Unlike Dick the Butcher

Unlike Dick the Butcher

• Unlike Dick the Butcher

• ”The first thing we do, let's kill all the lawyers”
• Not: medications are bad
• Rather, suggesting need for judicious use and continuous re-litigation

Demographics

• Demographics

• Aging and Multimorbidities
• Polypharmacy and ADR’s

• Age-related changes

• Pharmacodynamics (absorption, clearance)
• Body Composition

• What are we doing? Whose standard?

• Bad Drugs: Beer’s List, HEDIS High Risk Meds

• Semper Vigilentes – Med Review as a SOP

Population Explosion

• Population Explosion

• Where we are:
• Over 65 years old: 12.9% of population
• Over 75: 6.1% 18,766,000
• Where we’re going

Compression of Morbidity

• Compression of Morbidity

Large heterogeneity  difficult to find applicable studies

• Large heterogeneity  difficult to find applicable studies

• “No index…prospectively tested and found to be accurate in a large diverse sample…no study was completely free from potential sources of bias. Testing of transportability was limited, raising concerns about overfitting and underfitting. These factors limit a clinician's ability to assess the accuracy of these indices across patient groups that differ according to severity of illness, methodology of data collection, geographic location, and time.”

• The Controversy

• How far can we extrapolate data for this population?
• To what extent can we base clinical practice on biologic plausibility in the absence of clinical trail data?

Over 50% of older adults have 3+ chronic conditions

• Over 50% of older adults have 3+ chronic conditions

• Increased risk of:

• Death
• Institutionalization
• Increased utilization of healthcare resources
• Decreased quality of life
• Higher rates of adverse effects of treatment or interventions

• Almost all existing “guidelines” have single disease focus

• Best approaches to decision-making and clinical management of older adults with multimorbidity remain unclear

Difficult to define a uniform threshold for treatment complexity and feasibility

• Difficult to define a uniform threshold for treatment complexity and feasibility

• Influenced by

• Treatment regimen
• Older adult’s unique characteristics

• Barriers to assessing complexity and feasibility

• Time-consuming
• Lack of necessary training

~100,000 emergency hospitalizations/year due to adverse drug events (ADEs)

• ~100,000 emergency hospitalizations/year due to adverse drug events (ADEs)

• 10.7% of hospital admissions in older adults

• “If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the US!”

Absorption

• Absorption

• Other drugs, nutrition, gastric emptying

• Distribution

• ↑adipose/↓lean, water

• Binding/Localization

• ↓albumin

• Biotransformation

• ↓Hepatic Clearance (some drugs), great variability

• Elimination

• ↓GFR

Less stringent control reasonable in those with a long history of diabetes, limited life expectancy, or comorbid conditions

• Less stringent control reasonable in those with a long history of diabetes, limited life expectancy, or comorbid conditions

Hematologic

• Hematologic

• Endocrine agents

• Cardiovascular agents

• Central Nervous System Agents

• Anti-infective

Influenced by the way risk information is presented to the patient

• Influenced by the way risk information is presented to the patient

• Multimorbidity patients face more preference-based and complex decisions

• Eliciting preferences may make clinical management more time-consuming

Medication Management Capacity

• Medication Management Capacity

• Drug Regimen Unassisted Grading Scale (DRUGS)
• Edelberg HK, Shallenberger E, Wei JY. Medication management capacity in highly functioning community-living older adults: detection of early deficits. J Am Geriatr Soc. 1999 May;47(5):592-6.
• Hopkins Medication Schedule (HMS)
• Carlson MC, Fried, LP, Xue QL, et al. Validation of the Hopkins Medication Schedule to Identify Difficulties in Taking Medications Journal of Gerontology: Feb 2005;60A,2: Health Module 217-223
• Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE)
• Orwig D, Brandt N, Gruber-Baldini, A. Medication Management Assessment for Older Adults in the Community. The Gerontologist 2006;46:661-668

Methods to Look at Inappropriate Prescribing e.g.:

• Methods to Look at Inappropriate Prescribing e.g.:

• American Geriatrics Society 2012 Beer’s Criteria
• STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions)
• START (Screening Tool to Alert doctors to the Right Treatment)
• Clinical Judgment

Original 1991 – Nursing home pts

• Original 1991 – Nursing home pts

• Updates

• 1997: All elderly; adopted by CMS in 1999 for nursing home regulation
• 2003: Era of generalization to Med D, then NCQA, HEDIS
• 2012: Further adoption into quality measures

Specific aim – update 2003 Beers Criteria using a comprehensive, systematic review and grading of evidence

• Specific aim – update 2003 Beers Criteria using a comprehensive, systematic review and grading of evidence

• Strategy:

• Incorporate new evidence

• Grade the evidence

• Use an interdisciplinary panel

• Incorporate exceptions

Framework

• Framework

• Expert panel

• 11 members

• IOM 2011 report on guideline development

• Includes a period for public comment

• Literature search

Co-chairs

• Co-chairs

• Donna Fick, PhD
• Todd Semla, MS, PharmD

• Panelists (voting)

