IHI Expedition Expedition: Improving Medication Safety from the Patient’s Perspective Session 1: Improving Polypharmacy February 26, 2015 These presenters have nothing to disclose E. Robert Feroli Jr., PharmD, FASHP Amanda Brummel, PharmD, BCACP Frank Federico, RPh Joelle Baehrend
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IHI ExpeditionExpedition: Improving Medication Safety from the Patient’s Perspective
Session 1: Improving Polypharmacy
February 26, 2015
These presenters have
nothing to disclose
E. Robert Feroli Jr., PharmD, FASHPAmanda Brummel, PharmD, BCACPFrank Federico, RPhJoelle Baehrend
Today’s Host2
Dorian Burks, Project Coordinator, Institute for
Healthcare Improvement, is a current coordinator for
web-based Expeditions. He also contributes to the IHI
work in the Triple Aim and Improvement Capability
focus areas, as well as the Leading Quality
Improvement series. Dorian is a member of the
Diversity and Inclusion Council at IHI, where he and
fellow staff members develop strategies to enhance
IHI’s inclusive culture, both internally and externally.
Dorian graduated from Massachusetts Institute of
Technology in Cambridge, MA where he received his
Bachelor of Science degree in Biology and humanities
concentration in Anthropology.
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• More reliable processes for medication reconciliation
• Ways to engage patients in improving medication safety
• Learn from others doing this work
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Survey Results - Current State
My hospital has a process to address medication
management and reduce polypharmacy where appropriate.
• Do not know current status of this practice: 5%
• Do not currently have this practice in place: 11%
• Have a process that supports this practice: 47%
• Process is reliably applied: 11%
• Need further clarification on this practice: 26%
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Faculty21
Frank Federico, RPh, Executive Director, Strategic Partners,
Institute for Healthcare Improvement (IHI), works in the areas of patient safety, application of reliability principles in health care,
preventing surgical complications, and improving perinatal care. He is faculty for the IHI Patient Safety Executive Training Program and co-chaired a number of Patient Safety
Collaboratives. Prior to joining IHI, Mr. Federico was the Program Director of the Office Practice Evaluation Program and a Loss Prevention/Patient Safety Specialist at Risk Management
Foundation of the Harvard Affiliated Institutions, and Director of Pharmacy at Children's Hospital, Boston. He has authored numerous patient safety articles, co-authored a book chapter in
Achieving Safe and Reliable Healthcare: Strategies and Solutions, and is an Executive Producer of "First, Do No Harm, Part 2: Taking the Lead." Mr. Federico serves as Vice Chair of the
National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP). He coaches teams and lectures extensively, nationally and internationally, on patient safety.
Improving PolypharmacyE. Robert Feroli and Amanda Brummel
22
Faculty23
E. Robert (Bob) Feroli Jr., PharmD, FASHP has been a
pharmacist at Johns Hopkins Hospital for 36 years and has
served as a Medication Safety Officer for the past 11 years.
He established a Medication Use Safety Pharmacy
Residency (accredited by ASHP). Dr. Feroli teaches on topics
of safe medication use practices and rational therapeutics,
and has faculty appointments at the Johns Hopkins University
Schools of Medicine and Nursing, and the University Of
Maryland School Of Pharmacy. Dr. Feroli also participates in
error prevention efforts, investigations of errors, and serves
as chairman of the Medication Error Reduction
Implementation Team (MERIT). He also works with 12
international hospitals that have formed affiliations with Johns
Hopkins on using the medication use system to improve
safety, efficiency, therapeutic appropriateness, and
compliance with Joint Commission International (JCI)
standards.
Faculty24
Amanda Brummel, PharmD, BCACP serves as the Director of
Clinical Ambulatory Pharmacy Services. Dr. Brummel has been
employed by Fairview Pharmacy Services since 1999 when she
graduated from the University of Minnesota. While at Fairview, she
has built and practiced Medication Therapy Management (MTM) in
multiple clinic locations, was the clinical supervisor for the MTM
department, the MTM Operations & Program Manager. Currently Dr.
