Transcript Prescribing Practice

Prescribing Practices
Andrew M. Peterson, PharmD, PhD
Dean, Mayes College of Healthcare
Business and Policy
University of the Sciences
Presentation Format
• Case-based approach
• Topics
– Medication Compliance
– Medication Errors
– Underlying theme
• Identify trends in laws and regulations that can
impact your prescribing practice
• Describe emerging technologies and how they
are influencing the medication use process
Medication Compliance Objectives
• Differentiate among the concepts of
medication adherence, compliance and
persistence
• Identify four predictors of medication
compliance
• Articulate three reasons for medication noncompliance specific to the elderly
• Given a specific case, identify at least two
strategies to improve medication compliance
Medication Compliance
• Non- compliance to medical therapy is a major threat
to public health in the United States
• Non- compliance to prescribed medication costs
nearly 125,000 lives per year.
• 10% of hospital and 23% of nursing home admissions
are linked to compliance.
• $300 billion annually
• 1/3 of all prescriptions NOT picked up
– Non- compliance to pharmacotherapy is estimated
to be 50% overall
• wide ranges reported in the literature for different
disease states (30-70%)
Sources: Noncompliance with Medication Regimens. An Economic Tragedy. Emerging Issues in Pharmaceutical Cost Containing. Washington, DC.
National Pharmaceutical Council. 1992;1-16.; Luscher TF. Vetter W. Adherence to medication. Journal of Human Hypertension. 4 Suppl 1:436, 1990 Feb; McGhan WF, Peterson AM. Pharmacoeconomic impact of patient noncompliance. IMPACT – US Pharmacist. October 2001.
Case Description
Definitions
• Compliance
– the extent to which patients are obedient and
follow the instructions of a health care
professional1
• Adherence
– the extent to which a person’s behavior – taking
medication, following a diet, and/or executing
lifestyle changes corresponds with agreed upon
recommendations from a health care provider2
• Persistence
– how long a patient remains on therapy,
introducing length of treatment as a factor
Sources: 1. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. Boston:
Plenum Press; 1987: 20, 52, 26-29; 2. World Health Organization. Adherence to long term therapies: evidence for
action. 2003. www.who.int/chronic_conditions/adherencereport/en. Viewed Nov 2003.
Measuring Compliance
• Objective Measures
– Direct
• Blood levels
– Indirect
• Pill Counts
– Manual, Electronic
• Pharmacy Refill Data
• Health Outcomes
• Subjective Measures
– Patient self reports
– Practitioner reports
Variables Potentially Related to
Compliance
• Patient variables
– Patient characteristics
– Diagnosis/symptoms/severity
– Knowledge/Health Beliefs
• Treatment variables
– Treatment complexity
– Dosing
– Adverse effects
• Relationship variables
– Inadequate communication/poor rapport
– Method of teaching/environment
– Follow-up/assessment
Adapted from: Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s
Guidebook. Boston: Plenum Press; 1987: 20, 52, 26-29.
Patient Characteristics
• Age1
– Elderly – average compliance is 45%
– Adolescents – 40-60%
– Pediatrics patients (parent as caregiver) – 34-82%
• Sex2,3
Race
– Kidney transplant patients, Dunn et al found that men
were significantly
more noncompliant than women.
Intelligence
– In contrast, Schweizer et al found no significant
differences in compliance due to gender in more than
600 transplant recipients
Education
Sources: 1. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s
Guidebook. Boston: Plenum Press; 1987: 20, 52, 26-29. 2. Dunn J, Golden D, Van Buren CT,
Lewis RM, Lawen J, Kahan BD Causes of graft loss beyond two years in the cyclosporine era.
Transplantation. 1990;49:349-353. 3. Schweizer RT, Rovelli M, Palmeri D, Vossler E, Hull D,
Bartus S. Noncompliance in organ transplant recipients. Transplantation. 1990;49;374-377.
Compliance Rates by Diagnosis
Condition
Reported Rates of noncompliance
Arthritis
55-71%
Asthma
20%
Diabetes
40-50%
Epilepsy
30-50%
Hypertension
40%
Schizophrenia
41%
Source: Noncompliance with Medication Regimens. An Economic Tragedy. Emerging Issues
in Pharmaceutical Cost Containing. Washington, DC. National Pharmaceutical
Council. 1992;1-16.
