costs nearly 125,000 lives per year.

    • 10% of hospital and 23% of nursing home admissions are linked to compliance.

    • $300 billion annually

    • 1/3 of all prescriptions NOT picked up

  • Non- compliance to pharmacotherapy is estimated to be 50% overall

    • wide ranges reported in the literature for different disease states (30-70%)

Sources: Noncompliance with Medication Regimens. An Economic Tragedy. Emerging Issues in Pharmaceutical Cost Containing. Washington, DC. National Pharmaceutical Council. 1992;1-16.; Luscher TF. Vetter W. Adherence to medication. Journal of Human Hypertension. 4 Suppl 1:43-6, 1990 Feb; McGhan WF, Peterson AM. Pharmacoeconomic impact of patient noncompliance. IMPACT – US Pharmacist. October 2001.


Case description

Case Description


Definitions

Definitions

  • Compliance

    • the extent to which patients are obedient and follow the instructions of a health care professional1

  • Adherence

    • the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed upon recommendations from a health care provider2

  • Persistence

    • how long a patient remains on therapy, introducing length of treatment as a factor

Sources: 1. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. Boston: Plenum Press; 1987: 20, 52, 26-29; 2. World Health Organization. Adherence to long term therapies: evidence for action. 2003. www.who.int/chronic_conditions/adherencereport/en. Viewed Nov 2003.


Measuring compliance

Measuring Compliance

  • Objective Measures

    • Direct

      • Blood levels

    • Indirect

      • Pill Counts

        • Manual, Electronic

      • Pharmacy Refill Data

      • Health Outcomes

  • Subjective Measures

    • Patient self reports

    • Practitioner reports


Variables potentially related to compliance

Variables Potentially Related to Compliance

  • Patient variables

    • Patient characteristics

    • Diagnosis/symptoms/severity

    • Knowledge/Health Beliefs

  • Treatment variables

    • Treatment complexity

    • Dosing

    • Adverse effects

  • Relationship variables

    • Inadequate communication/poor rapport

    • Method of teaching/environment

    • Follow-up/assessment

Adapted from: Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. Boston: Plenum Press; 1987: 20, 52, 26-29.


Patient characteristics

Age1

Elderly – average compliance is 45%

Adolescents – 40-60%

Pediatrics patients (parent as caregiver) – 34-82%

Sex2,3

Kidney transplant patients, Dunn et al found that men were significantly more noncompliant than women.

In contrast, Schweizer et al found no significant differences in compliance due to gender in more than 600 transplant recipients

Race

Intelligence

Education

Patient Characteristics

Sources: 1. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. Boston: Plenum Press; 1987: 20, 52, 26-29. 2. Dunn J, Golden D, Van Buren CT, Lewis RM, Lawen J, Kahan BD Causes of graft loss beyond two years in the cyclosporine era. Transplantation. 1990;49:349-353. 3. Schweizer RT, Rovelli M, Palmeri D, Vossler E, Hull D, Bartus S. Noncompliance in organ transplant recipients. Transplantation. 1990;49;374-377.


Compliance rates by diagnosis

Compliance Rates by Diagnosis

Source: Noncompliance with Medication Regimens. An Economic Tragedy. Emerging Issues in Pharmaceutical Cost Containing. Washington, DC. National Pharmaceutical Council. 1992;1-16.


Health beliefs and compliance

Health Beliefs and Compliance

  • 77% of patients compliant when curing a disease

  • 63% of patients compliant when preventing a disease

  • Over extended periods of time, compliance rates dropped dramatically to approximately 50% for either prevention or cure

Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes NRB, Taylor DW, Sackett DL, eds. Compliance in Healthcare. Baltimore: Johns Hopkins University Press; 1979:11-22.


Predictors of compliance

Predictors of Compliance

  • Questions to ask your patient

    • Do you ever forget to take your medicine?

    • Are you careless at times about taking your medicine?

    • When you feel better do you sometimes stop taking your medicine?

    • Sometimes if you feel worse when you take the medicine, do you stop taking it?

