How Can We Get the Best Medication History?
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1 How Can We Get the Best Medication History? Stephen Shalansky, Pharm.D., FCSHP Pharmacy Department, St. Paul s Hospital Faculty of Pharmaceutical Sciences, UBC
2 How Are We Doing Now?
3 Completeness of Medication Histories Documented by Various Health Care Professionals Before-Admission Medications Health Care Number of Number Proportion Number NOT Professional Med Histories of Meds Documented Documented Reviewed Physicians Staff ± ± ± 2.2 Residents ± ± ± 2.0 Nurses ± ± ± 2.2 Paramedics ± ± ± 1.9 Pharmacists With PharmaNet ± ± ± 1.4 Without PharmNet ± ± ± 1.6 Lo, Shalansky, Menezes. Can J Hosp Pharm 2004;57:32-38
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6 Class 1: unlikely to cause patient discomfort or clinical deterioration Class 2: potential to to cause moderate patient discomfort or clinical deterioration Class 3: potential to to cause severe patient discomfort or clinical deterioration 54% of patients had an unintended discrepancy 39% of discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration
7 No significant predictors of unintended discrepancies were identified
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9 Is PharmaNet the Answer? Canada Health Infoway Inc. is leading a national program towards the implementation of : Electronic health records Electronic drug profile and prescribing systems
10 The Accuracy of a Prescription Claims Database for Determining Medication Profiles of Heart Failure Patients Stephen Shalansky, Janice Yim, Linda Jang, Andrew Ignaszewski, Leon Jung, Catherine Clark Pharmacy Department and Division of Cardiology, St. Paul s Hospital UBC Faculties of Medicine and Pharmaceutical Sciences Burrard Pharmacy, Vancouver UNIVERSITY OF BRITISH COLUMBIA
11 PharmaNet Records all prescription transactions processed by community Pharmacies in British Columbia Not limited to specific health plans Excluded: HIV meds meds administered in hospital Can be accessed by: community pharmacists Hospital pharmacist Emergency room physicians Ministry and researchers can apply for data
12 PharmaNet Data Hospital access: Generic drug name and strength Dosage form Manufacturer Date and quantity dispensed Dose and directions Prescribing physicians Also available: Cost/billing, drug interactions, allergies, medical conditions, clinical notes, pharmacy demographics, physician demographics, access info., etc.
13 Use of PharmaNet Data Clinical, research, policy applications: Current medication profiles/medication history Adherence Therapeutic duplication Drug interactions Major source of medication use data for epidemiology research Ministry-initiated drug use evaluations
14 Objectives To quantify agreement between the PharmaNet database and: a) A thorough medication history interview Current medication profile: the number of outpatient prescription medications currently consumed (Primary) the types and doses of outpatient prescription medications currently consumed (Secondary) b) Medication Event Monitoring System (MEMS) medication adherence over a 6 month period (Pilot study).
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16 Results Demographics of 194 Patients Interviewed Male 149 (77%) Age, median (range) 65 (27-94) Recruitment Site Heart Function Clinic 162 (83%) Pre-Heart Transplant Clinic 19 (10%) Community Pharmacy 13 (7%) CHF class Class I 41 (21%) Class II 66 (34%) Class III 19 (10%) Class IV 1 (1%) Unknown 67 (34%) Prescription meds (mean ± SD) 7.5 ± 2.9 Total number meds reviewed 1457
