A SNAKE IN THE GRASS: MEDICATION MISUSE IN HYPERTENSION AND AN INTERDISCIPLINARY SOLUTION

Transcription

1 A SNAKE IN THE GRASS: MEDICATION MISUSE IN HYPERTENSION AND AN INTERDISCIPLINARY SOLUTION Todd R. Marcy, Pharm.D., BCPS, CDE, CACP University of Oklahoma March 20, 2014

2 2 Objectives Describe the impact of poor medication adherence on health outcomes Discuss models of inter-professional collaboration to reduce cardiovascular outcomes Review the development and launch of an interdisciplinary service to improve adherence in a family medicine practice

3 3 Webinar Flow Introduction Suboptimal medication use in the U.S. Pharmacist-managed services at the OU Family Medicine Center Consequence of poor hypertension medication adherence Development of a new service in a primary care setting

4 4 Etiologies of Medication-Related Problems Inadequate effect Poor adherence (under-use) Under-titration Drug interactions with other drugs, food, or concurrent diseases Condition severity > than maximal effect of drug Excessive effect Over-titration Poor adherence (over-use) Drug interactions with other drugs, food, or concurrent diseases Adverse effect unrelated to intended effect of the drug Preventable vs. unpreventable

5 5 Adverse Drug Effects 1.5 million ADE s in /3 in ambulatory settings A VA study found 19.6% had been prescribed a PIM from the Beers list About 27% of ADE in primary care are preventable Long-term care: 4.1 pade s/mo/100 resident-months 42% of all ADE were preventable Institute of Medicine. Preventing Medication Errors. In: Aspen P, et al, eds. Washington, D.C.: National Academy Press; Pugh MJ. J Manag Care Pharm 2006;12: Gurwitz JH. JAMA 2003;289: Gurwitz JH. Am J Med 2005;118:251-8

6 6 Adverse Drug Effects Polypharmacy is usual in elderly patients. Geriatric patients use 30-50% of all prescriptions. 57% of women over 65 take 5 prescriptions 12% of women over 65 take 10 prescriptions Swanlund SL. Appl Nurs Res 2010;23:22-9 Hajjar ER. Am J Geriat Pharmacother 2007;5:345-51

7 7 Adverse Drug Effects Conversely, needed pharmacotherapy is sometimes under-used. Systems for managing high-risk medications are inconsistently available. High risk patients can be identified and targeted, but few have access to specialized services. Lee SJ. JAMA 2011;305: Patient Safety and Clinical Pharmacy Services Collaborative National Performance Report PSPC 3: October 2010-September Available at:

8 8 Consequences of Inadequate Systems Loss of opportunity for health maximization Putting out fires instead of preventing them. Medical error Estimated $17.1 billion in harm from measurable medical errors in Adverse drug events: 27% of ADE in primary care are preventable. 2 Cost of improper medication prescribing and use Estimated cost to health system up to $290 billion annually 3 1. Van Den Bos J, et al. Health Affairs 2011: 30; Gurwitz JH. JAMA 2003;289: New England Healthcare Institute. Thinking Outside the Pillbox: Medication Adherence and Care Teams A Call for Demonstration Projects. Sept 2010.

9 9 Costly Medication-Related Problems Problem Estimated Avoidable Cost (2012) Non-adherence Delayed evidence-based treatment practice Antibiotic misuse Medication errors Suboptimal generics use Mismanaged polypharmacy in the elderly $105.4 billion $39.5 billion $35.1 billion $20.0 billion $11.9 billion $1.3 billion Avoidable Costs in U.S. Healthcare: The $213 Billion Opportunity from Using Medicine More Responsibly. Report by the IMS Institute for Healthcare Informatics. June 2013.

10 10 Questions to Consider What types of medication-related problems do you see in your practice?

11 11 Questions to Consider What are barriers to reducing medication-related problems?

12 12 Safer Medication Use Optimizing Systems Applying Knowledge Gaining Knowledge

13 13 Improving Care Trying harder rarely yields sustained change Systematic approaches improve likelihood of success Define the scope of your problem Identify a new or modified process Measure progress

14 14 System Changes Same process new result Target outcomes to improve New/modified process: people Current people doing different things New people doing new things New process: technology Current technology giving us new information New technology giving us new information

15 15 System Changes: Questions to Ask What outcomes must improve? What process changes may help? What resources can be generated or allocated? What partnerships can be cultivated? What barriers are in the way? What people can execute new processes? What process makes everyone a winner?

16 16 Pharmacist Services in OU Family Medicine Family Medicine Pharmacy OU Pharmacotherapy Services

17 17 OU Pharmacotherapy Services Pharm.D.-managed Referral-based Disease state management Diabetes Anticoagulation Started in 1998

18 18 OU Pharmacotherapy Services 9 pharmacists (~3 FTE) 2 pharmacy residents 1 community health worker 1 dietitian

19 19 Family Medicine Pharmacy 2 full time pharmacists with > 10 years of service 1 pharmacy resident Primarily distributive and education function Clinical services Vaccinations, MTM, education programs Desire to expand services Barriers include committed FTE

20 20 Partnership Expansion Family Medicine Pharmacy Desires greater contribution beyond traditional pharmacist role in partnership with primary care. Family Medicine Values interdisciplinary collaboration

21 21 Partnership Expansion Interdisciplinary meetings Identify condition(s) of focus Define a preliminary process Protocol preparation Gain appropriate support

22 HYPERTENSION 22

23 23 Condition of Interest - Hypertension 77.9 million U.S. adults have HTN 1 >69% of patients with new MI, stroke, or HF have HTN % of people with HTN are unaware of the condition and > 70% are uncontrolled 2 A 10% increase in HTN treatment would prevent ~ deaths 3 1. American Heart Association. Circulation 2014;129:e Chow C, et al. JAMA 2013;310: Farley TA, et al. Am J Prev Med 2010;38:600-9.

