Introduction
In July 1999, CMS expanded drug use review protocols of
nursing homes [NH] to include 41 inappropriate medications.
Evaluation of National Drug Use Reviews to
Improve Patient Safety in Nursing Homes
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:
Becky Briesacher, PhD1
Rhona Limcangco, MPharm2
Linda Simoni-Wastila, PhD1,2
Jalpa Doshi, PhD3
Jerry Gurwitz, MD1
1University
of Massachusetts
of Maryland
3University of Pennsylvania
„
use of inappropriate drugs,
„
adverse medication reactions, or
„
justification if exempted use.
2University
For noncompliance, surveyors may cite facility as
deficient in care and jeopardize CMS certification status.
May 2004
Funded by Centers of Medicare and Medicaid Services (CMS)
1
Background and Study Objective
Methods
New drug criteria based on 1997 consensus list of risky
medications for older adults (Beers criteria);
Data
„ Criteria apply to all adults 65+ and some relate to specific diseases.
„ Highest use of Beers drugs occurs in NHs. (23%-40%).
„ 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.
No agreement about best solutions to reduce use.
„ Advocates for policy interventions believe unsafe medication use
will continue unabated without drug reviews.
„ Our study linked a restricted file of MCBS LTC medications. LTC
medication file contains monthly chart abstracts of MARs.
„ Critics argue prescribing habits will naturally decline as new
practice patterns omit “archaic and offensive” drugs.
Study sample
To test if nationally-required drug use reviews reduce
exposure to inappropriate medications in NHs.
„ Medicare beneficiaries in NHs [unweighted n=2,242] and
comparator group in Assisted Living Facilities (ALF)
[unweighted n=664].
2
Methods
3
Methods
Criteria
Analysis
„ Study created measures for 38 of 41 CMS criteria
„ Study constructed quarterly observations of medication use
„ Estimated prevalent use and new exposures
„ (3 drugs omitted due to ill-defined disorders such as insomnia)
„ new drug use is preceded by three months’ without any use
„ Did not apply CMS protocols for exceptions
„ Criteria categorized by consensus classification of
justifiable use (Zhan 2001):
„ (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).
„ always avoid (e.g. Barbiturates such as Barbital)
„ rarely appropriate (e.g., Valium), or
„ some acceptable indications (e.g., Amitriptyline).
„ Compared pre- and post-policy estimates between NHs and ALFs
„ Medical claims/health surveys examined for disease
criteria
„ Statistical Approach: descriptive frequencies and multivariate
analysis controlling for demographics and health status
„ Diabetes, BPH, COPD, GERD/PUD, arrhythmia, or seizure/epilepsy.
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5
1
Figure 1.
to be avoided or rarely appropriate by
medication use always
Fig 1National US estimates of inappropriate
institutional residence, 1997-2000
Table 1. Population Characteristics, 1997 and 2000
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Nursing Home
1997
n=2,026,000
Average age
80.3
73.6
Female (%)
67.7
White race (%)
88.1
Fair-Poor Health (%)
65.8
ALF
NH
n=496,000
n=1,860, 000
n=585, 000
80.5
74.6
ALF
67.1
69.3
68.0
95.5
86.3
94.9
43.5
65.9
41.4
44.6
27.1
24.0
3.2
3.8
23.8
7.1
34.4
16.8
17.8
4.1
2.6
13.5
5.3
42.3
29.6
30.1
5.6
2.6
31.1
8.0
32.0
20.9
15.5
3.4
1.0
17.1
4.2
7.6
7.2
8.9
7.9
Average Monthly
Rx Use
July 1999 CMS Policy Expansion
5
4
Percent Prevalence
NH
Weighted total
Select Conditions (%)
Dementia/Alzheimer’s
Diabetes
Chronic lung disease
BPH
GERD/PUD
Seizure/Epilepsy
Arrhythmia
Assisted Living
2000
Characteristics
3
2
1
0
Q1-1997
Unweighted unique n=928 (1997) n=843 (2000) NH; n=250 (1997) n=289 (2000) ALF
Q2
Q3
Q4
Q1-1998
Q2
Q3
Source: MCBS, 1997-2000
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
7
Figure 2.
National estimates of inappropriate medication use that may have some indications by institutional
residence, 1997-2000
Fig 2
Nursing Homes
Q4
Quarters
6
Figure 3.
National US estimates of innapropriate medication use restricted with specific diagnoses,
by institutional residence, 1997-2000
Fig 3
Assisted Living
Nursing Home
Assisted Living
20
25
July 1999 CMS Policy Expansion
July 1999 CMS Policy Expansion
20
Perce nt Pre va len ce
Percent Prevalence
15
15
10
10
5
5
0
0
Q1-1997
Q2
Q3
Q4
Q1-1998
Q2
Q3
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
Q4
Q1-1997
Q2
Q3
Q4
Q1-1998
Q2
Q3
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
Q4
Quarters
Quarters
8
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Results
Caveats and Conclusion
Descriptive analysis found evidence of general trend toward
less Beers criteria prescribing in ALFs and NHs rather than
policy impact.
•Cross-over effects possible
•Post-policy observation may have been too short
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).
Study highlights unclear effectiveness of trying to improve
patient safety in NH through nationally mandated drug use
reviews.
Prescriber disfavor did not include disease criteria.
Our study is the first to evaluate CMS policy on inappropriate
medications.
Most prescribing in post-period is new use (16.4% in NH vs.
16.6% in ALFs)
Study is among the first to use MCBS LTC drug files.
Multivariate analysis detected no differences in post-policy
use of inappropriate drugs between NHs and ALFs.
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