17 Med Profile Discrepancies Between PharmaNet and Interview 194 Medication Profiles; 1457 meds All discrepancies # of patients with a discrepancy 138 (71.1%) # of discrepancies 353 Discrepancies in # of active meds # of patients 109 (56.2%) # of discrepancies 230 Discrepancies in type of meds # of patients 115 (59.3%) # of discrepancies 268 Discrepancies in doses of meds a # of patients 64 (33.0%) # of discrepancies 85 a for medications listed in both PNet and Interview
18 Number of Prescription Meds Currently Consumed Bland-Altman Agreement Plot Number of Medications Currently Consumed: PharmaNet versus Interview n = 194 Difference: PNet - Interview Mean difference: -1.0 meds per patient Limits of agreement: -4.7 to 2.8
19 Medication Class Involved in 353 Discrepancies Diuretics 76 (21.6%) Beta-blocker 37 (10.5%) ACE inhibitor 29 (8.2%) Supplements 26 (7.4%) Oral anti-diabetics 23 (6.5%) Other heart medications 48 (13.6%) Others 114 (32.3%)
20 Reasons for Discrepancies Number and Type of Medications n = 1457 meds Med listed on PNet but incorrectly appeared inactive 205 (14.1%) Overdue for refill by < 7 days 72 (4.9%) Overdue for refill by >7 but < 30 days 69 (4.7%) Overdue for refill by >30 days 64 (4.4%) Med listed on PNet but incorrectly appeared active 40 (2.7%) Med did not appear anywhere on PNet 23 (1.6%) Note: dosing discrepancies excluded: all medications involved in dosing discrepancies appeared on PharmaNet
21 Reasons for Discrepancies Number and Type of Medications Reason for Discrepancy N = 268 Discrepancies Overdue for refill; pt stated will refill soon 40 (15.0%) Dosing regimen recently changed 39 (14.6) Unknown 37 (13.9%) Medication stopped 31 (11.6%) reason unknown 16 because of SE s 7 because of med switching 4 because symptoms resolved 2 because of other reasons 2 Supply left from previous refill 30 (11.2%) Hospital provided medication during hospital stay 21 (7.9%) Medication recently restarted / old Rx 18 (6.7%) Patient stated non-compliance 14 (5.2%) Sample medication 11 (4.1%) Taken only when needed 10 (3.7%) Other known reasons 17 (6.3%)
22 Reasons for Discrepancies Dosing N = 85 Discrepancies Side Effects 11 (12.9%) Medication not working 9 (10.6%) Reason unknown to patient 8 (9.4%) Other known reasons 33 (38.8%) Not recorded 24 (28.2%)
23 Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot N = 45 Mean discrepancy 6.8% +/- 23.7% Limits of agreement: -40.6% to 54.2% Discrepancy (PNet MEMS) % Adherence (average of PNet and MEMS)
24 Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot N = 45 Mean discrepancy 6.8% +/- 23.7% Limits of agreement: -40.6% to 54.2% Discrepancy (PNet MEMS) MEMS misadventures in red (N=5) % Adherence (average of PNet and MEMS)
25 Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot N = 40 Mean discrepancy 0.7% +/- 11.9% Limits of agreement: -23.1% to 25.5 Discrepancy (PNet MEMS) % Adherence (average of PNet and MEMS)
26 Conclusions 70% of PharmaNet profiles contained some inaccurate or misleading information regarding current medication consumption Most medications currently consumed appeared somewhere on the PharmaNet profile It was often difficult to determine which were still active At least some doses were inaccurate for a third of patients interviewed
27 Conclusions Adherence calculated using refill data from PharmaNet may inaccurate: Limits of agreement with MEMS: -23.1% to /45 (11%) of patients did not use MEMS appropriately Gold Standard for measuring adherence?