Brummel has responsibility for the MTM program, the clinical
development and integration of pharmacy services in the Fairview
Health Network including our transitions of care approach and our
retail clinical services. She works closely with the Fairview Medical
Group and the Fairview Network in our population health approach
and new payer product development. Dr. Brummel is also an Adjunct
Associate Professor at the University of MN. She has published
multiple articles on MTM and pharmacy’s role in the care team. She
has chaired and served on multiple committees and is a current
member of the Minnesota Pharmacists Association, the American
Society of Health-System Pharmacists, the American College of
Clinical Pharmacy and Pharmacy Quality Alliance (PQA).
Polypharmacy
Bob Feroli, PharmD, FASHP, FSMSOMedication Safety Officer
Department of Pharmacy
Johns Hopkins Hospital
Polypharmacy
National Center for Health Statistics Data Brief No.42 Sept 2010
Polypharmacy
• As patients get sicker (regardless of age), the number of clinically appropriate medications generally goes up.
• As number of medications goes up, potential medication related problems go up
– Adverse drug effects
– Drug – Drug interactions
– Drug – Disease interactions
– Possibility of medication errors
– Poor adherence
– Cost of therapy
– Poor quality of life (e.g., pill burden)
Polypharmacy
• So what is “Polypharmacy”?
Polypharmacy
Polypharmacy
Homoeopathy
Polypharmacy - A prescription of many drugs in one compound
Polypharmacy
Illinois and Indiana Medical andSurgical Journal, Volume 1, Issue 1 (1846)
Reform Practical Therapeutics
Agenda item #6 – “To endeavor to substitute for the monstrous system of Polypharmacy now universallyprevalent, one that is, at least, vastly more simple, moreintelligible …”
I take aspirin for the headache caused bythe Zyrtec I take for the hayfever I got fromRelenza from the uneasy stomach from theRitalin I take for the short attention spancaused by the Scopederm Ts I take for themotion sickness I got from the LomotilI take for the diarrhea caused by theZenikal for the uncontrolled weight gainfrom the Paxil I take for the anxiety fromthe Zocor I take for my high cholesterolbecause exercise, a good diet, and regularchiropractic care are just too much trouble.
Dr. Jonathan Lazar (Lazar Spinal Care, P.C.)Image reproduced with permission
Polypharmacy
I take aspirin for the headache caused bythe Zyrtec I take for the hayfever I got fromRelenza from the uneasy stomach from theRitalin I take for the short attention spancaused by the Scopederm Ts I take for themotion sickness I got from the LomotilI take for the diarrhea caused by theZenikal for the uncontrolled weight gainfrom the Paxil I take for the anxiety fromthe Zocor I take for my high cholesterolbecause exercise, a good diet, and regularchiropractic care are just too much trouble.
Dr. Jonathan Lazar (Lazar Spinal Care, P.C.)Image reproduced with permission
Polypharmacy
Polypharmacy
Bushart RL, Massey EB, et.al.,Polypharmacy; Misleading, but manageable.
Clinical Interventions in Aging 2008:3(2) 383-389Review of literature Jan 1997 – May 2007
• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
– Potentially Inappropriate
Polypharmacy
Bushart RL, Massey EB, et.al.,Polypharmacy; Misleading, but manageable.
Clinical Interventions in Aging 2008:3(2) 383-389Review of literature Jan 1997 – May 2007
• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
– Potentially Inappropriate
• Medication used to treat a side effect of another medication
Polypharmacy
Bushart RL, Massey EB, et.al.,Polypharmacy; Misleading, but manageable.
Clinical Interventions in Aging 2008:3(2) 383-389Review of literature Jan 1997 – May 2007
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate
• Medication used to treat a side effect of another medication
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate
• Medication used to treat a side effect of another medication
• Using many (2,3,5,6 . . .) medications
• More than one medication to treat the same condition
• Using a medication that interacts with one another medication
• Medications prescribed more that twice daily
• Taking an OTC medication
• Obtaining medications from more than one pharmacy
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate
• Medication does not match a diagnosis
• Dose of medication does not match renal or liver function
• Equally effective less costly (& not more toxic) alternative is available
• Unnecessary duplication of therapy
• Complicated regimen affecting adherence
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate?
