Medication Regimen Complexity in Home Health

Care

June 10, 2010CTA site visit

2

Why should regimen complexity matter? Number of medications, dosage frequency,

administration, instructions & prescribed dose all have been linked individually to: Medication adherence Adverse drug events

Nurses typically use the number of medications as an approximation of complexity

The “whole may be greater than the sum of the parts” – complexity may have an “additive” effect on patient outcomes

3

VNSNY Analysis: Research Questions

1. Does the MRCI add to what we already know?

Is it any different from the count of medications?

2. Is the MRCI related to patient outcomes?

Emergency Department use Hospitalizations

4

Analysis: Population Studied

All new admissions to VNSNY’s Adult Acute Care program in 2008 Does not include patient episodes in

Lombardi or Congregate programs Includes all payersAt least one medication at admission

Median = 7 medicationsMedication regimen at admissionTotal patient episodes (N) studied =

89,645

5

Distribution of MRCI at VNSNY

Source: 89,645 new admissions to ADU in 2008. MRCI calculated as of admission entry date.

Scores range from 1.5 to 88.5Median score is 14.5

6

MRCI vs. Count of Medications

MRCI scores are correlated to medication count, as expected

At any given number of medications, MRCI scores vary widely For example, among patients on 7

medications MRCI scores range from 6.5 to 42.0

Average MRCI score is about 15.0

7

MRCI Ranges Widely at any Given Med Count

MRCI is related to medication count, but is not the same

8

Analysis: MRCI and Emergency Dept UseMRCI Decile % with ED visit

1 11.13

2 11.21

3 12.85

… …

8 18.42

9 22.19

10 25.54

Patients with higher MRCI scores are at greater risk for ED use

9

Analysis: MRCI and 60-day Hospitalization

MRCI Decile % with Hospitalization

1 12.72

2 13.34

3 15.24… …

8 21.91

9 25.00

10 28.82Patients with higher MRCI scores are at greater risk for hospitalization

10

Analysis: Does MRCI Predict Hospitalization?

Dependent variable is count of OBQI hospitalizations within 60 days of admission to VNSNY

Compare how MRCI performs vs. medication count Event count modeled using poisson regression

controlling for patient case-mix

Expected count of OBQI

hospitalizations within 60 days of

admission

=

MRCI, medication count, and other

patient characteristics at

start of care

11

Hospitalization Model Case-mix Adjustment

Constructed a priori based on prior work Case-mix at start of care includes:

Integumentary status Diagnosis of chronic disease

Diabetes, CHF, COPD, CVA, PVD, AMI, cancer, arrhythmia, hepatic / renal disease, HTN, Alzheimer’s, organic brain disease, HIV, osteoarthritis, dementia

Admission from inpatient hospital stay

Presence of anti-coagulant in regimen

Demographics (age, sex, region)

Functional status (ADL/IADL dependencies)

Clinical status Dyspnea, intravenous or

oxygen therapy, sensory status, pain, cognitive status, depression

Elimination status

12

Results: MRCI Predicts Hospitalizations

ModelCount

IRRp

MRCI IRR

p

Count of Medications only (Model 1) 1.0540.00

MRCI only (Model 2) 1.024 0.00

Both Count of Medications and MRCI (Model 3)

1.0190.0

81.018 0.00

Test 2 d.f. p value

Likelihood Ratio Test (Model 1 nested in Model 3)

55.64 2 0.00

Both MRCI score and medication count are highly significant predictors of OBQI hospitalizations within 60 days of home health admission Models are fully case-mix adjusted MRCI is a significant predictor after controlling for medication count MRCI is more strongly predictive of hospitalizations than medication count

Together, MRCI & medication count are better predictors of hospitalizations than either one alone

13

Predicted Effect of Changing MRCI Score

Modest reduction in medication complexity has the potential to lower the number of hospitalizations

experienced by home health patients

14

Summary of Analyses

Medication Regimen Complexity can be measured by adapting the MRCI for a home care population

MRCI score is related to, but not the same as, medication count

Higher regimen complexity is related to higher risk of hospitalizations

Reduction of regimen complexity, holding medication count constant, has the potential to reduce hospitalization events