Adverse Drug Events Impact on Hospital Readmissions Co hosted by FHA - - PowerPoint PPT Presentation

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Adverse Drug Events Impact on Hospital Readmissions Co hosted by FHA - - PowerPoint PPT Presentation

May 22, 2023 237 likes •798 views

Adverse Drug Events Impact on Hospital Readmissions Co hosted by FHA HIIN and HSAG Facilitators Edna Clifton HSAG, Florida QIN QIO Phyllis Byles FHA Scott King, PharmD Orlando Health Dr. P. Phillips Hospital March 7, 2017

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Adverse Drug Events Impact on Hospital Readmissions

Co‐hosted by FHA HIIN and HSAG Facilitators Edna Clifton‐HSAG, Florida QIN‐QIO Phyllis Byles‐FHA Scott King, PharmD‐Orlando Health Dr. P. Phillips Hospital March 7, 2017

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Agenda

  • Overview Mission to Care FHA HIIN‐goals
  • Data year to date for high risk medications

(HRMs)

  • Overview hospital specific reports‐analysis of

claims data for HRMs and hospital readmissions

  • Open Discussion – Q/A
  • Conclusions‐Next steps
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SLIDE 3

HIIN Overview

  • “Mission to Care” HIIN
  • Accomplishments of HEN 1.0 & 2.0
  • Core Topics and Data for HIIN
  • Resources‐ HRET HIIN & FHA HIIN
  • Hospital Process and Expectations
  • Questions/Open Discussion
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SLIDE 4
  • 32 states‐1600+ hospitals (largest HIIN collaborative nationally)

FHA HEN: 94 Hospitals

HIINs: Where are they?

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SLIDE 5

CMS

Partnership for Patients (PfP)

15 Other HIIN Entities across the Nation

AHA/HRET

31 other state

  • rganizations across

the nation‐1600+

FHA‐ Mission to Care

94 member hospitals

HIINs: How are they related?

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SLIDE 6

FHA HEN Results: 2012‐2016

Prevented 31,342 cases of harm Avoided $198 million in healthcare costs

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SLIDE 7

Where We are Going‐ HIIN

partnershipforpatients.cms.gov

GOALS:

20%

Overall Reduction in Hospital Acquired Conditions (baseline 2014)

12%

Reduction in 30‐Day Readmissions (baseline 2014) 145 Harms/1,000 Discharges

2010

142 Harms/1,000 Discharges

2011

132 Harms/1,000 Discharges

2012

121 Harms/1,000 Discharges

2013

121 Harms/1,000 Discharges

2014

97 Harms/1,000 Discharges

2019

New Goal

“America’s hospitals embrace the ambitious new goals CMS has proposed,” said Rick Pollack, president and CEO of the American Hospital Association (AHA). “The vast majority of the nation’s 5,000 hospitals were involved in the successful pursuit of the initial Partnership for Patients aims. Our goal is to get to zero

  • incidents. AHA and our members intend to keep

an unrelenting focus on providing better, safer care to our patients ‐‐ working in close partnership with the federal government and with each other.”

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SLIDE 8

Historical Comparison

Original HEN HEN 2.0 HIIN Funding Source Affordable Care Act Affordable Care Act Medicare Trust Fund Project Timeline 2 base years; 1 optional year 1 base year; no optional year 2 base years; 1 optional year Project Aim 40% reduction in preventable harm; 20% reduction in readmissions 40% reduction in preventable harm; 20% reduction in readmissions 20% reduction in all cause harm; 12% reduction in readmissions Number of hospitals 1,378 1,497 ~1710 Number/Types of Topics 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAP/VAE, VTE 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAE, VTE 10 core harm topics plus readmissions ADE, CAUTI, CLABSI, C‐ diff, Falls, Pressure Ulcers, Sepsis, SSI, VAE, VTE Number of Primes 26 17 16 Data Submission Baseline 2010 2010 2014 Data Measures Mix of national, state, and organizationally defined measures Nationally defined (standardized) outcome measures Nationally defined (standardized) outcome measures

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Financial Incentives for Strong Quality Processes

‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐1.00% ‐1.25% ‐1.50% ‐1.75% ‐2.00% ‐2.00% ‐1.00% ‐2.00% ‐3.00% ‐3.00% ‐3.00% ‐3.00% ‐1.00% ‐1.00% ‐1.00% ‐1.00%

‐9% ‐8% ‐7% ‐6% ‐5% ‐4% ‐3% ‐2% ‐1% 0% 2011 2012 2013 2014 2015 2016 2017 2018 PERCENT PAYMENT REDUCTION

IQR VBP Readmission Reduction HACS

National health expenditures=$3.4 Trillion‐in hospitals=$1.1 Trillion (2016)