• Medication does not match a diagnosis
• Dose of medication does not match renal or liver function
• Equally effective less costly (& not more toxic) alternative is available
• Unnecessary duplication of therapy
• Complicated regimen affecting adherence
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate?
• Medication does not match a diagnosis
• Dose of medication does not match renal or liver function
• Equally effective less costly (& not more toxic) alternative is available
• Unnecessary duplication of therapy
• Complicated regimen affecting adherence
– Therapeutically appropriate therapy vs.
patient's ability to adhere to therapeutic regimen
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate?
• Medication does not match a diagnosis
• Dose of medication does not match renal or liver function
• Equally effective less costly (& not more toxic) alternative is available
• Unnecessary duplication of therapy
• Complicated regimen affecting adherence
– Therapeutically appropriate therapy vs.
patient's ability to adhere to therapeutic regimen
» The simplest most appropriate therapeutic regimen for a particular patient may be too complex for them to follow.
Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389
Potentially Inappropriate?
• Medication does not match a diagnosis
• Dose of medication does not match renal or liver function
• Equally effective less costly (& not more toxic) alternative is available
• Unnecessary duplication of therapy
• Complicated regimen affecting adherence
– Therapeutically appropriate therapy vs.
patient's ability to adhere to therapeutic regimen
» The simplest most appropriate therapeutic regimen for a particular patient may be too complex for them to follow.
» We must use a risk : benefit approach to find the mostappropriate therapy given the patient’s values and ability to adhere to the chosen regimen.
Polypharmacy• Medication regimens should optimize for:
– Clinical Appropriateness– Safety– Affordability– Ease of use– Patient’s ability & willingness to adhere
• Concurrent method to promote rational therapeutics– Reconciliation: Based on the response from medications taken
“yesterday.” What, if any, changes are appropriate going forward.
• Retrospective - “triggers” to identify potentially inappropriate therapy – Polypharmacy (e.g., patient on more than x drugs)– IHI trigger tool– Beer’s criteria– STOPP (Screening Tool of Older People’s Prescriptions)– START (Screening Tool to Alert to Right Treatment)
Seek the “sweet spot”
Comprehensive Medication Management
Amanda Brummel PharmD, BCACP
Director, Clinical Ambulatory Services
Fairview Pharmacy Services
45
February 26, 2015
Practitioners’ responsibilities:
• To identify a patient’s drug-related needs and commit to meet those needs
• To ensure that all of a patient’s drug therapy is appropriately indicated, the most effective, the safest and the patient is compliant
• To work in collaboration with all members of a patient’s care team
Pharmacy StrategiesFoundation of Comprehensive Medication Management (CMM)
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Comprehensive Medication ManagementBuilt upon the philosophy and process of “pharmaceutical care practice”
ASSESSMENT CARE PLAN EVALUATION
•Ensure all drug therapy isindicated, effective, safeand convenient
•Identify drug therapy problems
•Resolve drug therapy problems
•Establish therapeutic goals
•Prevent drug therapyproblems
•Record actual patient outcomes
•Evaluate progress inmeeting therapeutic goals
•Reassess for new problems
Continuous Follow-upWorking in collaboration with all members of the healthcare
team
ESTABLISH A THERAPEUTIC RELATIONSHIP
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Assessment
• Establish therapeutic relationship
• Understand patient’s goals of therapy
Meet the patient
• Reason for encounter
• Patient history, medication experience, clinical information
Elicit relevant information
• Indication, efficacy, safety, convenience
Make drug therapy decisions
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• Unnecessary drug therapy?
• Additional drug therapy needed?INDICATION
• Ineffective drug?
• Dosage too low?
• Drug interaction reducing efficacy?EFFICACY
• Adverse drug reaction?
• Dosage too high?
• Drug interaction increasing toxicity?SAFETY
• Willingness to take medications?
