1. Preliminary Report on Inappropriate Medication Use in Elderly Patients in the Practice Partner Research Network (PPRNet) Andrea M. Wessell, PharmD, BCPS, CDE Practice Partner Research Network South Carolina College of Pharmacy Medical University of South Carolina

2. Research Team Steven Ornstein, M.D. Steven Ornstein, M.D. Paul Nietert, Ph.D. Paul Nietert, Ph.D. Ruth Jenkins, M.S. Ruth Jenkins, M.S. Loraine Roylance, B.S. Loraine Roylance, B.S. Lynne Nemeth, R.N., Ph.D. Lynne Nemeth, R.N., Ph.D. Heather Liszka, M.D. Heather Liszka, M.D. Chris Feifer, Dr.P.H. (USC, Los Angeles) Chris Feifer, Dr.P.H. (USC, Los Angeles) Sarah Corley, M.D. (Alexandria, VA) Sarah Corley, M.D. (Alexandria, VA) Andria Thomas, Ph.D. (MCG, Augusta GA) Andria Thomas, Ph.D. (MCG, Augusta GA) Susan Andrews, M.D. (Murfreesboro, TN) Susan Andrews, M.D. (Murfreesboro, TN) Physician Micro Systems, Inc. (Seattle, WA) Physician Micro Systems, Inc. (Seattle, WA) PPRNet Physicians, Nurses, Staff (across U.S.) PPRNet Physicians, Nurses, Staff (across U.S.) MUSC, Charleston, SC

3. Background

4. The Problem Patients > 65 years of age Patients > 65 years of age 12% of the US population 12% of the US population Consume 35% of all prescription medications Consume 35% of all prescription medications 1 in 5 hospital readmissions are due to adverse drug events 1 in 5 hospital readmissions are due to adverse drug events Frailty associated with old age and medication management are Institute of Medicine ‘Priority Areas’ for transforming health care quality Frailty associated with old age and medication management are Institute of Medicine ‘Priority Areas’ for transforming health care quality www.agingstats.gov/chartbook2004/population.html J Am Pharm Assoc 2002;42:847-57. www.iom.edu/report.asp?id=4290

5. Defining Inappropriate Medication Use Beers Criteria 1991, 1992, 1997 Expert Panel 1996 1996 Medical Expenditure Panel Survey Categories Always inappropriate Rarely appropriate Appropriate for some indications but often misused JAMA 2001;286:2823-29.

6. “Always Inappropriate” Medications Barbiturates Barbiturates Flurazepam (Dalmane) Flurazepam (Dalmane) Meprobamate (Miltown, Equanil) Meprobamate (Miltown, Equanil) Chlorpropamide (Diabinese) Chlorpropamide (Diabinese) Meperidine (Demerol) Meperidine (Demerol) Pentazocine (Talwin) Pentazocine (Talwin) Trimethobenzamide (Tigan) Belladonna alkaloids (Donnatal and others) Dicyclomine (Bentyl) Hyoscyamine (Levsin, Levsinex) Propantheline (Pro- Banthine) JAMA 2001;286:2823-29.

7. “Rarely Appropriate” Medications Chlordiazopoxide (Librium) Chlordiazopoxide (Librium) Diazepam (Valium) Diazepam (Valium) Propoxyphene (Darvocet) Propoxyphene (Darvocet) Carisoprodol (Soma) Carisoprodol (Soma) Chlorzoxazone (Paraflex) Chlorzoxazone (Paraflex) Cyclobenzaprine (Flexeril) Cyclobenzaprine (Flexeril) Metaxalone (Skelaxin) Metaxalone (Skelaxin) Methocarbamol (Robaxin) Methocarbamol (Robaxin) JAMA 2001;286:2823-29.