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Readmissions

Baseline Oct‐16 Nov‐16 Dec‐16 FL Rate 10.8 10.1 10.3 8.4 HRET HIIN Rate 9.0 8.4 8.6 7.4 # FL Reporting 76 56 46 22 #HRET HIIN Reporting 1,274 591 551 439 0.0 2.0 4.0 6.0 8.0 10.0 12.0

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

Florida HEN 2.0 Baseline: 10.0 (74 hospitals) Florida HEN 2.0 Apr‐June 2016: 9.5 (73 hospitals)

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Readmissions ‐ Medicare

Baseline Oct‐16 Nov‐16 Dec‐16 FL Rate 13.7 12.5 12.4 7.6 HRET HIIN Rate 11.9 10.5 10.8 9.0 # FL Reporting 40 40 36 20 #HRET HIIN Reporting 838 447 423 350 0.0 3.0 6.0 9.0 12.0 15.0

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

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ADEs ‐ opioids

Baseline Oct‐16 Nov‐16 Dec‐16 FL Rate 0.6 0.5 0.5 0.4 HRET HIIN Rate 0.5 0.4 0.4 0.4 # FL Reporting 57 46 45 37 #HRET HIIN Reporting 1,040 627 608 555 0.0 0.2 0.4 0.6 0.8

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

Florida HEN 2.0 Baseline: 0.6 (54 hospitals) Florida HEN 2.0 Apr‐June 2016: 0.4 (54 hospitals)

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ADEs ‐ hypoglycemia

Baseline Oct‐16 Nov‐16 Dec‐16 FL Rate 6.8 3.6 3.5 3.0 HRET HIIN Rate 3.9 4.3 4.5 4.5 # FL Reporting 48 35 31 31 #HRET HIIN Reporting 1,010 626 605 567 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

Florida HEN 2.0 Baseline: 7.5 (53 hospitals) Florida HEN 2.0 Apr‐June 2016: 5.7 (54 hospitals)

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ADEs ‐ excessive anticoagulation

Baseline Oct‐16 Nov‐16 Dec‐16 FL Rate 2.5 2.0 2.3 2.2 HRET HIIN Rate 3.4 3.3 3.1 3.1 # FL Reporting 52 46 45 43 #HRET HIIN Reporting 1,066 659 636 590 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

Florida HEN 2.0 Baseline: 3.4 (48 hospitals) Florida HEN 2.0 Apr‐June 2016: 1.8 (59 hospitals)

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Reducing Adverse Drug Events

Edna Clifton

Associate Director Care Coordination Health Services Advisory Group (HSAG)

March 7, 2017

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Overview

HSAG is contracted by the Centers for Medicare & Medicaid Services (CMS) to work with healthcare providers to:

  • Improve coordination of care
  • Reduce hospital readmissions
  • Improve medication safety by reducing adverse drug

events (ADEs) for patients in the community

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Readmissions and Medication Safety

HSAG works with hospitals to reduce ADEs.

  • ADEs contribute to readmissions and are the leading

cause of preventable patient harm.1

  • The Department of Health and Human Services (HHS)

identified the following medication classes as high priority medication targets for the National Action Plan for Adverse Drug Event Prevention2 (common, preventable, and measurable ADEs):

– Anticoagulants – Diabetic agents – Opioids

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  • 1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107–16.
  • 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention.

Washington, DC: Author.

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ADEs Contribute to Increased Costs and Negatively Impact Patient Care

Add an additional $3.5 billion in healthcare costs; of this, up to $5.6 million per U.S. hospital.3 Prolong hospital stays by 1.7 to 4.6 days.2 Account for 1/3 of adverse events encountered in hospitals.4

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  • 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention.

Washington, DC: Author.

  • 3. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.
  • 4. U.S. Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

Washington, DC. 2010 November. Report No.: OEI-06-09-00090.

$3.5

BILLION

ADEs

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Emergency Department (ED) Visits for ADEs

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  • 5. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA.

2016;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

Associated with anticoagulants

17.6% of the visits, with 48.8% of cases resulting in hospitalization.5

Associated with diabetic agents

13.3% of the visits, with 38.5% resulting in hospitalization.5

Associated with

  • pioids

6.8% of the visits, with 24.6% resulting in hospitalization.5

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Engaging With Hospitals to Create and Implement ADE Interventions

  • Data reveal that many facilities rank above the

state average for high‐risk readmission rates related to one or more of the three high‐risk medication (HRM) classes:

  • A hospital’s ADE rate is measured by counting

the number of hospital admissions and ED visits related to an ADE from one of the three HRMs.

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anticoagulants diabetic agents

  • pioids
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Florida Medicare Readmissions Within 30 Days Calendar Year 2015

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148,154 Readmissions Within 30 Days 54,512 Readmissions Within 7 Days 16,246 7‐Day Readmissions Were on HRMs

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Florida Medicare Readmissions Within 30 Days—2015 (cont.)

