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Transcript of The PILL Clinic: Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA...
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The PILL Clinic:The PILL Clinic:Pharmacologic Pharmacologic
Intervention in Late LifeIntervention in Late LifeMarci Salow, PharmDMarci Salow, PharmD
Juliana Millan, MDJuliana Millan, MD
VA Boston Healthcare System GRECCVA Boston Healthcare System GRECC
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ObjectivesObjectives
Discuss PILL clinic concept and Discuss PILL clinic concept and developmentdevelopment
Provide overview of patient selection and Provide overview of patient selection and assessment strategiesassessment strategies
Review short-term outcomes Review short-term outcomes
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PILL Clinic Concept:PILL Clinic Concept:
Focused & multidisciplinary approach to:Focused & multidisciplinary approach to:
Reducing polypharmacyReducing polypharmacy
Assessing for inappropriate prescribingAssessing for inappropriate prescribing• Reduce risk of ADRsReduce risk of ADRs
Providing patient and provider educationProviding patient and provider education• Assessing patient perceptions about medicationsAssessing patient perceptions about medications
Medication reconciliationMedication reconciliation
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Multi-disciplinary TeamMulti-disciplinary Team
GeriatricianGeriatrician
Geriatric FellowGeriatric Fellow
Pharmacist Pharmacist
Pharmacy residentPharmacy resident
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Why a PILL clinic?Why a PILL clinic?
Gaps in current systemGaps in current system
Potential inappropriate medication usePotential inappropriate medication use
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Why a PILL clinic?Why a PILL clinic?
Non-adherence Non-adherence
PolypharmacyPolypharmacy Increase risk of adverse drug reactions Increase risk of adverse drug reactions
(ADRs)(ADRs) ADRs ~12% of elderly hospital admissionsADRs ~12% of elderly hospital admissions
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Why a PILL clinic?Why a PILL clinic?
Medication Use in the ElderlyMedication Use in the Elderly ~12% of the US population is ~12% of the US population is ≥≥65 years65 years 3 out of 4 are taking prescription 3 out of 4 are taking prescription
medicationmedication 2-6 prescription drugs 2-6 prescription drugs 1-3 over-the-counter products1-3 over-the-counter products
50% of all drugs used in US50% of all drugs used in US
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Complex Medication Management:Complex Medication Management:Contributing FactorsContributing Factors
Pharmacokineticsand
PharmacodynamicsCHANGES
ADVERSE DRUG
REACTIONS
MULTIPLEMedications
Medical conditionsPrescribersPharmacies
GAPS IN CURRENTSYSTEM
NONADHERENCE
COMPLEX MEDICATION
MANAGEMENT
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Patient SelectionPatient Selection
3 criteria for patient selection3 criteria for patient selection
≥≥65 years65 years
≥≥ 14 medications14 medications
≥≥ 1 Beers criteria drug1 Beers criteria drug
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Patient SelectionPatient Selection
992 veterans identified by electronic 992 veterans identified by electronic
medication record auditmedication record audit
*Age range 65 – 95
*Prescribed medications 14 – 31
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PatientPatient selectionselection
661 patients 661 patients 1+ medications from Beers criteria 1+ medications from Beers criteria
66 providers contacted66 providers contacted 22 responses22 responses 11 agreed to have their patients contacted11 agreed to have their patients contacted
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PatientPatient SelectionSelection
Of the 661 patients:Of the 661 patients:
41% - using 2 or more Beers criteria 41% - using 2 or more Beers criteria medicationsmedications
Top DrugsTop Drugs
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meclizine
5% temazepam
5%quinine
8%
fluoxetine
9%
diazepam
14%
iron>BID
12%
amitriptyline
7%
ranitidine BID
10%
diphenhydramine
8%
propoxyphene
9%
oxybutynin
13%
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PatientPatient SelectionSelection
Phone calls to identified patientsPhone calls to identified patients
Clinic scheduleClinic schedule 4 hours / week4 hours / week
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PatientPatient AssessmentAssessment
Pt seen by pharmacist, geriatrician, Pt seen by pharmacist, geriatrician, pharmacy residentpharmacy resident
Survey completed by patientSurvey completed by patient
Brown bag review of medsBrown bag review of meds
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8
