embedding advanced clinical decision support tool

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2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California

Embedding an Advanced Clinical Decision Support Tool in Long-Term Care Settings to Mitigate Adverse Drug Events

November 5th, 20211:30 – 2:30 PDT

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Meet the Speakers

Jessica A. Growette, RPh, BCGP, CMWA EMTM Community Pharmacist Lead

Jessica’s pharmacy experience includes 20 years of direct patient care in both community and long term care pharmacy settings. Working for a health plan administrator, she wrote the plan’s application for participation in the CMS Enhanced Medication Therapy pilot program and developed the intervention program. She has spent the last four years actively engaging community pharmacies for EMTM participation utilizing MedWise Client Solutions.

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Disclosure - Jessica

• I am an employee of Tabula Rasa HealthCare.• I declare to not have any other real or apparent conflicts of interest or

financial interests with any pharmaceutical manufacturers, medical device company, or in any product or service, including grants, employment, gifts, stock holdings, and honoraria related to the content of this presentation.

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Meet the Speakers

Melissa Metzger, PharmD, BCGP, CMWA EMTM Clinical Pharmacist Manager

Melissa is a Board Certified Geriatric Pharmacist who has been practicing pharmacy for the past 15 years. She has held management roles in both community practice and hospice care settings. For the past 4 years, she has worked as a clinical pharmacist providing enhanced medication therapy management services to patients. In the last year, she has been promoted to manager and actively works as part of the operations team to implement new programs and initiatives utilizing MedWise software at Tabula Rasa HealthCare.

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Disclosure - Melissa



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Meet the Speakers

Pam Lincoln-Giang, PharmD, BCGP, CMWA Sr. Director, Strategic Growth

Pam has spent the past ten years in value-based health care. Previously she was the director of pharmacy for a home-based provider organization where she built out their clinical pharmacy program. She currently serves as the senior director of strategic growth for Tabula Rasa HealthCare where she is tasked with helping ensure the company’s long-term and sustainable growth.

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Disclosure - Pam



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Learning Objectives

1. List factors that contribute to increased risk of adverse drug events (ADEs) in the long-term care (LTC) population

2. Describe the implementation of an advanced clinical decision support tool in the LTC setting

3. Identify opportunities to mitigate the risk of ADEs in LTC patients using a novel decision support tool

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Self Assessment Question 1

According to Gurwitz, et.al, what percentage of adverse drug events (ADEs) in nursing home residents is considered preventable?

A. 22%B. 46%C. 51%D. 68%

Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109:87-94

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ADEs in Long-term Care (LTC)

• On average, LTC residents take 7 to 8 medications per month

• The risk of an ADE increases 7-10% with each additional medication

Coggins MD. Focus on Adverse Drug Events. Today’s Ger Med. 2015;8(6):8

Lown Institute Medication Overload: America’s Other Drug Problem, 4/1/19

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2006 2008 2010 2012 2014 2016 2018 2020 2025 2030

# of

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ions

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ADEs

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ADE Harm Hospital ization s ER Visi ts

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ADEs in Long-term Care (LTC)

• ADEs in nursing homes occur at a rate of almost 10 per 100 resident-months

• An estimated 2 million ADEs occur annually in LTC, with > 10 per average sized center (bed size of 105)

• 1 in 7 LTC residents are hospitalized as a result of an ADE

Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. 2005;118:251-258Doshi JA, Shaffer T, Briesacher BA. National estimates of medication use in nursing homes: findings from the 1997 Medicare current beneficiary survey and the 1996 medical expenditure survey. J Am Geriatr Soc. 2005;53(3):438-443Handler SM, Hanlon JT. Detecting adverse drug events using a nursing home specific trigger tool. Ann Long term Care. 2010;18(5):17-22

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Overall Costs of ADEs

1.3 million ER visits Average cost per visit $1,245

$1.62 billion annually

2 million hospital stays Average cost per stay $9,700

$19.4 billion annually

Caldwell N, Srebotnjak T, Wang T, Hsia R. “How Much Will I Get Charged for This?” Patient Charges for Top Ten Diagnoses in the Emergency Department.PLoS One. 2013;8(2):e55491 Pfunter A, Wier LM, Steiner C. Costs for Hospital Stays in the United States, 2010. HCUP Statistical Brief #146. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

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The Bottom Line

1995 2000 2008 2016

Rx Spending Versus Cost of Illness* 1995-2016(*Drug Related Morbidity and Mortality)

Rx Sp end (b il lio ns) COI (b ill io ns)

$77$101

$251$290

$528

$67 $101$177

$450

For every dollar we spend on prescription medication,we spend more than another dollar trying to address problems caused by the medications.