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Of the 54,512 readmissions within 7 days, 16,246 (29.8%) readmissions were for beneficiaries who were on HRMs.

That is almost 3 out of every 10 readmissions!

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Medicare Fee‐For‐Service (FFS) Beneficiaries on HRMs in Florida—2015

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Anticoagulants 5.59% Diabetic Agents 8.07% Opioids 7.75%

Diabetic agents are the most common drug type used, closely followed by opioids agents. Fewer beneficiaries use anticoagulants.

Represents beneficiaries with at least 30‐days supply of drug type. Patients may be included in more than one drug type category.

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ADE Rates Among Medicare FFS Beneficiaries Discharged on HRMs in Florida—2015 (ADEs per 1,000 Discharges)

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Anticoagulant ADEs 48.42 Diabetic Agent ADEs 28.72

Opioid ADEs 5.53

Despite lower frequency of use, patients taking anticoagulants have the highest rate of ADEs per 1,000 discharges among Medicare beneficiaries on HRMs, followed by diabetic agents. Opioids have much lower ADE rates based on claims data.

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30‐Day Readmissions Among Medicare FFS Beneficiaries on HRMs in Florida—2015

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30‐Day All‐Cause Readmission Rate

19.6%

30‐Day HRM Readmission Rate

23.7%

  • Readmissions among beneficiaries on HRMs are

much more frequent than the general population, suggesting ample opportunity for improvement.

  • Percent of 30‐day readmits with an anticoagulant
  • r diabetes agent ADE are much higher than the

percent of readmits with an opioid ADE.

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Factors That Contribute to ADEs

  • Sub‐optimal medication reconciliation
  • Failure to confirm patient’s understanding of

their medication regimen

  • Inappropriate medication use by the patient

and inappropriate prescribing

  • Failure to monitor patient’s therapeutic lab

values, drug treatment outcomes, and patient’s adherence

  • Poor multidisciplinary communication and

polypharmacy

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What You Can Do to Reduce the Incidence of ADEs

  • Target patients who are receiving HRMs

– Medicare claims data is used to focus on medication safety improvement efforts

  • Goal

– Improve medication safety and reduce the incidence of ADEs related to hospital readmissions

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Best Practices to Reduce the Risk of ADEs

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Best Practice Description

Pharmacist‐led medication reconciliation and medication therapy review

Compares active medication orders to all of the current medications that the patient has been taking, identifies and addresses medication related problems (i.e., duplication of therapy, unnecessary medications, inappropriate dosing, drug‐drug interactions)

Bedside delivery of medications prior to discharge

Prevents delay or interruption in medication therapy following discharge, verifies insurance coverage, manages prior authorizations or drug substitutions (i.e., therapeutic equivalent substitutions based on cost, availability, formulary, insurance)

Pharmacist‐led discharge medication counseling

Provides information on proper medication administration, side effects, disease state education

Post‐discharge follow‐up

Reinforces the discharge plan, assesses patient retention of information, addresses patient questions and concerns, assesses medication therapy adherence

Medication therapy management (MTM)

Improves medication use, enhances health care professionals collaboration, enhances communication between patients and their health care team, encourages patient involvement

Comprehensive medication history

Assists with obtaining high quality, complete, and accurate medication history

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Hospital ADE Report

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High‐Risk Medication (HRM) Categories

  • Data sources are Medicare FFS Part A and Part

D claims.

  • Beneficiaries are considered on an HRM if

they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest.

  • Beneficiaries may qualify as being on a HRM

for more than one drug class.

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High‐Risk Medication (HRM) Categories (cont.)

  • Adverse Drug Events (ADEs) are evaluated based on

the beneficiary’s HRM drug classification.

– If a beneficiary is on an opioid and has a claim identified as an ADE related to opioid, this is counted in the numerator. – If a beneficiary is on an opioid and has a claim identified as an ADE related to anticoagulants, this is not counted in the numerator.

  • Missing data points or figures indicate there were no

applicable data for your hospital during the specified time period.

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Readmissions

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Readmissions (cont.)