• Ability to take medications?COMPLIANCE
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Care Plan
• Clinical goals
• Drug therapy goalsEstablish goals of therapy
• Non-drug therapy, education
• Patient-specific drug choices
Interventions: DTP resolutions, achieving goals of therapy, achieving
patient goals prevention of DTP
• Patient specific and clinically appropriate
• Method of follow-upSchedule follow-up evaluation
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Follow-up evaluation
• Evaluate effectiveness of drug therapy
Compare actual patient outcomes to goals
• Evaluate safety and patient’s ability to adhere to therapy
• Explore reasons for non-adherence
Monitor for adverse effects and compliance
• Assess for changes in condition status and drug therapy
Assess for new drug therapy problems
• Continuous careSchedule next follow-up
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Drug Therapy Problems Identified
2014
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Dosage Too Low 31 %
Needs Additional Drug Therapy 21 %
Noncompliance 15 %
Adverse Drug Reaction 11 %
Dosage Too High 10 %
Unnecessary Drug Therapy 8 %
Ineffective Drug 6 %
19,963 Drug Therapy Problems Resolved
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Confirmation of DTPs
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Estimated Cost Interventions
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Fairview Published Results
• An average 12-to-1 return on investment in terms of reduced overall health-care costs, documented in “Clinical and Economic Outcomes of Medication Therapy Management Services: The Minnesota Experience” (Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211)
• MTM contributed to optimal care in complex patients with diabetes documented in “Optimal Diabetes Care Outcomes Following Face-to-Face Medication Therapy Management Services” (Brummel A.R. et al, Population Health Management: 2012)
• Medication therapy management: 10 years of experience in a large integrated health care system. (Ramalho de Oliveira, D., Journal of Managed Care Pharmacy : JMCP, 16(3), 185-195.)
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Health Care Costs After MTM
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
Facilities
(-57.9%)
Professional
(-11.1%)
Prescriptions
(+ 19.5%)
Total Cost
(-31.5%)
1 YearbeforeMTM
1 YearafterMTM
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
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Optimal Diabetes Care Outcomes
2006 Pre-MTM, 2007 MTM, 2008 Post-MTM
“Optimal Diabetes Care Outcomes Following Face-to-Face Medication Therapy Management Services” (Brummel A.R. et al, Population Health Management: 2012)
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Activation, Engagement, and Shared Decision-Making
• Patient activation
Measure of patient’s knowledge, skills, and
ability to manage their health
• Patient engagement
Steps patients take on their own
Combines ‘activation’ with interventions
Promote positive patient behavior
Obtaining preventive care or exercising
• Shared decision making—Patients and providers together
Patient’s condition, treatment options, the medical evidence behind treatment options, risks and benefits, and patients’ preferences, arrive at treatment plan
Robert Wood Johnson Foundation. Patient Engagement. February 14, 2013. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf. Accessed September 5, 2014.
Patients who had
decision-making
support
• Overall medical
costs were 5.3%
lower
• 12.5% fewer hospital
admissions
• 20.9% fewer
preference-sensitive
heart surgeries
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Activation Level and Cost
• PAM scores were predictive of billed costs of care
• With targeted interventions, least activated patients realize the greatest gains
• Care for patients with Level 1 Activation cost 8-21% more than patients with Level 2-4
Some variance by condition
Costs for Level 1 patients with hypertension were 14% higher than Level 4
Costs for Level 1 patients with asthma were 21% higher than Level 4
Caveat: Predicted costs were no different for patients at Level 2-4
Health Affairs, 32, no.2, 2013. Judith H. Hibbard. Patients With Lower Activation Associated With Higher Costs. http://content.healthaffairs.org/content/32/2/216.full.html. Accessed September 7, 2014.
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Key Points
• Comprehensively review a patient’s medication therapy
Look to make sure each medication is
Indicated
Effective
Safe
Convenient/Compliance
• Consider a patient’s medication experience
• Engage them in the decision making process when choosing their medication therapy
• Follow up to evaluate their outcomes and assess for new drug therapy problems