Watanabe JH, McInnis T, Hirsch JD. Cost of Prescription Drug-Related Morbidity and Mortality. Ann Pharmacother. 2018 Sep;52(9):829-837

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Proactive ADE Risk MitigationRisk Stratification

Medication Reconciliation

Identification of Medication-Related Problems

Recommendations to Lower Risk

Evaluation of Subsequent Impact on Outcomes

Med

icat

ion

Safe

ty R

evie

w

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Decision Support Tool• Allows clinicians to make better informed decisions about patient care

• Creates a risk score to determine the likelihood of having an adverse event

• Utilizes novel science to look at all medications simultaneously and allow the pharmacist to make recommendations to mitigate risk

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A Medication - Based Risk Score

5 domains contribute to risk score

+ Adverse Event Data (FAERS)+ Anticholinergic Burden+ Sedative Burden+ Long QT Syndrome+ Competitive Inhibition

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Competitive Inhibition

• Approximately 80% of medications are metabolized via the CYP450 system

• Substrates of the CYP450 system show various degrees of affinity for CYP450 enzymes

• Simultaneous multi-drug interactions can be predicted

Tannenbaum C, et al. Understanding and preventing drug-drug and drug-gene interactions. Expert Rev Clin Pharmacol. 2014;7:533-44.

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Advanced Medication Science

Assesses the combined risk of a patient’s medications in

aggregate and guides pharmacists and prescribers

toward individualized medication decision support

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Medication Decision Support

Risk Score Risk Factors Matrix Visualization ADE Windrose

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Test Program Design• Three consultant organization participants• Six consultant pharmacists completed training• 10 hours of online process and clinical training modules• 8 hours of live case discussion

• Each pharmacy to complete 20 clinical reviews within 6 months utilizing the medication decision support tool• Feedback from consultant pharmacists obtained through• Online survey through Survey Monkey• Periodic touchpoint meetings• Review session at end of program

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Test Program Activities• Identify patients of concern• Complete medication reconciliation• Utilize medication decision support tool to complete clinical review• Submit recommendations to prescribers for regimen optimization*• Provide optimized medication administration schedule*

*as appropriate

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Patient Case 1VG is a 70yo female who was recently hospitalized for a multi-drug resistant UTI. She presents with:• Alzheimer’s disease with behavioral

disturbance• Congestive heart failure • Stage 2 chronic kidney disease• Gastroesophageal reflux disease • Major depressive disorder • Hypothyroidism

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Patient Case 1 (Cont)

Pertinent Subjective Findings• VG is agitated and experiencing

visual hallucinations• She reports feeling dizzy upon

standing occasionally

Pertinent Objective Findings• Temperature – 98.6◦F • Weight – 70kg• BP – 125/75mmHg• HR – 60bpm• CrCl – 71mL/min• K – 3.3mEq/L (3.5 – 5mEq/L)

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Medication ListAcetaminophen 500mg – 2 tabs PO Q6H PRNAlprazolam 0.5mg – 1 tab PO BIDCarvedilol 6.25mg – 1 tab PO BIDDonepezil 10mg – 1 tab PO QDEscitalopram 10mg – 1 tab PO QDFurosemide 40mg – 1 tab PO QDLevothyroxine 75mcg – 1 tab PO QDMemantine 10mg – 1 tab PO BID

Milk of magnesia 400mg/5ml – 2 TBS PO QD PRNOmeprazole 20mg – 1 cap PO QDOndansetron 4mg ODT –1 tab PO BID PRNOxybutynin ER 10mg – 1 tab PO QDPravastatin 40mg – 1 tab PO QDQuetiapine 50mg – 1 tab PO QHSSenna plus 8.6mg-50mg – 1 tab PO QD PRN

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Patient Case 1 – Risk and Prioritization

1) Pharmacist identifies high risk score of 32/502) Pharmacist identifies contributing risk factors• Aggregated Sedative Burden• Aggregated Anticholinergic Burden• Competitive Inhibition Burden

3) Pharmacist identifies clinically significant drug-drug-interactions that may be exacerbating above risk factors, including:

• Omeprazole vs. escitalopram, alprazolam, oxybutynin and quetiapine

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Patient Case 1 – RecommendationsDiscontinue oxybutynin, if deemed clinically appropriate

• Rationale: Oxybutynin is highly anticholinergic (3/3) and increases this patient’s risk of anticholinergic related side effects such as dry mouth, constipation, confusion and falls

Switch omeprazole to pantoprazole, if deemed clinically appropriate

• Rationale: Omeprazole inhibits CYP2C19, and competitively inhibits CYP3A4 causing increased risk of side effects with escitalopram, alprazolam, oxybutynin, and quetiapine