33
31
28
0
5
10
15
20
25
30
35
Patient (%)
<10 10 to 15 16 to 20 20 or >
Number of Meds
Prescription Medication
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49
38
3
10
0
5
10
15
20
25
30
35
40
45
50
Patient (%)
0 1 to 2 3 to 5 5 to 10
Number of Meds
OTC Medication Use
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Patient AssessmentPatient Assessment
Medication reconciliationMedication reconciliation Patient educationPatient education Medication optimizationMedication optimization
Changes to therapyChanges to therapy
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PatientPatient SurveySurvey
How many medications do you take?How many medications do you take? How do you take your medications?How do you take your medications? The medications I take include:The medications I take include:
Only prescriptions from VAOnly prescriptions from VA OTC productsOTC products Herbals/vitaminsHerbals/vitamins otherother
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PatientPatient surveysurvey
Which of the following statements apply? Which of the following statements apply? True/FalseTrue/False I take too many medsI take too many meds I take meds too many times during the dayI take meds too many times during the day I am taking medication that doesn’t work for I am taking medication that doesn’t work for
meme I am having side effects.I am having side effects.
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PatientPatient SurveySurvey
I don’t understand the purpose of my meds.I don’t understand the purpose of my meds. I have a problem getting medication from the I have a problem getting medication from the
pharmacypharmacy I forget to take medication.I forget to take medication. I don’t know what meds I should be taking.I don’t know what meds I should be taking. When I feel better/worse, I sometimes stop When I feel better/worse, I sometimes stop
my meds.my meds.
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Medication ReconciliationMedication Reconciliation
1.1. CompareCompare
2.2. ClarifyClarify
3.3. CommunicateCommunicate
4.4. ReconcileReconcile
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Medication ReconciliationMedication Reconciliation
1.1. CompareCompare
Brown Bag ReviewBrown Bag Review Discussion with patient and CaregiverDiscussion with patient and Caregiver Electronic medication recordElectronic medication record
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MedicationMedication ReconciliationReconciliation
2. 2. ClarifyClarify Actual medication Actual medication
patient is takingpatient is taking Including Including
OTC/herbals/ OTC/herbals/ vitaminsvitamins
Non-VA medsNon-VA meds
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CrucialCrucial StepsSteps
3. Communicate & Reconcile3. Communicate & Reconcile
Omissions, inconsistencies, discrepanciesOmissions, inconsistencies, discrepancies
Involve other practitionersInvolve other practitioners
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What was that again?What was that again?
““Medication reconciliation is something that at first glance Medication reconciliation is something that at first glance seems like it should be an easy thing to do……It turns seems like it should be an easy thing to do……It turns out it’s not all that easy.”out it’s not all that easy.”R. Croteau MD, JCAHO Executive Director for Strategic InitiativesR. Croteau MD, JCAHO Executive Director for Strategic Initiatives
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PatientPatient AssessmentAssessment
AnticholinergicAnticholinergic RiskRisk AssessmentAssessment
More susceptible to anticholinergic effectsMore susceptible to anticholinergic effects Central Central
cognitive changescognitive changesmemory impairmentmemory impairmentconfusionconfusion
Peripheral Peripheral dry mouthdry mouthblurred vision blurred vision constipationconstipation
Increased risk of fallsIncreased risk of falls
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Anticholinergic Risk Score
46
13
28
8
0
5
0 5 10 15 20 25 30 35 40 45 50
0
1 to 2
3 to 4
5 to 6
7 to 8
9 to 10
Sco
re
Percentage of Patients
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Medication AssessmentMedication Assessment
Medications Medications IndicationIndication DuplicationDuplication Side effects?Side effects? ARS scoreARS score
Optimizing therapyOptimizing therapy Can any medications be discontinued?Can any medications be discontinued? Can any medications be switched?Can any medications be switched? Risk / benefit analysisRisk / benefit analysis
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ClinicClinic PatientsPatients
39 patient uniques 39 patient uniques
Age range 64-92Age range 64-92
Average age 75Average age 75
MaleMale
