Transcript Pharmacologic Intervention in Late Life: The PILL Clinic

The PILL Clinic:
Pharmacologic
Intervention in Late Life
Marci Salow, PharmD
Juliana Millan, MD
VA Boston Healthcare System GRECC
Objectives
 Discuss
PILL clinic concept and
development
 Provide
overview of patient selection and
assessment strategies
 Review
short-term outcomes
PILL Clinic Concept:

Focused & multidisciplinary approach to:

Reducing polypharmacy

Assessing for inappropriate prescribing
• Reduce risk of ADRs

Providing patient and provider education
• Assessing patient perceptions about medications

Medication reconciliation
Multi-disciplinary Team
Geriatrician
Geriatric Fellow
Pharmacist
Pharmacy resident
Why a PILL clinic?
 Gaps
in current system
 Potential
inappropriate medication use
Why a PILL clinic?
 Non-adherence
 Polypharmacy


Increase risk of adverse drug reactions
(ADRs)
ADRs ~12% of elderly hospital admissions
Why a PILL clinic?
Medication Use in the Elderly
 ~12% of the US population is ≥65 years
 3 out of 4 are taking prescription
medication


2-6 prescription drugs
1-3 over-the-counter products
 50%
of all drugs used in US
Complex Medication Management:
Contributing Factors
Pharmacokinetics
and
Pharmacodynamics
CHANGES
ADVERSE
DRUG
REACTIONS
NON
ADHERENCE
COMPLEX
MEDICATION
MANAGEMENT
GAPS IN
CURRENT
SYSTEM
MULTIPLE
Medications
Medical conditions
Prescribers
Pharmacies
Patient Selection
3 criteria for patient selection

≥65 years

≥ 14 medications

≥ 1 Beers criteria drug
Patient Selection
992 veterans identified by electronic
medication record audit
*Age range
*Prescribed medications
65 – 95
14 – 31
Patient selection
 661

1+ medications from Beers criteria
 66


patients
providers contacted
22 responses
11 agreed to have their patients contacted
Patient Selection
Of the 661 patients:
 41%
- using 2 or more Beers criteria
medications
 Top
Drugs
oxybutynin
13%
m eclizine
5%
propoxyphene
9%
tem azepam
5%
quinine
8%
fluoxetine
9%
diphenhydram ine
8%
diazepam
14%
ranitidine BID
10%
am itriptyline
7%
iron>BID
12%
Patient Selection
 Phone
 Clinic

calls to identified patients
schedule
4 hours / week
Patient Assessment
 Pt
seen by pharmacist, geriatrician,
pharmacy resident
 Survey
 Brown
completed by patient
bag review of meds
Prescription Medication
33
35
31
28
30
25
20
Patient (%)
15
8
10
5
0
<10
10 to 15
16 to 20
Number of Meds
20 or >
OTC Medication Use
49
50
45
38
40
35
30
Patient (% )
25
20
15
10
10
3
5
0
0
1 to 2
3 to 5
Number of Meds
5 to 10
Patient Assessment
 Medication
reconciliation
 Patient education
 Medication optimization

Changes to therapy
Patient Survey
 How
many medications do you take?
 How do you take your medications?
 The medications I take include:




Only prescriptions from VA
OTC products
Herbals/vitamins
other
Patient survey
 Which
of the following statements apply?
True/False




I take too many meds
I take meds too many times during the day
I am taking medication that doesn’t work for
me
I am having side effects.
Patient Survey





I don’t understand the purpose of my meds.
I have a problem getting medication from the
pharmacy
I forget to take medication.
I don’t know what meds I should be taking.
When I feel better/worse, I sometimes stop
my meds.
Medication Reconciliation
1.
2.
3.
4.
Compare
Clarify
Communicate
Reconcile
Medication Reconciliation
1.
Compare



Brown Bag Review
Discussion with patient and Caregiver
Electronic medication record
Medication Reconciliation
2. Clarify



Actual medication
patient is taking
Including
OTC/herbals/
vitamins
Non-VA meds
Crucial Steps
3. Communicate & Reconcile

Omissions, inconsistencies, discrepancies

Involve other practitioners
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 it’s not all that easy.”
R. Croteau MD, JCAHO Executive Director for Strategic Initiatives
Patient Assessment
Anticholinergic Risk Assessment




More susceptible to anticholinergic effects
Central
cognitive changes
memory impairment
confusion
Peripheral
dry mouth
blurred vision
constipation
Increased risk of falls
Anticholinergic Risk Score
9 to 10
7 to 8
5
0
5 to 6
Score
8
3 to 4
28
1 to 2
13
0
46
0
5
10
15
20
25
30
Percentage of Patients
35
40
45
50
Medication Assessment

Medications





Indication
Duplication
Side effects?
ARS score
Optimizing therapy



Can any medications be discontinued?
Can any medications be switched?
Risk / benefit analysis
Clinic Patients

39 patient uniques

Age range 64-92

Average age 75

Male
AGE
50
45
40
Percent
35
30
25
20
15
10
5
0
64-69
70-74
75-79
Age Range
80 or >
Visit Findings
100
95
90
80
percentage
70
60
50
41
40
36
30
26
23
20
15
10
10
10
0
1
type
polypharm
duplication
Age-Drug
untreated disease state
ADR
drug with no indication
DDI
Food-Drug
Charlson Comborbidity Index
5 or >
18%
0
1 to 2
3 to 4
5 or >
0
8%
1 to 2
41%
3 to 4
33%
Interventions
 95
total including education, reconciliation,
medication changes

~
14 involving BEERs criteria medications
3.4 interventions per patient
Type
sc
he
du
f/u
25
re
fe
rr
al
fo
r
re
c
39
le
d
ed
40
m
ed
s
ca
tio
n
m
ed
u
itc
he
d
en
t
15
sw
ad
ju
st
m
n
ed
ed
ic
at
io
m
10
se
m
ed
re
vi
ew
39
do
in
iti
at
ed
tin
u
ed
Occurances
40
di
sc
on
m
Interventions at Initial Visit
45
39
35
30
23
20
13
8
5
7
5
0
Discontinued Medications
Med without indication
8
OTC product
8
Quinine
2
Benzodiazepine
8
Beers criteria med
14
0
2
4
6
8
Occurances
10
12
14
16
Initiated Medications
bowel regimen
2
anti-gout
2
analgesic
3
antidepressant
1
0
0.5
1
1.5
2
Occurances
2.5
3
3.5
Interventions
 Patient




education
Medication chart
Expiration dating
Disease state education
Medication counseling
• Example: Inhaler use, max dose acetaminophen,
NTG use
Patient Survey Results

8% identified number of medications correctly

78% use a pillbox

21% believe they take too many meds

92% believe they take meds too many times
during the day
Patient Survey Results
100
92
90
Patient Percentage
80
78
74
too many adm times
70
pill box
60
purpose unknow n
50
40
believe side effects exist
36
problem getting meds
29
30
too many meds
21
20
12
10
0
1
Patient Responses
don't know w hat meds to take
Patient Survey Results
10
9
9
stop m ed if feel
w orse
8
Patient Percentage
8
7
ID m eds correctly
6
6
5
4
stop m ed if feel
better
4
forget to take m eds
3
2
1
0
1
Patient Responses
What we’ve learned so far…
 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.
What we’ve learned so far….
 Providers

? Reluctant to refer
 Patients

need more education
need more education
Patients eager to talk about their meds and
make changes
Future Directions
 Aggressive
recruitment of patients
 Further data analysis


Correlations or patterns?
Follow-up review of patients at 1 year
 Patient
satisfaction survey
Questions??
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