Discontinue alprazolam, if deemed clinically appropriate

• Rationale: Long term benzodiazepine use is not recommended in geriatric patients as it increases risk of falling, cognitive impairment and delirium

Re-evaluate quetiapine, if deemed clinically appropriate

• Rationale: Quetiapine is highly anticholinergic (3/3) and increases the patient’s risk of anticholinergic related side effects, including death

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Patient Case 2LC is a 65yo male who presents with:• Hypertension• Congestive heart failure • Hyperlipidemia• Gastroesophageal reflux disease• Major depressive disorder• Epilepsy

*Patient case study developed by Dr. Abigail M. Wright, PharmD, MS with LLW Consulting

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Medication List

Acetaminophen 500mg – 2 tabs PO Q8H PRNAmlodipine 10mg – 1 tab PO QDAspirin 81mg – 1 tab PO QDAtorvastatin 40mg – 1 tab PO QDClopidogrel 75mg – 1 tab PO QDFurosemide 20mg – 1 tab PO BIDGabapentin 100mg – 1 cap PO TID

Levetiracetam 500mg – 1 tab PO BIDLoratadine 10mg – 1 tab PO QD PRNMelatonin 10mg – 1 tab PO QDOmeprazole 20mg – 1 cap PO QDOndansetron 4mg – 1 tab PO Q4H PRNSertraline 50mg –1.5 tab PO QDTrazodone 50mg –½ tab PO QHS

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Patient Case 2 – Risk and Prioritization

1) Pharmacist identifies high risk score of 34/502) Pharmacist identifies contributing risk factors• Aggregated Sedative Burden• Competitive Inhibition Burden

3) Pharmacist identifies clinically significant drug-drug-interactions that may be exacerbating above risk factors, including:

• Omeprazole vs. clopidogrel, sertraline and loratadine

• Amlodipine vs. sertraline and loratadine

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Patient Case 2 – RecommendationsSwitch omeprazole to famotidine, if deemed clinically appropriate

• Rationale: Omeprazole inhibits CYP2C19, and competitively inhibits CYP3A4 causing risk for therapeutic failure with clopidogrel, and increased risk of side effects with sertraline and loratadine

Change sertraline time of administration from morning to noon

• Rationale: Sertraline competitively inhibits CYP2B6, CYP2C19 and CYP3A4 causing risk for therapeutic failure with clopidogrel

Switch loratadine to fexofenadine, if deemed clinically appropriate

• Rationale: Amlodipine competitively inhibits CYP3A4 causing increased risk of side effects with loratadine

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Self Assessment Question 2

Which medication does NOT have anticholinergic properties?

A. QuetiapineB. OxybutyninC. DonepezilD. Furosemide

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Test Program Results

• Pharmacists completed 38 medication reviews from all practice sites• They made 2-3 recommendations per review• Risk score decreased almost 7 points on average (50-point scale)

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Problem Summary

Sedative Burden/ Anticholinergic Burden

26.67%

Medication Dosage8%

Competitive Inhibition66.71%

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Recommendation Summary

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Conclusion• The tool is especially helpful for antiepileptics, antidepressants and

psychoactive medications• The matrix and bullseye were the most useful parts of the tool• Integration with consulting software is necessary• Facilitate risk stratification• Import medication list • Consolidate documentation• Incorporate regulatory considerations• Maximize efficiency

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References1. Caldwell N, Srebotnjak T, Wang T, Hsia R. “How Much Will I Get Charged for This?” Patient

Charges for Top Ten Diagnoses in the Emergency Department. PLoS One. 2013;8(2):e55491 2. Coggins MD. Focus on Adverse Drug Events. Today’s Geriatric Medicine. 2015;8(6):83. Doshi JA, Shaffer T, Briesacher BA. National estimates of medication use in nursing homes:

findings from the 1997 Medicare current beneficiary survey and the 1996 medical expenditure survey. J Am Geriatr Soc. 2005;53(3):438-443

4. Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. 2005;118:251-258

5. Handler SM, Hanlon JT. Detecting adverse drug events using a nursing home specific trigger tool. Ann Long term Care. 2010;18(5):17-22

6. Pfunter A, Wier LM, Steiner C. Costs for Hospital Stays in the United States, 2010. HCUP Statistical Brief #146. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

7. Watanabe JH, McInnis T, Hirsch JD. Cost of Prescription Drug-Related Morbidity and Mortality. Ann Pharmacother. 2018 Sep;52(9):829-837

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http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

embedding advanced clinical decision support tool

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