Presentation is loading. Please wait.

Presentation is loading. Please wait.

The PILL Clinic: Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC.

Similar presentations


Presentation on theme: "The PILL Clinic: Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC."— Presentation transcript:

1 The PILL Clinic: Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC

2 Objectives Discuss PILL clinic concept and development Discuss PILL clinic concept and development Provide overview of patient selection and assessment strategies Provide overview of patient selection and assessment strategies Review short-term outcomes Review short-term outcomes

3 PILL Clinic Concept: Focused & multidisciplinary approach to: Focused & multidisciplinary approach to: Reducing polypharmacy Reducing polypharmacy Assessing for inappropriate prescribing Assessing for inappropriate prescribing Reduce risk of ADRsReduce risk of ADRs Providing patient and provider education Providing patient and provider education Assessing patient perceptions about medicationsAssessing patient perceptions about medications Medication reconciliation Medication reconciliation

4 Multi-disciplinary Team Geriatrician Geriatric Fellow Pharmacist Pharmacy resident

5 Why a PILL clinic? Gaps in current system Gaps in current system Potential inappropriate medication use Potential inappropriate medication use

6 Why a PILL clinic? Non-adherence Non-adherence Polypharmacy Polypharmacy Increase risk of adverse drug reactions (ADRs) Increase risk of adverse drug reactions (ADRs) ADRs ~12% of elderly hospital admissions ADRs ~12% of elderly hospital admissions

7 Why a PILL clinic? Medication Use in the Elderly ~12% of the US population is 65 years ~12% of the US population is 65 years 3 out of 4 are taking prescription medication 3 out of 4 are taking prescription medication 2-6 prescription drugs 2-6 prescription drugs 1-3 over-the-counter products 1-3 over-the-counter products 50% of all drugs used in US 50% of all drugs used in US

8 Complex Medication Management: Contributing Factors COMPLEX MEDICATION MANAGEMENT Pharmacokinetics and Pharmacodynamics CHANGES ADVERSE DRUG REACTIONS MULTIPLE Medications Medical conditions Prescribers Pharmacies GAPS IN CURRENT SYSTEM NON ADHERENCE

9 Patient Selection 3 criteria for patient selection 65 years65 years 14 medications 14 medications 1 Beers criteria drug 1 Beers criteria drug

10 Patient Selection 992 veterans identified by electronic medication record audit *Age range65 – 95 *Prescribed medications14 – 31

11 Patient selection 661 patients 661 patients 1+ medications from Beers criteria 1+ medications from Beers criteria 66 providers contacted 66 providers contacted 22 responses 22 responses 11 agreed to have their patients contacted 11 agreed to have their patients contacted

12 Patient Selection Of the 661 patients: 41% - using 2 or more Beers criteria medications 41% - using 2 or more Beers criteria medications Top Drugs Top Drugs

13

14

15

16 Patient Selection Phone calls to identified patients Phone calls to identified patients Clinic schedule Clinic schedule 4 hours / week 4 hours / week

17 Patient Assessment Pt seen by pharmacist, geriatrician, pharmacy resident Pt seen by pharmacist, geriatrician, pharmacy resident Survey completed by patient Survey completed by patient Brown bag review of meds Brown bag review of meds

18

19

20 Patient Assessment Medication reconciliation Medication reconciliation Patient education Patient education Medication optimization Medication optimization Changes to therapy Changes to therapy

21 Patient Survey 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 VA Only prescriptions from VA OTC products OTC products Herbals/vitamins Herbals/vitamins other other

22 Patient survey Which of the following statements apply? True/False Which of the following statements apply? True/False I take too many meds I take too many meds I take meds too many times during the day I take meds too many times during the day I am taking medication that doesnt work for me I am taking medication that doesnt work for me I am having side effects. I am having side effects.

23 Patient Survey I dont understand the purpose of my meds. I dont understand the purpose of my meds. I have a problem getting medication from the pharmacy I have a problem getting medication from the pharmacy I forget to take medication. I forget to take medication. I dont know what meds I should be taking. I dont know what meds I should be taking. When I feel better/worse, I sometimes stop my meds. When I feel better/worse, I sometimes stop my meds.

24 Medication Reconciliation 1. Compare 2. Clarify 3. Communicate 4. Reconcile

25 Medication Reconciliation 1. Compare Brown Bag Review Brown Bag Review Discussion with patient and Caregiver Discussion with patient and Caregiver Electronic medication record Electronic medication record

26 Medication Reconciliation 2. Clarify Actual medication patient is taking Including OTC/herbals/ vitamins Non-VA meds

27 Crucial Steps 3. Communicate & Reconcile Omissions, inconsistencies, discrepancies Omissions, inconsistencies, discrepancies Involve other practitioners Involve other practitioners

28 What was that again? Medication reconciliation is something that at first glance seems like it should be an easy thing to do……It turns out its not all that easy. R. Croteau MD, JCAHO Executive Director for Strategic Initiatives

29 Patient Assessment Anticholinergic Risk Assessment More susceptible to anticholinergic effects More susceptible to anticholinergic effects Central Central cognitive changes memory impairment confusion Peripheral Peripheral dry mouth blurred vision constipation Increased risk of falls Increased risk of falls