  • Moriskey et al:

    • 75% with high scores had BP under control at year 2 (p<0.01)

    • α=0.61

Morisky DE. Green LW. Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care. 1986:24:67-74.


Compliance predictability by variable

Compliance Predictability by Variable

Adapted from Benner J. ISPOR 2007


Factors affecting elderly compliance

Factors Affecting Elderly Compliance

  • Cognitive Ability

  • Prospective Memory Changes

  • Functional Literacy


Cognitive impairment predicts noncompliance

Cognitive Impairment Predicts Noncompliance

  • STUDY

    • 220 Japanese community dwelling elders

    • MMSE scores estimated impairment

    • Pill counts as compliance

    • Logistic regression to determine predictors of non-compliance

      • Variables: Age, sex, eyesight, hearing, number of drugs, frequency, packaging, medication calendar, drug knowledge and cognitive ability

  • RESULTS

    • Average age: 75.7 years

    • 27% MMSE ≤23 (impaired)

    • 34.6% noncompliant

    • Odds Ratio

      • Cognitive Impairment – 2.94 (1.32-6.58)

Okuno et al, 2001 – Eur J Clin Pharmacol


Prospective memory changes affect compliance

Prospective Memory Changes Affect Compliance

  • Cognitive performance declines with age

    • Korten et al, 1997 – Psych Med

  • Decline not seen in language, visio-spatial ability or abstract reasoning

    • Small et al, 1999 – Neurology

  • Difficulty with prospective memory increases with additional tasks

    • Martin, 2001 – Int J Behavioral Development

  • Poor memory performance amplified when executive function required

    • D’Yewalle, 2001 – Am J Psychology

  • Difficulty still exists even when task was habitual

    • Einstein, 2001 – Psychol Science


Basic question

Basic Question…

“Did I take it today or do I think I took it because I have been for the past x years?”


Compensation for memory changes

Compensation for Memory Changes


Omitting repeating doses

Omitting/Repeating Doses

  • Unintentionally omitting or repeating a dose

    • Small interruptions to routines

      • phone call, doorbell

    • Larger interruptions to routines

      • Shopping, dining out

  • Intentionally omitting doses


  • Compensation for memory changes1

    Compensation for Memory Changes

    • Association

    • Location

    • Mental Planning

    • Pain

    • Physical Reminder

    • Pill Box

    • Visibility

    Boron JB, et al. Medication adherence strategies in older adults. Proceedings of human factors and ergonomics society – 50th annual meeting; 2006.


    Functional literacy

    Functional Literacy

    • Physical Challenges

      • Eyesight changes

      • Manual dexterity

  • Cognitive Challenges

    • Dose selection

    • Understanding directions

    • Drug / disease knowledge

  • System Challenges

    • Readability of pharmacy labels

    • Dosage form (inhaler, injectable)

      Medication Management Skills


  • Medication management skills

    Medication Management Skills

    • DRUGS (Drug Regimen Unassisted Grading Scale)

      • Identify medication

      • Open container

      • Remove appropriate dosage

      • Demonstrate appropriate timing

    • Correlated to medication compliance


    Identifying the medication

    Identifying the Medication


    Opening the med and removing appropriate dosage

    Opening the Med and Removing Appropriate Dosage


    Comprehension of warning labels increase with literacy level

    Comprehension of Warning Labels Increase with Literacy Level

    Education Level

    <67-8>9

    59%67%84% ‡

    6%50%78% *

    0%5%14% *

    Data: Davis TC. LSU Health Science Center, Shreveport, LO.