28 A Couple More Points on Adherence An accurate list of what was prescribed or filled is not necessarily an accurate list of what is being consumed Initiating medications that the patient was not previously taking can be dangerous
29 Predictors of Nonadherence Depression Cognitive impairment Asymptomatic disease Inadequate discharge planning/follow-up Side effects Lack of belief in benefit Lack of insight in illness Poor provider-patient relationship Barriers to care Missed appointments Complexity of treatment Cost Osterberg L. N Engl J Med 2005;353:487-97
30 Predictors of Nonadherence Non-Adherent Adherent P value (N=49) (N=328) Age 62 ± ± Male 41 (84%) 239 (73%) 0.12 Number of Rx meds 4.0 ± ± 3.4 <0.001 Adverse effects 18 (37%) 151 (46%) 0.22 Use of adherence aids 18 (37%) 180 (55%) 0.02 Alternative medications 49 (20%) 85 (26%) 0.38 Attends clinic 22 (45%) 144 (44%) 0.93 Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9
31 Predictors of Nonadherence Non-Adherent Adherent P value (N=49) (N=328) Age 62 ± ± Male 41 (84%) 239 (73%) 0.12 Number of Rx meds 4.0 ± ± 3.4 <0.001 Adverse effects 18 (37%) 151 (46%) 0.22 Use of adherence aids 18 (37%) 180 (55%) 0.02 Alternative medications 49 (20%) 85 (26%) 0.38 Attends clinic 22 (45%) 144 (44%) 0.93 Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9
32 More Meds = Better Adherence? N = 367 Adjusted Odd Ratio N = 111 N = 137 N = 70 N = 49 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% Proportion Non-Adherent to 3 4 to 6 7 to 9 10 or more 0% Number of Regularly Scheduled Prescription Medications Adjusted OR for non-adherence Proportion who were non-adherent (unadjusted) Have you changed your daily routine to accommodate your medication schedule? Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9
33 Morisky Score Non-Adherent Adherent P value (N=49) (N=328) Do you ever forget to take your medicines? 29 (59%) 138 (42%) 0.03 Are you careless at time about taking your medicine? 13 (27%) 72 (22%) 0.47 When you feel better, do you sometimes stop taking your medicine? 6 (12%) 7 (2%) <0.001 Sometimes if you feel worse when you take your medicine, do you stop taking it? 12 (25%) 27 (8%) <0.001 Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9
34 Morisky Score Non-Adherent Adherent P value (N=49) (N=328) Do you ever forget to take your medicines? 29 (59%) 138 (42%) 0.03 Are you careless at time about taking your medicine? 13 (27%) 72 (22%) 0.47 When you feel better, do you sometimes stop taking your medicine? 6 (12%) 7 (2%) <0.001 Sometimes if you feel worse when you take your medicine, do you stop taking it? 12 (25%) 27 (8%) <0.001 Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9
35 There s still a place for medication history interviews!
36 Recommendations Questions for Medication History Interviews Ask about all medications: Prescription Over-the-counter Anything from a herbalist or health store? Herbs Vitamins or supplements Teas Traditions remedies (from other countries?) Name, dosage form, dose, schedule, last dose taken (be specific about prn medications) Have you recently started any medications, or had the dose changed? Side effects/non-adherence more likely
37 Recommendations Questions for Medication History Interviews Balance open-ended questions with yes/no questions Nonbiased questions No leading questions Vague responses may indicate non-adherence Avoid medical jargon
38 Recommendations Questions for Medication History Interviews Encourage questions from patient Encourage bringing meds and use of medication wallet card Give out wallet cards Prompt regarding non-pill dosage forms and prns Creams, drops, inhalers, spray, samples Allergies: ask about symptoms Use multiple sources of information: Medication labels Family Community pharmacy Family physician
39 Recommendations Questions for Medication History Interviews If you have access to prescription refill records: Did the doctor change the dose or stop any of your medications recently? Many discrepancies identified in our study resulted from physician-initiated changes or discontinuation Have you recently? changed the dose or stopped any of your medications Many of the identified discrepancies were the result of patient-initiated deviations from the written prescription
40 Recommendations Questions for Medication History Interviews If you have access to prescription refill records: Do you have trouble taking or remembering to take any of your medications? A substantial number of patients admitted non-adherence with little prompting Have any of the medications been causing side effects? Experiencing side effects is one of the common reasons for stopping a medication or changing the dosing of a medication If you re pressed for time, focus on: Medications with a relatively high incidence of side effects: e.g. beta blockers Medications that are doses based on symptoms: e.g. diuretics
41 Recommendations Questions for Medication History Interviews If you have access to prescription refill records: Your PharmaNet profile indicates that you may have run out of some medications. Are you still taking any of these? Overdue for refills were the most common reason identified for discrepancies Have you spent any days in the hospital for the past year? Hospital providing medications during admission accounted for 8% of the discrepancies in this cohort
42 Recommendations Questions for Medication History Interviews Adherence: Review the prescription refill records if possible. Morisky Questions: When you feel better, do you sometimes stop taking your medicine? Sometimes if you feel worse when you take your medicine, do you stop taking it? Health Beliefs: Have you changed your daily routine to accommodate your medication schedule? Don t assume patients taking few medications are adherent, or patients taking a large number of medications are non-adherent
43 Ask the Right Questions! How much time do you spend using your exercise treadmill each week?
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