Health Beliefs and Compliance
• 77% of patients compliant when curing
a disease
• 63% of patients compliant when
preventing a disease
• Over extended periods of time,
compliance rates dropped dramatically
to approximately 50% for either
prevention or cure
Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes NRB,
Taylor DW, Sackett DL, eds. Compliance in Healthcare. Baltimore: Johns Hopkins
University Press; 1979:11-22.
Predictors of Compliance
• Questions to ask your patient
– Do you ever forget to take your medicine?
– Are you careless at times about taking your
medicine?
– When you feel better do you sometimes stop
taking your medicine?
– Sometimes if you feel worse when you take the
medicine, do you stop taking it?
• Moriskey et al:
– 75% with high scores had BP under control at
year 2 (p<0.01)
– α=0.61
Morisky DE. Green LW. Levine DM. Concurrent and predictive validity of a selfreported measure of medication adherence. Medical Care. 1986:24:67-74.
Compliance Predictability by Variable
Variables
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Patient demographics
(age, sex, race, socioeconomic status)
Utility as a
Predictor
Weak
Explanation
Literature lacks consensus
Usefulness depends on
therapeutic area and patient
population
Patient/provider
relationship
Regimen
characteristics
Patient health services
use
Moderate
General consensus in literature
Effect may vary by therapeutic
area and population
Time since initiation
Medication compliance
history
Strong
Always the strongest predictors
and easy to measure
Adapted from Benner J. ISPOR 2007
Factors Affecting Elderly Compliance
• Cognitive Ability
• Prospective Memory Changes
• Functional Literacy
Cognitive Impairment Predicts
Noncompliance
• STUDY
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220 Japanese community dwelling elders
MMSE scores estimated impairment
Pill counts as compliance
Logistic regression to determine predictors of noncompliance
• Variables: Age, sex, eyesight, hearing, number of drugs,
frequency, packaging, medication calendar, drug knowledge
and cognitive ability
• RESULTS
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Average age: 75.7 years
27% MMSE ≤23 (impaired)
34.6% noncompliant
Odds Ratio
• Cognitive Impairment – 2.94 (1.32-6.58)
Okuno et al, 2001 – Eur J Clin Pharmacol
Prospective Memory Changes Affect
Compliance
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Cognitive performance declines with age
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Korten et al, 1997 – Psych Med
Decline not seen in language, visio-spatial ability or
abstract reasoning
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Small et al, 1999 – Neurology
Difficulty with prospective memory increases with
additional tasks
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Martin, 2001 – Int J Behavioral Development
Poor memory performance amplified when
executive function required
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D’Yewalle, 2001 – Am J Psychology
Difficulty still exists even when task was habitual
–
Einstein, 2001 – Psychol Science
Basic Question…
“Did I take it today or do I think
I took it because I have been
for the past x years?”
Compensation for Memory Changes
Omitting/Repeating Doses
• Unintentionally omitting or repeating a
dose
• Small interruptions to routines
– phone call, doorbell
• Larger interruptions to routines
– Shopping, dining out
• Intentionally omitting doses
Compensation for Memory Changes
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Association
Location
Mental Planning
Pain
Physical Reminder
Pill Box
Visibility
Boron JB, et al. Medication adherence strategies in older adults. Proceedings of human
factors and ergonomics society – 50th annual meeting; 2006.
Functional Literacy
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Physical Challenges
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Cognitive Challenges
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Eyesight changes
Manual dexterity
Dose selection
Understanding directions
Drug / disease knowledge
System Challenges
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Readability of pharmacy labels
Dosage form (inhaler, injectable)
Medication Management Skills
Medication Management Skills
• DRUGS (Drug Regimen Unassisted
Grading Scale)
– Identify medication
– Open container
– Remove appropriate dosage
– Demonstrate appropriate timing
• Correlated to medication compliance
Identifying the Medication
Opening the Med and Removing
Appropriate Dosage
Comprehension of Warning Labels
Increase with Literacy Level
Education Level
<6
7-8
>9
59%
67%
84% ‡
6%
50%
78% *
0%
5%
14% *
Data: Davis TC. LSU Health Science Center,
Shreveport, LO.