    * p<.0001, ‡ p<.05;


    Prescribing practices

    Demonstrating Appropriate Timing

    Davis, T. C. et. al. Ann Intern Med 2006;145:887-894


    Medication management skills1

    Medication Management Skills

    • DRUGS (Drug Regimen Unassisted Grading Scale)

      • Identify medication

      • Open container

      • Remove appropriate dosage

      • Demonstrate appropriate timing

    • Correlated to medication compliance


    Case description1

    Case Description


    Medication errors objectives

    Medication Errors Objectives

    • Define the nature and significance of medication errors

    • Describe two types of medication errors and opportunities to improve systems and prevent errors

    • Given a specific case, identify at least two strategies to prevent a medication error from occurring


    Case description2

    Case Description


    Definitions1

    Definitions

    Error - The failure of a planned action to be completed as intended or the use of a wrong plan to achieve the aim

    Adverse Event - An injury caused by medical management rather than the underlying condition

    Preventable Adverse Event - An adverse event attributable to an error

    VHA Medication Safety Report: 2004


    Statistics on medication errors

    Statistics On Medication Errors

    • 44,000 to 98,000 Americans die from medical errors each year

    • 7,000 die from medication errors alone

    • 20 to 28% of adverse drug events are preventable

    • Cost per error is $2,013 to $4,700 per admission


    Preventing medication errors

    Preventing Medication Errors

    • Consumer Actions to Enhance Medication Safety

    • Issues for Discussion with Patients by Providers

    • e-prescribing by 2010

    • Drug naming, labeling and packaging

    • Oversight and regulation


    Medication error

    Medication Error

    • Bates: “Any error occurring in the medication use process.”

    • NCCMERP “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.”

      • related to professional practice systems including:

        • Prescribing/order communication

        • Product labeling, packaging and nomenclature

        • Compounding/dispensing/distribution

        • Administration/education/monitoring and use


    High alert medications

    High Alert Medications

    • High alert drugs are drugs that bear a heightened risk of causing significant patient harm when they are used in error.(ISMP.org; accessed Nov 6, 2009)

    • ISMP suggestions to reduce risk:

      • improving access to information about these drugs

      • limiting access to high-alert medications

      • using auxiliary labels and automated alerts;

      • standardizing the ordering, storage, preparation, and administration

      • employing redundancies such as automated or independent double checks when necessary.


    High alert medications1

    High Alert Medications

    • Anticoagulants (warfarin, heparin & LMWH)

      • Current TJC National Patient Safety Goal

    • Chemotherapy

    • Pediatric medications

    • Parenteral narcotics (opiates)

    • Insulin

    • Magnesium sulfate

    • Potassium chloride injection concentrate

    • Neuromuscular blockers

    • Vasoactive substances


    Medication safety opportunities for improvement

    Medication Safety:Opportunities for Improvement

    • Selection and procurement

    • Storage

    • Prescribing

    • Dispensing

    • Administration / Counseling

    • Monitoring

      System vs Knowledge vs Competent?


    Look alike sound alike error prevention

    Look-Alike/Sound Alike:Error Prevention

    • Education: Information from the literature

    • Tall Man Lettering:

      • NovoLOG and NovoLIN

      • oxyCODONE and OxyCONTIN

      • ceFAZolin and cefTRIAXONE

      • FLUoxetine and DULOXetine.

    • Tall Man lettering on medication labels, shelving labels, medication records, etc.


    Drug administration technology

    Drug Administration Technology

    • Automated medication cabinets

      • Pyxis, OmniCell

      • Interfaced with pharmacy profiles

    • Pharmacy generated MARs

    • Smart pumps

      • Drug library with standard concentrations

      • Defines soft and hard administration limits

    • Bedside barcode administration system


    Medication reconciliation

    Medication Reconciliation

    • Avoid errors such as omission, duplication, dosing errors or drug interactions

    • Each transition of care

    • Five steps

      • Develop list of previous meds

      • List of newly prescribed meds

      • Compare the lists

      • Respond to differences

      • New list to care-givers and patient


    Ideal medication error prevention program

    Ideal Medication Error Prevention Program

    • Addresses all components of the medication use process

    • Uses an interdisciplinary approach to resolving problems

    • Involves all levels of employees, practitioners and administration

    • Identifies and addresses underlying causes

    • Supports system improvements, reduces risk, and improves patient outcomes


    Case description3

    Case Description


    Key issues to remember

    Key Issues to Remember

    • People will make mistakes

    • Mistakes are opportunities to learn where the process is broken

    • Effective change requires all stakeholders’ participation


    Conclusion

    Conclusion


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