24 24 HTN Med Adherence and CV Outcomes Adherence to hypertension medication 1 Database review of 18,806 assess CV morbidity Newly diagnosed with HTN and started on medication No previous CV disease Assigned adherence categories : low( 40%), intermediate (40-79%), high ( 80%) Outcome: CV Morbidity Acute myocardial infarction, angina pectoris, acute stroke, transient ischemic attack 1. Mazzaglia G, et al. Circulation 2009;120:

25 25 HTN Med Adherence and CV Outcomes (cont) Duration: 4.6 years follow-up Adherence: Low adherence: 8.1% Intermediate adherence: 40.5% High adherence: 51.4% High adherence vs. low adherence for CV morbidity HR 0.62 (95%CI: ), p=0.032 Mazzaglia G, et al. Circulation 2009;120:

26 26 Adherence and Health Care Use Retrospective evaluation of pharmacy and medical claims data from Inclusion: 2 outpatient visits, 1 admission, or one ED visit 4 cohorts: HF, HTN, diabetes, dyslipidemia Measured adherence using medication possession ratio (MPR) Compared adherence vs. non-adherence over a variety of clinical and financial outcomes MPR < 80%: defined as non-adherent Roebuck MC, et al. Health Affairs 2011: 30:91-9.

27 27 Adherence and Health Care Use 135,008 patients included Adherence results in 1.18 (dyslipidemia) to 5.72 (HF) less days admitted per year. $429 (HTN) to $1,058 (HF) MORE drug spending per year. $1,258 (dyslipidemia) to $7,823 (HF) LESS total health spending. more clinic visits. less ED visits. Roebuck MC, et al. Health Affairs 2011: 30:91-9.

28 28 Adherence and Health Care Use Roebuck MC, et al. Health Affairs 2011: 30:91-9.

29 29 Adherence and Health Care Use Better adherence is associated with lower cost and improved outcomes. Will interventions targeting adherence reduce outcomes and cost? If so, what interventions work and which is best?

30 30 EVALUATING OUR POPULATION

31 31 Assess Current Practice Chart Review 75 patients of FMC and FMP Retrospective chart review of patients with <80% adherence to HTN meds

32 32 Assess Current Practice Chart Review Measurable Payer: Medicaid Medicare Mean Age Cardiovascular Comorbidity (CAD, HF, MI, CVA) Blood Pressure < 140/90 last 12 months Measure 31 (41.3%) 30 (40.0%) 56.3 years 20 (26.7%) 31.5% Mean Chronic Medications (SD) 6.4 medications (3.9) Mean Anti-Hypertensive Medication (SD) Mean Anti-Hypertensive Adherence (SD) 2.3 medications (1.1) 59.1% (20.1) Low Anti-Hypertensive Adherence 15 patients (20.3%)

33 33 Problem Summary National Problem Under-diagnosis Problem in our Population? Unknown Poor control Yes Poor adherence Yes High rate of CV events Yes

34 34 Questions to Consider What are barriers to hypertension control in the patients you manage?

35 35 Solution Barriers Inadequate time during primary care visits Multiple co-morbidities Challenges in obtaining good history Need objective assessment of adherence Assessment of barriers to adherence can take time Patient education: medication, lifestyle, and disease needed A systematic approach = time and money

36 36 Opportunity Long history of relationship with OU Pharmacotherapy. Family Medicine Pharmacy Good relationships between pharmacists and physicians Interested in greater connection with patients Supported by OU Pharmacotherapy Access to students and pharmacy residents

37 37 System Changes: Questions to Ask What outcomes must improve? Hypertension adherence, hypertension control, CV outcomes What process changes will help? More focused time with patient to identify problems and execute solutions What partnerships are available? What resources can be generated? Pharmacists in the Family Medicine Pharmacy Resource generation: low level billing available, increased dispensing revenue

38 38 System Changes: Questions to Ask What barriers are in the way? Uncertain cost justification Patient interest What people can execute new processes? Pharmacists, pharmacy residents, students What process makes everyone a winner? Pilot hypertension adherence service

39 39 Service Process Patients with known or suspected poor adherence are identified by pharmacy Pharmacy solicits a referral to PCP PCP can refer without solicitation Pharmacy contacts referred patients for appointment

40 40 Service Process Visits in a semi-private room in pharmacy Medications reviewed Education (medications and conditions) Adherence assessed (including barriers) Adherence plan created Recommendations communicated in EMR note Monitoring Alterations in drugs/doses if needed Follow-up to assess improvement

41 41 Early Experience Service launched as a pilot in November 2013 Patient recruitment has been a challenge Transportation and unfamiliarity with service are challenges 22 visits through March 17, 2014 Physician support is strong Patient satisfaction is high

42 42 Questions to Consider How much of a problem is poor medication adherence in your population?

43 43 Questions to Consider What system changes might work to improve hypertensionrelated outcomes in your practice?

44 44 Conclusions Hypertension is a problem with multiple possible intervention points. System change to improve outcomes is difficult. Evaluating potential partners from other disciplines is worthwhile.

45 A SNAKE IN THE GRASS: MEDICATION MISUSE IN HYPERTENSION AND AN INTERDISCIPLINARY SOLUTION Todd R. Marcy, Pharm.D., BCPS, CDE,CACP University of Oklahoma March 20, 2014