Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment

OBJECTIVES: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. DESIGN: Quasi-experimental, longitudinal study. SETTING: Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. PARTICIPANTS: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). MEASUREMENTS: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. RESULTS: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. CONCLUSION: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.     

Inappropriate Medication Use as a Risk Factor for Self-Reported Adverse Drug Effects in Older Adults

OBJECTIVES: To determine the association between inappropriate medication use and self‐reported adverse drug effects (ADEs). DESIGN: Prospective cohort study with three annual mailed surveys. SETTING: Population‐based sample of Iowa Medicare beneficiaries. PARTICIPANTS: Cohort members (n=626) with established mobility disability and complete pharmacy dispensing records, continuous Medicare eligibility, and survey data. MEASUREMENTS: The number of unique drug ingredients dispensed and inappropriate use were assessed for the year before the ADE survey. Inappropriate medication use was defined according to published criteria: contraindicated drugs for elderly people, drug–disease interactions (constructed from linked Medicare claims), drug–drug interactions, and therapeutic duplications. An ADE was defined from the following question: “In the past 12 months, have you experienced an unwanted effect or side effect of a medication?” RESULTS: Of respondents to the ADE survey, 22.0% reported having experienced an ADE in the past year, and 322 (51.4%) received at least one potential inappropriate medication. Factors associated univariately with ADE self‐report were number of medications, number of mobility limitations, any inappropriate medication use, and each of the individual domain appropriateness indicators, as well as number of different domains of inappropriate use. The adjusted odds ratio for developing an ADE was 2.14 (95% confidence interval=1.26–3.65) for those with inappropriate use versus no inappropriate use. CONCLUSION: Efforts to reduce ADEs by reducing medication inappropriateness should be encouraged as a complement to efforts focused on reducing the number of medications prescribed.     

Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization

BACKGROUND  

Several physician organizations and the Centers for Medicare and Medicaid Services (CMS) support compliance measures for written discharge instructions. CMS has identified clear discharge instructions with specific attention to medication management as a necessary intervention.     

Home‐Based Primary Care: Beyond Extension of the Independence at Home Demonstration

The Independence at Home (IAH) Demonstration Year 2 results confirmed that the first‐year savings were 10 times as great as those of the pioneer accountable care organizations during their initial 2 years. We update projected savings from nationwide conversion of the IAH demonstration, incorporating Year 2 results and improving attribution of IAH‐qualified (IAH‐Q) Medicare beneficiaries to home‐based primary care (HBPC) practices. Applying IAH qualifying criteria to beneficiaries in the Medicare 5% claims file, the effect of expanding HBPC to the 2.4 million IAH‐Q beneficiaries is projected using various growth rates. Total 10‐year system‐wide savings (accounting for IAH implementation but before excluding shared savings) range from $2.6 billion to $27.8 billion, depending on how many beneficiaries receive HBPC on conversion to a Medicare benefit, mix of clinical practice success, and growth rate of IAH practices. Net projected savings to the Centers for Medicare and Medicaid Services (CMS) after routine billing for IAH services and distribution of shared savings ranges from $1.8 billion to $10.9 billion. If aligning IAH with other advanced alternative payment models achieved at least 35% penetration of the eligible population in 10 years, CMS savings would exceed savings with the current IAH design and HBPC growth rate. If the demonstration were simply extended 2 years with a beneficiary cap of 50,000 instead of 15,000 (as currently proposed), CMS would save an additional $46 million. The recent extension of IAH, a promising person‐centered CMS program for managing medically complex and frail elderly adults, offers the chance to evaluate modifications to promote more rapid HBPC growth.     

Adverse drug events resulting from patient errors in older adults

OBJECTIVES: To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors. DESIGN: A subanalysis within a cohort study of Medicare enrollees. SETTING: A large multispecialty group practice. PARTICIPANTS: Thirty thousand Medicare enrollees followed over a 12-month period. MEASUREMENTS: Primary outcomes were ADEs, defined as injuries due to a medication, and potential ADEs, defined as medication errors with the potential to cause an injury. The subset of these events that were related to patient errors was identified. RESULTS: The majority of patient errors leading to adverse events (n=129) occurred in administering the medication (31.8%), modifying the medication regimen (41.9%), or not following clinical advice about medication use (21.7%). Patient-related errors most often involved hypoglycemic medications (28.7%), cardiovascular medications (21.7%), anticoagulants (18.6%), or diuretics (10.1%). Patients with medication errors did not differ from a comparison group in age or sex but were taking more regularly scheduled medications (compared with 0-2 medications, odds ratio (OR) for 3-4 medications=2.0, 95% confidence interval (CI)=0.9-4.2; OR for 5-6 medications=3.1, 95% CI=1.5-7.0; OR for >or=7 medications=3.3, 95% CI=1.5-7.0). The strongest association was with the Charlson Comorbidity Index (compared with a score of 0, OR for a score of 1-2=3.8, 95% CI=2.1-7.0; OR for a score of 3-4=8.6, 95% CI=4.3-17.0; OR for a score of >or=5=15.0, 95% CI=6.5-34.5). CONCLUSION: The medication regimens of older adults present a range of difficulties with the potential for harm. Strategies are needed that specifically address the management of complex drug regimens.     

Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher‐quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value‐based payment programs into a new Merit‐based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90‐day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.     