* p<.0001, ‡ p<.05;
Demonstrating Appropriate Timing
Davis, T. C. et. al. Ann Intern Med 2006;145:887-894
Medication Management Skills
• DRUGS (Drug Regimen Unassisted
Grading Scale)
– Identify medication
– Open container
– Remove appropriate dosage
– Demonstrate appropriate timing
• Correlated to medication compliance
Case Description
Medication Errors Objectives
• Define the nature and significance of
medication errors
• Describe two types of medication errors
and opportunities to improve systems
and prevent errors
• Given a specific case, identify at least
two strategies to prevent a medication
error from occurring
Case Description
Definitions
Error - The failure of a planned action to be
completed as intended or the use of a
wrong plan to achieve the aim
Adverse Event - An injury caused by medical
management rather than the underlying
condition
Preventable Adverse Event - An adverse
event attributable to an error
VHA Medication Safety Report: 2004
Statistics On Medication Errors
• 44,000 to 98,000
Americans die from
medical errors each year
• 7,000 die from medication
errors alone
• 20 to 28% of adverse drug
events are preventable
• Cost per error is $2,013 to
$4,700 per admission
Preventing Medication Errors
• Consumer Actions to
Enhance Medication Safety
• Issues for Discussion with
Patients by Providers
• e-prescribing by 2010
• Drug naming, labeling and
packaging
• Oversight and regulation
Medication Error
• Bates: “Any error occurring in the medication use
process.”
• NCCMERP “Any preventable event that may
cause or lead to inappropriate medication use or
patient harm, while the medication is in the control
of the health care professional, patient, or
consumer.”
– related to professional practice systems including:
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Prescribing/order communication
Product labeling, packaging and nomenclature
Compounding/dispensing/distribution
Administration/education/monitoring and use
High Alert Medications
• High alert drugs are drugs that bear a
heightened risk of causing significant patient
harm when they are used in error. (ISMP.org;
accessed Nov 6, 2009)
• ISMP suggestions to reduce risk:
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improving access to information about these drugs
limiting access to high-alert medications
using auxiliary labels and automated alerts;
standardizing the ordering, storage, preparation,
and administration
– employing redundancies such as automated or
independent double checks when necessary.
High Alert Medications
• Anticoagulants (warfarin, heparin & LMWH)
– Current TJC National Patient Safety Goal
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Chemotherapy
Pediatric medications
Parenteral narcotics (opiates)
Insulin
Magnesium sulfate
Potassium chloride injection concentrate
Neuromuscular blockers
Vasoactive substances
Medication Safety:
Opportunities for Improvement
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Selection and procurement
Storage
Prescribing
Dispensing
Administration / Counseling
Monitoring
System vs Knowledge vs
Competent?
Look-Alike/Sound Alike:
Error Prevention
• Education: Information from the
literature
• Tall Man Lettering:
– NovoLOG and NovoLIN
– oxyCODONE and OxyCONTIN
– ceFAZolin and cefTRIAXONE
– FLUoxetine and DULOXetine.
• Tall Man lettering on medication labels,
shelving labels, medication records, etc.
Drug Administration Technology
• Automated medication cabinets
– Pyxis, OmniCell
– Interfaced with pharmacy profiles
• Pharmacy generated MARs
• Smart pumps
– Drug library with standard concentrations
– Defines soft and hard administration limits
• Bedside barcode administration system
Medication Reconciliation
• Avoid errors such as omission, duplication,
dosing errors or drug interactions
• Each transition of care
• Five steps
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Develop list of previous meds
List of newly prescribed meds
Compare the lists
Respond to differences
New list to care-givers and patient
Ideal Medication Error Prevention
Program
• Addresses all components of the medication use
process
• Uses an interdisciplinary approach to resolving
problems
• Involves all levels of employees, practitioners and
administration
• Identifies and addresses underlying causes
• Supports system improvements, reduces risk, and
improves patient outcomes
Case Description
Key Issues to Remember
• People will make mistakes
• Mistakes are opportunities to learn
where the process is broken
• Effective change requires all
stakeholders’ participation
Conclusion