1. Evaluation of National Drug Use Reviews to Improve Patient Safety in Nursing Homes Becky Briesacher, PhD 1 Rhona Limcangco, MPharm 2 Linda Simoni-Wastila, PhD 1,2 Jalpa Doshi, PhD 3 Jerry Gurwitz, MD 1 1 University of Massachusetts 2 University of Maryland 3 University of Pennsylvania May 2004 Funded by Centers of Medicare and Medicaid Services (CMS)

2. 1 Introduction In July 1999, CMS expanded drug use review protocols of nursing homes [NH] to include 41 inappropriate medications. Largest effort to codify standards of safe medication use in NHs since the 1987 OBRA to reduce antipsychotics. State surveyors and consultant pharmacists must evaluate medication records for: use of inappropriate drugs, adverse medication reactions, or justification if exempted use. For noncompliance, surveyors may cite facility as deficient in care and jeopardize CMS certification status.

3. 2 Background and Study Objective New drug criteria based on 1997 consensus list of risky medications for older adults (Beers criteria); Criteria apply to all adults 65+ and some relate to specific diseases. Highest use of Beers drugs occurs in NHs. (23%-40%). No agreement about best solutions to reduce use. Advocates for policy interventions believe unsafe medication use will continue unabated without drug reviews. Critics argue prescribing habits will naturally decline as new practice patterns omit archaic and offensive drugs. To test if nationally-required drug use reviews reduce exposure to inappropriate medications in NHs.

4. 3 Methods Data 1997-2000 Medicare Current Beneficiary Survey (MCBS), nationally representative dataset of community-dwelling and institutionalized Medicare beneficiaries Overlapping panel samples selected w/stratified probability design (n=12,000) Data contain surveys of health status and medical care linked to Medicare Part A and B claims. Our study linked a restricted file of MCBS LTC medications. LTC medication file contains monthly chart abstracts of MARs. Study sample Medicare beneficiaries in NHs [unweighted n=2,242] and comparator group in Assisted Living Facilities (ALF) [unweighted n=664].

5. 4 Methods Criteria Study created measures for 38 of 41 CMS criteria (3 drugs omitted due to ill-defined disorders such as insomnia) Criteria categorized by consensus classification of justifiable use (Zhan 2001): always avoid (e.g. Barbiturates such as Barbital) rarely appropriate (e.g., Valium), or some acceptable indications (e.g., Amitriptyline). Medical claims/health surveys examined for disease criteria Diabetes, BPH, COPD, GERD/PUD, arrhythmia, or seizure/epilepsy.

6. 5 Methods Analysis Study constructed quarterly observations of medication use Estimated prevalent use and new exposures new drug use is preceded by three months without any use Did not apply CMS protocols for exceptions (e.g., some criteria do not apply if medication given intermittently) Plotted exposure rates in relation to policy implementation (11 quarters prior and 5 quarters post). Compared pre- and post-policy estimates between NHs and ALFs Statistical Approach: descriptive frequencies and multivariate analysis controlling for demographics and health status

7. 6 Table 1. Population Characteristics, 1997 and 2000 Source: MCBS, 1997-2000

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11. 10 Results Descriptive analysis found evidence of general trend toward less Beers criteria prescribing in ALFs and NHs rather than policy impact. Pre-policy and Post-policy prevalence rates: NH 28.8% (95% CI: 27.3-30.3) to 25.6% (CI: 24.1-27.1, p<.05) ALF 22.4% (CI: 19.8-25.0) to 19.0% (CI: 16.7-21.3). Prescriber disfavor did not include disease criteria. Most prescribing in post-period is new use (16.4% in NH vs. 16.6% in ALFs) Multivariate analysis detected no differences in post-policy use of inappropriate drugs between NHs and ALFs.

12. 11 Caveats and Conclusion Cross-over effects possible Post-policy observation may have been too short Study highlights unclear effectiveness of trying to improve patient safety in NH through nationally mandated drug use reviews. Our study is the first to evaluate CMS policy on inappropriate medications. Study is among the first to use MCBS LTC drug files.