• Judith Beizer, PharmD
• Nicole Brandt, PharmD
• Catherine DuBeau, MD
• Nina Flanagan, CRNP,CS-BC
• Joseph Hanlon, PharmD, MS
• Peter Hollmann, MD
• Sunny Linnebur, PharmD
• Stinderpal Sandhu, MD
• Michael Steinman, MD

Literature search: ADE, inappropriate drug use, med errors, polypharmacy x age/human/English

• Literature search: ADE, inappropriate drug use, med errors, polypharmacy x age/human/English

Survey to panel to rate (strong agreestrong disagree)

• Survey to panel to rate (strong agreestrong disagree)

• 2003 Beers meds
• New additions

• Ratings tallied, shared with panel, 2 rounds of consensus

• In-person: review survey draft and lit search

• 4 groups reviewed lit, selected citations

• Evidence tables prepared, rated quality of evidence and strength of recommendation

• Final group consensus

Quality

• Quality

• High Evidence

• Consistent results from well-designed, well-conducted studies that directly assess effects on health outcomes (2 consistent, higher-quality RCTs or multiple, consistent observational studies with no significant methodological flaws showing large effects)

• Moderate Evidence

• Sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies, generalizability, indirect nature of the evidence on health outcomes (1 higher-quality trial with > 100 participants; 2 higher-quality trials with some inconsistency, or 2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence

• Low Evidence

• Insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies; important flaws in design or conduct, gaps in the chain of evidence
• Or lack of information on important health outcomes

Strength of recommendation

• Strength of recommendation

• Strong:

• Benefits clearly > risks and burden OR risks and burden clearly > benefits

• Weak:

• Benefits finely balanced with risks and burden

• Insufficient:

• Insufficient evidence to determine net benefits or risks

• Continuous arrivals of new drugs on the market1

• Older formulations unavailable in European formularies2

• Only 12-21% of the medications identified are being used by older adults3

• Tangible benefit to patients in terms of clinical outcomes2

Table 2: Medications or medication classes that should be avoided in persons 65 years or older

• Table 2: Medications or medication classes that should be avoided in persons 65 years or older

• Table 3: Medications that should not be used in older person known to have specific medical diseases or conditions.

• Table 4: Medications that should be used with caution

A total of 53 medications or medication classes, which are divided into three tables.

• A total of 53 medications or medication classes, which are divided into three tables.

• Constructed and organized by:

• major therapeutic classes and
• organ systems

34 potentially inappropriate medications/classes to avoid in older adults independent of diagnoses or conditions.

• 34 potentially inappropriate medications/classes to avoid in older adults independent of diagnoses or conditions.
• Notable mentions:
• Sliding Scale Insulin
• Antipsychotics for Behavioral Health issues associated with dementia
• Non benzodiazepine Hypnotics
• Megestrol

Older adults often under-represented in drug trials potentially underestimating medication related problems/evidence grading.

• Older adults often under-represented in drug trials potentially underestimating medication related problems/evidence grading.

• Does not comprehensively address the needs of palliative and hospice care patients

• Does not address other types of potential potentially inappropriate medications

• e.g.:
• dosing of primarily renally eliminated medications,
• drug-drug- interactions

This is just one tool that can be utilized to optimize medication management in older adults.

• This is just one tool that can be utilized to optimize medication management in older adults.

• Need to make sure the Beers list is used in a patient centered manner

For the Health Professional

• For the Health Professional

• Downloadable pocket card

• Evidence tables with links to supporting references

• Beers app – AGS iGeriatrics

• For the Layperson

• Summary in lay language

• Q & A on what to do if one of your drugs is on the Beers list

• Medication diary & tips for safe use of meds

Quality prescribing includes:

• Quality prescribing includes:

• Correct drug for correct diagnosis

• Appropriate dose (label; dose adjustments for co-morbidity, drug-drug interactions)

• Avoiding underuse of potentially important medications (e.g., bisphosphonates for osteoporosis)

• Avoiding overuse (e.g., antibiotics)

• Avoiding potentially inappropriate drugs

• Avoiding withdrawal effects with discontinuation

• Consideration of cost

Quality Metrics

• Quality Metrics

• HEDIS: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2013/HEDIS2013FinalNDCLists.aspx

• Improved patient care

• Decrease liability

Medication Management & Monitoring takes a team!

• Medication Management & Monitoring takes a team!

• It needs to be patient centered.

• Most importantly, monitoring needs to be evaluated on an ongoing basis.

Kataloq: system -> files -> documents -> about acp -> chapters
chapters -> Inferior vena cava syndrome in a patient with giant hepatic hemangiomas
documents -> Quality Standards for Diabetes Care Toolkit
documents -> Aortic Stenosis Decision Paper
documents -> Aortic Stenosis: Feedback template
chapters -> I will not discuss off label use or investigational use in my presentation
documents -> Guidelines for Verifying Death
documents -> Direct Laboratory Notification of Communicable Diseases
documents -> Dermatology Workforce Service Forecast
documents -> Chapter 14: Treatment processes, filtration and adsorption