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Readmissions for HRM Beneficiaries on an Anticoagulant

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Readmissions for HRM Beneficiaries on a Diabetic Agent

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Readmissions for HRM Beneficiaries on an Opioid

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Readmissions by Drug Category

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Overall ED Utilization within 30 Days of Discharge from an IP Visit

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Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Anticoagulant

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Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on a Diabetic Agent

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Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Opioid

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General Utilization by HRM Beneficiaries

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General Utilization by HRM Beneficiaries

  • n Anticoagulants

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General Utilization by HRM Beneficiaries

  • n Diabetic Agents

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General Utilization by HRM Beneficiaries

  • n Opioids

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Anticoagulant ADEs by Prescription

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Drug Class Number

  • f ADEs

Warfarin 838 Direct Factor Xa Inhibitors (New Oral Anticoagulants) 107 Direct Thrombin Inhibitors 42 Heparins and Heparinoid‐Like Agents 27

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ICD‐9 Diagnosis Code Description Count

79092 Abnormal coagulation profile 472 E9342 Anticoagulants causing adverse effect in therapeutic use 255 5789 Hemorrhage of gastrointestinal tract, unspecified 68 59970 Hematuria, unspecified 64 7847 Epistaxis 59 59971 Gross hematuria 44 5693 Hemorrhage of rectum and anus 28 56212 Diverticulosis of colon with hemorrhage 20 4590 Unspecified hemorrhage 20 5781 Blood in stool 19

ICD‐10 Diagnosis Code Description Count

R791 Abnormal coagulation profile 66 T45515A Adverse effect of anticoagulants, initial encounter 50 K922 Gastrointestinal hemorrhage, unspecified 22 R319 Hematuria, unspecified 17 T45511A Poisoning by anticoagulants, accidental (unintentional), initial encounter 13 R040 Epistaxis 12 R310 Gross hematuria 11 K921 Melena 9 R042 Hemoptysis 6 K5521 Angiodysplasia of colon with hemorrhage 4

Anticoagulant ADEs by Diagnosis Code1

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1 Only the top 10 diagnosis codes are shown

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Diabetic Agent ADEs by Prescription

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Drug Class Number of ADEs Insulin 341 Sulfonylureas Dipeptidyl Peptidase‐4 (DPP‐4) Inhibitors Thiazolidinediones Antidiabetic Combination Agents Glucagon‐Like Polypeptide‐1 (GLP‐1) Receptor Agonists 104 26 11 8 4 Meglitinides Biguanides 3 2 Alpha‐Glucosidase Inhibitors 1

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Diabetic Agent ADEs by Diagnosis Code2

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ICD‐9 Diagnosis Code Description Count

25080 Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled 284 25082 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled 63 E9323 Insulins and antidiabetic agents causing adverse effect in therapeutic use 24 25081 Diabetes with other specified manifestations, type I (juvenile type), not stated as uncontrolled 19 79029 Other abnormal glucose 17 2512 Hypoglycemia, unspecified 17 25083 Diabetes with other specified manifestations, type I (juvenile type), uncontrolled 12 9623 Poisoning by insulins and antidiabetic agents 4 2511 Other specified hypoglycemia 1

ICD‐10 Diagnosis Code Description Count

E11649 Type 2 diabetes mellitus with hypoglycemia without coma 62 E1169 Type 2 diabetes mellitus with other specified complication 15 E10649 Type 1 diabetes mellitus with hypoglycemia without coma 7 T38X1A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter 3 T38X5A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter 2 R7309 Other abnormal glucose 1

2 Only the top 10 diagnosis codes are shown

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Opioid ADEs by Prescription

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Drug Class Number of ADEs

Oxycodone 22 Hydrocodone Combinations 14 Morphine 7 Codeine and Codeine Combinations 5 Fentanyl 5 Hydromorphone 5 Methadone 2

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Opioid ADEs by Diagnosis Code3,4

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ICD‐9 Diagnosis Code Description Count

96509 Poisoning by opiates and related narcotics,

  • ther

16 96500 Poisoning by opium (alkaloids), unspecified 14 E9352 Other opiates and related narcotics causing adverse effect in therapeutic use 11 E8502 Accidental poisoning by other opiates and related narcotics 11 E9500 Suicide and self‐inflicted poisoning by analgesics, antipyretics, and antirheumatics 11 496 Chronic airway obstruction, not elsewhere classified 4 78009 Other alteration of consciousness 3 96502 Poisoning by methadone 3 29281 Drug‐induced delirium 3 E9800 Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted 3

ICD‐10 Diagnosis Code Description Count

T40601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter 2 F1123 Opioid dependence with withdrawal 2 T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter 2 T40605A Adverse effect of unspecified narcotics, initial encounter 2 T40602A Poisoning by unspecified narcotics, intentional self‐harm, initial encounter 1 T400X1A Poisoning by opium, accidental (unintentional), initial encounter 1 F1193 Opioid use, unspecified with withdrawal 1 T404X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter 1 T402X5A Adverse effect of other opioids, initial encounter 1 R0681 Apnea, not elsewhere classified 1

3 Only the top 10 diagnosis codes are shown

4 Some opioid ADEs require two diagnosis codes used in combination

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Contact to Obtain Your Hospital Report

Email Nina Rose nrose@HSAG.com

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Questions?

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Thank you!

Edna Clifton

813.865.3579 Cell 813.753.5379 eclifton@hsag.com

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This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No FL‐11SOW‐C.3.6‐02172017‐01