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Safe Prescribing in the Oklahoma Elderly (SPOkE) Better Options. Better Outcomes.

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.

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  1. Safe Prescribing in the Oklahoma Elderly (SPOkE)Better Options. Better Outcomes.

  2. 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

  3. America’s “Other” Drug Problem

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. Historical Context

  11. 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

  12. 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)

  13. 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

  14. The SPOkE Project:Safe Prescribing in the Oklahoma Elderly

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Interventions Stakeholder / Partnership Development • OPhA • Pharmacy Providers of Oklahoma • OU College of Pharmacy • RHAO • OSMA & OSMA Geriatrics Subcommittee • Oklahoma Geriatrics Society • OAFP • OOA

  21. 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

  22. 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

  23. 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. )

  24. 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 )

  25. 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

  26. 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

  27. 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

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