4/26/2016 DISCLOSURES DEVELOPMENT OF A PHARMACIST DRIVEN - - PDF document

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DEVELOPMENT OF A PHARMACIST DRIVEN MEDICATION REVIEW PROCESS TO ADDRESS POLYPHARMACY WITHIN A NEUROLOGY CLINIC

Lindsey Firman, PharmD PGY-1 Pharmacy Resident Bozeman Health Deaconess Hospital Bozeman, Montana April 30, 2016

DISCLOSURES

 IRB Status: Exempt  Co-investigators:

 Kristal Barker, PharmD  Betsy Biggerstaff, PharmD  Natalie Cooper, PharmD  Jennifer Schultz, PharmD, FASHP  Amanda

Woloszyn, PharmD, BCPS  Conflicts of interest: None  Project Sponsorship: None

http://www.criticalmassachusetts.com/2011/06/disclosure-is-no-substitute-for.html

OBJECTIVES

1.

Identify patients at risk for polypharmacy mediated adverse effects

2.

Integrate medication review into the daily process and employ different methods of communication with other healthcare providers

BACKGROUND

Polypharmacy is generally defined as a high number of medications, but more specifically can mean greater than a threshold number of medications or unnecessary use of medications Examples:

Five or more medications regardless of necessity Greater than 9 medications or any unnecessary medications Any incidence of unnecessary medications, regardless of number

http://www.champ-program.org/page/101/geriatric-medication-management-toolkit

BACKGROUND

Polypharmacy affects all stages of healthcare and has significant consequences

Healthcare costs Adverse drugs reactions Drug interactions Medication non-adherence Functional decline, including cognitive

impairment and falls

Prescribing cycle

http://thinkprogress.org/health/2012/10/22/1062441/how-rising-health-care-costs-impact-the-national-budget/ http://www.firstaidforfree.com/wp-content/uploads/2015/09/Falls.jpg http://drwills.com/wp-content/uploads/2015/05/drugcycle.jpg

BACKGROUND

Polypharmacy is prevalent and incidence will increase as the population continues to age

Setting Definition of polypharmacy Prevalence of polypharmacy Ambulatory care Greater than 5 medications 37% Hospital discharge Greater than 9 medications 37% Long term care facilities 5 or more medications 38-91% 10 or more medications 10-65% Table 1. Reported prevalence of polypharmacy in literature

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BACKGROUND AND OBJECTIVE

Interdisciplinary teams have addressed polypharmacy in various settings Neurology clinic is an ideal setting for review as side effects can have a significant impact on this patient population Objective: Develop a process for identifying high risk polypharmacy patients and communicating potential interventions to providers

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METHODS- CHART REVIEW PHASE

1. 50 randomly selected patients of Bozeman Health Neuroscience Center 2. Diagnosis of Parkinson’s disease, Alzheimer’s disease, dementia or other memory loss 3. The data gathered included:

a. Age b. Sex c. Primary diagnosis d. Number of comorbidities e. Creatinine clearance f. Potential interventions g. Number of medications in the following categories: 1. Meeting Beer’s list criteria 2. Meeting START criteria 3. Drug interactions category D or X 4. Dose adjustments needed 5. No indication 6. Monitoring needed 7. Therapeutic duplication 8. Inappropriate OTCs 9. Potential adverse reactions

http://www.bcmj.org/sites/default/files/md2b-bleackley-chart-reviews- photo.jpg

DATA AND RESULTS- CHART REVIEW

Patient Characteristics n=50 (%) Male 21 (42%) Over 65 years of age 40 (80%) Parkinson’s Diagnosis 27 (54%) Alzheimer’s or Dementia Diagnosis 23 (46%) Greater than 4 comorbidities 23 (46%) Greater than 5 medications 31 (62%) Medication Regimen Data Mean Range Medications 9.3 1-17 Vitamins or Herbals 1.7 0-10 Medications meeting Beer’s List criteria 1.6 0-5 Medications meeting STOPP criteria 1.4 0-5 Medications that meet START criteria 0.3 0-2 Drug interactions rating D

• r higher

1.8 0-9 Potential Interventions 1.9 0-4

2 4 6 8 10 12 <65 65-74 75-85 >85 Mean Number Age Group

Graph 1. Data By Age Group

Mean Number of Comorbidities Mean Number of Medications Mean Number of Potential Interventions

Table 2. Patient characteristics Table 3. Chart review results

METHODS-ACTIVE INTERVENTION PHASE

Weekly review of upcoming appointments in the neurology clinic

Figure 1. Screen shot of provider schedule with medication list

METHODS-ACTIVE INTERVENTION PHASE

 Identified patients with extensive

drug lists, high risk medications, and certain high risk disease states for further review