30

31 Medication Assessment Medications Medications Indication Indication Duplication Duplication Side effects? Side effects? ARS score ARS score Optimizing therapy Optimizing therapy Can any medications be discontinued? Can any medications be discontinued? Can any medications be switched? Can any medications be switched? Risk / benefit analysis Risk / benefit analysis

32 Clinic Patients 39 patient uniques 39 patient uniques Age range Age range Average age 75 Average age 75 Male Male

33

34

35

36 Interventions 95 total including education, reconciliation, medication changes 95 total including education, reconciliation, medication changes 14 involving BEERs criteria medications 14 involving BEERs criteria medications ~ 3.4 interventions per patient ~ 3.4 interventions per patient

37

38

39

40 Interventions Patient education Patient education Medication chart Medication chart Expiration dating Expiration dating Disease state education Disease state education Medication counseling Medication counseling Example: Inhaler use, max dose acetaminophen,Example: Inhaler use, max dose acetaminophen, NTG use

41 Patient Survey Results 8% identified number of medications correctly 8% identified number of medications correctly 78% use a pillbox 78% use a pillbox 21% believe they take too many meds 21% believe they take too many meds 92% believe they take meds too many times during the day 92% believe they take meds too many times during the day

42

43

44 What weve learned so far… High numbers of patients do not know what medications they take and why. High numbers of patients do not know what medications they take and why. Frequency of dosing is of concern to patients and pill burden is less of a concern. Frequency of dosing is of concern to patients and pill burden is less of a concern.

45 What weve learned so far…. Providers need more education Providers need more education ? Reluctant to refer ? Reluctant to refer Patients need more education Patients need more education Patients eager to talk about their meds and make changes Patients eager to talk about their meds and make changes

46 Future Directions Aggressive recruitment of patients Aggressive recruitment of patients Further data analysis Further data analysis Correlations or patterns? Correlations or patterns? Follow-up review of patients at 1 year Follow-up review of patients at 1 year Patient satisfaction survey Patient satisfaction survey

47 Questions??

48 References 1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277: Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. JAMA. 1997;277: Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA.1998; 279: : Physicians Insurers Association of America. Medication Error Study. June Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and Lancet. 1998;351: Rochon PA, Gurwitz JH. Drug therapy. Lancet. 1995;346: Inga Klarin, Anders Wimo, Johan Fastbom The Association of Inappropriate Drug Use with Hospitalisation and Mortality Drugs Aging 2005; 22(1): Mannesse CK Derkx FH de Ridder MA, Man int Veld A, van der Cammen TJ. Adverse drug reactions in elderly patients as contributing factor for hospital admission: cross sectional study Br Med J 1997;315: admission: cross sectional study Br Med J 1997;315: Mannesse CK Derkx FH de Ridder MA, Man int Veld A, van der Cammen TJ. Contribution of adverse drug reactions to hospital admissions of older patients. Age Ageing 2000; 29:35-9 patients. Age Ageing 2000; 29: Cunningham G, Dodd TRP, Grant DJ, Murdo MET, Richards RME. Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassesement. Age Ageing 1997; 26: prevention and subsequent reassesement. Age Ageing 1997; 26: Schneeweiss S, Hasford J, Gottler M, Hoffmann A, Riethling AK, Avorn J. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol Jul;58(4): Epub 2002 Jun 12. departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol Jul;58(4): Epub 2002 Jun Hugh McGavock Prescription-related illness –a scandalous pandemic. Journal of Evaluation in Clinical Practice, 10, 4, Gandhi TK, Weingart SN, Borus J et al. Adverse drug events in ambulatory care. N Eng J Med 2003; 348: Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004; 164: Simon SR, Chan KA, Soumerai SB et al. Potentially Inappropriate Medication Use by Elderly Persons in U.S. Health Maintenance Organizations, JAGS : JAGS : Higashi T, Shekelle PG, Solomon DH, Knight EL, et al. The quality of pharmacologic care for vulnerable older patients. Division of General Internal Medicine, University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California 90095, USA. Medicine, University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California 90095, USA. 17. Hanlon JT, Schmader KE, Ruby CM Weinberger M Suboptimal Prescribing in Older Inpatients and Outpatients. JAGS : Beers, MH, Baran RW, Frenia K. Drugs and the Elderly, Part I: The problems Facing Managed Care. The American Journal of Managed Care. 2000; Vol No No DArcy PF. Adverse drug reactions and interactions with herbal medicines. Part 1. Adverse reactions. Advers Drug React Toxicol Rev. 1991;10: DArcy PF. Adverse drug reactions and interactions with herbal medicines. Part 2. Adverse reactions. Advers Drug React Toxicol Rev. 1993;12: Chan TY. Monitoring the safety of herbal medicines. Drug Saf. 1997;17: Jaski, ME, Schwartzberg JG, Guttman RA, Noorani M. Medication review and documentation in physi31. Hughes, CM Medication Non-Adherence in the Elderly How Big is the Problem? Drugs Aging 2004; 21(12): the Problem? Drugs Aging 2004; 21(12): Frank E. Enhancing patient outcomes: treatment adherence. J Clin Psychiatry 1997;58 Suppl. 1:11-4


Download ppt "The PILL Clinic: Pharmacologic Intervention in Late Life Marci Salow, PharmD Juliana Millan, MD VA Boston Healthcare System GRECC."

Similar presentations


Ads by Google