Variations between clinical trial participants and Medicare beneficiaries in evidence used for Medicare national coverage decisions

BACKGROUND: There is a paucity of data on the adequacy of the resources and tools used by the Centers for Medicaid and Medicare Services (CMS) in making national coverage determinations about services for beneficiaries. The objective of this study was to determine the extent to which clinical trials relied on by the CMS are applicable to Medicare beneficiaries. METHODS: We performed a meta-analysis of data on 40 009 individuals from all 141 trials included in the technology assessments for the 6 cardiovascular disease meetings of the CMS advisory panel and compared them with the demographics of the Medicare population. RESULTS: Medicare beneficiaries differ significantly from the cardiovascular clinical trial participants used to inform Medicare coverage decisions. Clinical trial participants, compared with beneficiaries, are more likely to be younger (60.1 vs 74.7 years), male (75.4% vs 41.8%), and non-US residents (60% vs 0%). The clinical trials, moreover, rarely included outcome stratification by age, sex, and race. CONCLUSIONS: Participants in cardiovascular studies relied on by the CMS for coverage determinations differ substantially from the Medicare population. Data frequently are not available on relevant subgroup populations. Suggestions are made that address the need for data more relevant to Medicare beneficiaries by increasing enrollment of, and reporting on, women and elderly individuals in clinical trials and use of relevant data for coverage decisions.     

Medication Use Quality and Safety in Older Adults: 2019 Update

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.     

Receipt of High Risk Medications among Elderly Enrollees in Medicare Advantage Plans

BACKGROUND

Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage (MA) plans to report prescribing rates of high risk medications (HRM).

OBJECTIVE

To determine predictors of receipt of HRMs, as defined by the National Committee for Quality Assurance’s “Drugs to Avoid in the Elderly” quality indicator, in a national sample of MA enrollees.

DESIGN AND PARTICIPANTS

Retrospective analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data for 6,204,824 enrollees, aged 65 years or older, enrolled in 415 MA plans in 2009. To identify predictors of HRM use, we fit generalized linear models and modeled outcomes on the risk-difference scale.

MAIN OUTCOME MEASURES

Receipt or non-receipt of one or two HRMs.

KEY RESULTS

Approximately 21 % of MA enrollees received at least one HRM and 4.8 % received at least two. In fully adjusted models, females had a 10.6 (95 % CI: 10.0–11.2) higher percentage point rate of receipt than males, and residence in any of the Southern United States divisions was associated with a greater than 10 percentage point higher rate, as compared with the reference New England division. Higher rates were also observed among enrollees with low personal income (6.5 percentage points, 95 % CI: 5.5–7.5), relative to those without low income and those residing in areas in the lowest quintile of socioeconomic status (2.7 points, 95 % CI: 1.9–3.4) relative to persons residing in the highest quintile. Enrollees ≥ 85 years old, black enrollees, and other minority groups were less likely to receive these medications. Over 38 % of MA enrollees residing in the hospital referral region of Albany, Georgia received at least one HRM, a rate four times higher than the referral region with the lowest rate (Mason City, Iowa).

CONCLUSIONS

Use of HRMs among MA enrollees varies widely by geographic region. Persons living in the Southern region of the U.S., whites, women, and persons of low personal income and socioeconomic status are more likely to receive HRMs.     

Elderly patients' preferences and experiences with providers in managing their drug costs

OBJECTIVES: To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.
DESIGN: Cross-sectional survey.
SETTING: A Medicare managed care plan (>400,000 members) in one state in 2002.
PARTICIPANTS: One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.
MEASUREMENTS: Participants' preferences and experiences with providers discussing costs and participation in choosing medications.
RESULTS: Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.
CONCLUSION: Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.     

Centers for Medicare and Medicaid Services’ readmission reports inaccurately describe an institution's decompensated heart failure admissions

Hospitals typically use Center for Medicare and Medicaid Services’ (CMS ) Hospital Readmission Reduction Program (HRRP ) administrative reports as the standard of heart failure (HF ) admission quantification. We aimed to evaluate the HF admission population identified by CMS HRRP definition of HF hospital admissions compared with a clinically based HF definition. We evaluated all hospital admissions at an academic medical center over 16 months in patients with Medicare fee‐for service benefits and age ≥65 years. We compared the CMS HRRP HF definition against an electronic HF identification algorithm. Admissions identified solely by the CMS HF definition were manually reviewed by HF providers. Admissions confirmed with having decompensated HF as the primary problem by manual review or by the HF ID algorithm were deemed “HF positive,” whereas those refuted were “HF negative.” Of the 1672 all‐cause admissions evaluated, 708 (42%) were HF positive. The CMS HF definition identified 440 admissions: sensitivity (54%), specificity (94%), positive predictive value (87%), negative predictive value (74%). The CMS HF definition missed 324 HF admissions because of inclusion/exclusion criteria (15%) and decompensated HF being a secondary diagnosis (85%). The CMS HF definition falsely identified 56 admissions as HF . The most common admission reasons in this cohort included elective pacemaker or defibrillator implantations (n = 13), noncardiac dyspnea (n = 9), left ventricular assist device complications (n = 8), and acute coronary syndrome (n = 6). The CMS HRRP HF report is a poor representation of an institution's HF admissions because of limitations in administrative coding and the HRRP HF report inclusion/exclusion criteria.