 Emailed provider with

recommendations or clarifications as appropriate based on review

 Data was collected similar to the

chart review, with an emphasis on intervention outcomes

Figure 2. Example medication list and interventions

METHODS- ACTIVE INTERVENTION PHASE

 Extensive drug lists

 Generally looking at patients who had long medication lists  Included blatant drug interactions that were found on brief review

 High risk medications

 Benzodiazepines  Anticholinergics  Sleeps aids, including z-drugs and diphenhydramine  Opioids

 High risk disease states- for sensitivity to side effects or difficulty in treating

 Parkinson’s disease  Alzheimer’s disease  Peripheral neuropathy

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DATA AND RESULTS- ACTIVE INTERVENTION PHASE

Patient Characteristics n=29 (%) Male 11 (38%) Over 65 years of age 16 (55%) Parkinson’s, Alzheimer’s,

• r Dementia Diagnoses

13 (45%) Greater than 9 medications 28 (97%) Medication Regimen Data Mean Range Medications 15.3 8-27 Vitamins or Herbals 2.8 0-8 Drug interactions rating D

• r higher

5.4 0-18 Potential Interventions 3.2 0-6 Interventions to attempt 3.0 0-6 Successful interventions 1.3 0-3

39 interventions on a total of 29 patients- average of 1.3 accepted interventions per patient 88 potential interventions to attempt led to 39 interventions- 41% success rate

Table 4. Patient characteristics during intervention phase Table 5. Results of intervention phase

DATA AND RESULTS- ACTIVE INTERVENTION PHASE

 What constitutes a successful intervention?

DATA AND RESULTS- ACTIVE INTERVENTION PHASE

 What constitutes a successful intervention?

Any action on or change to a patient’s chart or medication list that follows a given recommendation

DATA AND RESULTS- COMPARISON

Random selection of patients with specific diagnoses versus Deliberate selection of patients with high numbers of medications and varying diagnoses Mean age was 73 during chart review and 63 during active intervention phase

9.3 1.7 1.8 1.9 15.3 2.8 5.4 3.3 2 4 6 8 10 12 14 16 18 Number of medications Number of vitamins/herbals Number of interactions category D or X Potential Interventions Mean Number Findings

Graph 2. Comparison of Chart Review and Active Intervention Phase Findings

Chart Review Active Intervention Phase

DISCUSSION

 Polypharmacy was clearly present in patients of the neurology clinic  Rates were higher than that generally reported in literature-

 62% in chart review phase had nine or more medications  Could be attributed to higher risk population

 The mean number of potential interventions increased from 1.9 to 3.2

when population was selected based on high number of medications

 There was a 42% success rate on attempted interventions

DISCUSSION

On further review, only 18 of the 29 patients had successful interventions- providing an average rate of 2.1 interventions per patient if any were accepted

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DISCUSSION

On further review, only 18 of the 29 patients had successful interventions- providing an average rate of 2.1 interventions per patient if any were accepted

Communication is KEY!!

DISCUSSION

On patients where the provider was able to address the interventions, interventions were more likely to be successfully made

DISCUSSION

On patients where the provider was able to address the interventions, interventions were more likely to be successfully made. Why wouldn’t the provider be able to make the interventions?

DISCUSSION

On patients where the provider was able to address the interventions, interventions were more likely to be successfully made. Why wouldn’t the provider be able to make the interventions?

1.

Certain visit types do not allow time for medication discussion

Example: Procedure visits for Botox injections or electromyography (EMG)

DISCUSSION

On patients where the provider was able to address the interventions, interventions were more likely to be successfully made. Why wouldn’t the provider be able to make the interventions?

1.

Certain visit types do not allow time for medication discussion

Example: Procedure visits for Botox injections or electromyography (EMG) 2.

Provider forgets to bring the printed medication list and interventions

Especially common if notification was sent too many days before the appointment and was lost in an email inbox or if provider was seeing multiple patients without returning to his office in between

LIMITATIONS

 Methods changed between phases  Communication with neurologist  Time consuming work up of patients  Primary care versus specialty care

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CONCLUSION

 There is a need for pharmacist intervention with polypharmacy  Pharmacists can have a direct impact on patient care  Identification of patients and work up take time  Efficient and effective communication with busy providers is key  Primary care is the setting where a majority of interventions need to be

made

FUTURE DIRECTIONS

 Work within the EMR to communicate with providers  Work within the primary care clinic to make interventions  Use polypharmacy as a trigger for comprehensive medication reviews  Continue to track interventions and follow patients

QUESTIONS?

Lindsey Firman, PharmD Bozeman Health Deaconess Hospital lfirman@bozemanhealth.org 406-414-1050

REFERENCES

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