8. National Benchmarks Always inappropriate: 2.6% Always inappropriate: 2.6% Dicyclomine Dicyclomine Hyoscyamine Hyoscyamine Chlorpropamide Chlorpropamide Rarely appropriate: 9.1% Rarely appropriate: 9.1% Propoxyphene Propoxyphene Diazepam Diazepam Cyclobenzaprine Cyclobenzaprine JAMA 2001;286:2823-29. AHRQ 2004 National Healthcare Quality Report, www.qualitytools.ahrq.gov/qualityreport

9. Practice Partner Research Network (PPRNet) Practice-based learning and research organization among primary care users of a common EMR Practice-based learning and research organization among primary care users of a common EMR 101 practices 101 practices 502 clinicians 502 clinicians 37 U.S. States 37 U.S. States

10. Accelerating the Translation of Research into Practice (A-TRIP) in PPRNet Demonstration project evaluating multi-method intervention to help primary care practices adopt multi-component QI and improve ~80 indicators Demonstration project evaluating multi-method intervention to help primary care practices adopt multi-component QI and improve ~80 indicators Funded by AHRQ as part of Partnerships for Quality RFA (Grant 1 U18 HS13716) Funded by AHRQ as part of Partnerships for Quality RFA (Grant 1 U18 HS13716)

11. A-TRIP Interventions Practice Performance Reports Practice Performance Reports Practice Site Visits Practice Site Visits Network Meetings Network Meetings © PPRNet, 2003

12. PPRNet-TRIP Improvement Model Prioritize Performance Prioritize Performance Involve All Staff Involve All Staff Redesign Delivery System Redesign Delivery System Activate Patients Activate Patients Use EMR Tools Use EMR Tools Jt Comm J Qual & Safety, August 2004, 30(8):432-441. © PPRNet, 2003

13. Methods

14. Inclusion Criteria Study timeframe 1/1/2004 and 1/1/2005 Study timeframe 1/1/2004 and 1/1/2005 PPRNet practices with complete diagnosis, lab, medication and vital sign data PPRNet practices with complete diagnosis, lab, medication and vital sign data Active patients > 65 years Active patients > 65 years

15. Outcome Measures Percent of patients > 65 yrs with prescriptions written in the last 30 days and last year Percent of patients > 65 yrs with prescriptions written in the last 30 days and last year Inappropriate medications Inappropriate medications Rarely appropriate medications Rarely appropriate medications Frequency of individual prescriptions within categories Frequency of individual prescriptions within categories

16. Statistical Analysis General linear mixed model, including auto- regressive type 1 error structure, to assess change in the prescribing measures over time General linear mixed model, including auto- regressive type 1 error structure, to assess change in the prescribing measures over time Analyzed at the practice level Analyzed at the practice level

17. Results

18. Eligible Practices 68 PPRNet practices 68 PPRNet practices 47,092 patients > 65 years on 1/1/2004 47,092 patients > 65 years on 1/1/2004 49,285 patients > 65 years on 1/1/2005 49,285 patients > 65 years on 1/1/2005

19. Patients > 65 yrs with an active prescription 1.33% # 1.72% 0.31% # 0.31% 30 days 1 year 2005 2004 2005 2004 9.53% # 9.54% 2.52% # 2.60%Inappropriate Rarely appropriate # # p=not significant

20. Inappropriate Medications (n=2,642)

21. Rarely Appropriate Medications (n=18,704)

22. Conclusions and Discussion

23. Conclusions In this multi-method QI demonstration project, inappropriate and rarely appropriate prescribing in older patients did not change in one year In this multi-method QI demonstration project, inappropriate and rarely appropriate prescribing in older patients did not change in one year Further evaluation of the effectiveness of interventions regarding medication use in this patient population is warranted Further evaluation of the effectiveness of interventions regarding medication use in this patient population is warranted

24. Discussion Explanations for lack of change Explanations for lack of change Disagreement with measures and/or treatment alternatives Disagreement with measures and/or treatment alternatives Adverse outcomes with discontinuation of inappropriate medications Adverse outcomes with discontinuation of inappropriate medications Initial focus on diabetes and cardiovascular disease indicators Initial focus on diabetes and cardiovascular disease indicators One year timeframe One year timeframe

25. Preliminary Report on Inappropriate Medication Use in Elderly Patients in the Practice Partner Research Network (PPRNet) Andrea M. Wessell, PharmD, BCPS, CDE Practice Partner Research Network South Carolina College of Pharmacy Medical University of South Carolina