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AGE
0
5
10
15
20
25
30
35
40
45
50
64-69 70-74 75-79 80 or >
Age Range
Per
cen
t
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Visit Findings
95
41
2623
15
10 10
36
0
10
20
30
40
50
60
70
80
90
100
1
type
per
cen
tag
e
polypharm duplication Age-Drug untreated disease state
ADR drug with no indication DDI Food-Drug
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Charlson Comborbidity Index
3 to 433%
1 to 241%
08%5 or >
18%
0
1 to 2
3 to 4
5 or >
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InterventionsInterventions
95 total including education, reconciliation, 95 total including education, reconciliation, medication changesmedication changes 14 involving BEERs criteria medications14 involving BEERs criteria medications
~ 3.4 interventions per patient~ 3.4 interventions per patient
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Interventions at Initial Visit
3940
8
13
5
39 39
23
7
0
5
10
15
20
25
30
35
40
45
med
revi
ew
disco
ntinued
med
initi
ated
med
icat
ion
dose a
djust
men
t
switc
hed m
eds
educa
tion
med
rec
sched
uled fo
r f/u
refe
rral
Type
Occ
ura
nce
s
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Discontinued Medications
14
8
2
8
8
0 2 4 6 8 10 12 14 16
Beers criteria med
Benzodiazepine
Quinine
OTC product
Med without indication
Occurances
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Initiated Medications
1
3
2
2
0 0.5 1 1.5 2 2.5 3 3.5
antidepressant
analgesic
anti-gout
bowel regimen
Occurances
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InterventionsInterventions
Patient educationPatient education
Medication chart Medication chart Expiration datingExpiration dating Disease state educationDisease state education Medication counselingMedication counseling
• Example: Inhaler use, max dose acetaminophen,Example: Inhaler use, max dose acetaminophen,
NTG useNTG use
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PatientPatient SurveySurvey ResultsResults
8% identified number of medications correctly8% identified number of medications correctly
78% use a pillbox78% use a pillbox
21% believe they take too many meds21% believe they take too many meds
92% believe they take meds too many times 92% believe they take meds too many times during the dayduring the day
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Patient Survey Results
92
7874
21
12
36
29
0
10
20
30
40
50
60
70
80
90
100
1
Patient Responses
Pa
tie
nt
Pe
rce
nta
ge
too many adm times
pill box
purpose unknow n
believe side effects exist
problem getting meds
too many meds
don't know w hat meds to take
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Patient Survey Results
9
8
6
4
0
1
2
3
4
5
6
7
8
9
10
1
Patient Responses
Pa
tie
nt
Pe
rce
nta
ge
stop med if feelworse
ID meds correctly
stop med if feelbetter
forget to take meds
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WhatWhat we’vewe’ve learnedlearned soso far…far…
High numbers of patients do not know High numbers of patients do not know what medications they take and why.what medications they take and why.
Frequency of dosing is of concern to Frequency of dosing is of concern to patients and pill burden is less of a patients and pill burden is less of a concern.concern.
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WhatWhat we’vewe’ve learnedlearned soso far….far….
Providers need more educationProviders need more education ? Reluctant to refer? Reluctant to refer
Patients need more educationPatients need more education Patients eager to talk about their meds and Patients eager to talk about their meds and
make changesmake changes
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FutureFuture DirectionsDirections
Aggressive recruitment of patientsAggressive recruitment of patients Further data analysis Further data analysis
Correlations or patterns?Correlations or patterns? Follow-up review of patients at 1 yearFollow-up review of patients at 1 year
Patient satisfaction surveyPatient satisfaction survey
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Questions??Questions??
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ReferencesReferences
1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-11.1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-11.2. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. JAMA. 1997;277:301-6.2. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. JAMA. 1997;277:301-6.3. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA.1998;3. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA.1998; 279: 1200-5.279: 1200-5.4. Physicians Insurers Association of America. Medication Error Study. June 1993.4. Physicians Insurers Association of America. Medication Error Study. June 1993.5. 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