SAN FRANCISCO COUNTY: IMPROVING THE SAFETY OF SEDATIVE-HYPNOTIC PRESCRIBINGMichelle Geier, PharmD

Psychiatric and Substance Use Disorders Clinical Pharmacist

Behavioral Health Services, San Francisco Health Network

DISCLOSURES

The presenter has no conflicts of interest

CREATING A PERFORMANCE IMPROVEMENT PROJECT

JAN 2014: BHS DECIDED TO TAKE ON SAFER SEDATIVE-HYPNOTICS AS A PERFORMANCE IMPROVEMENT PROJECT

Large population effected The potential for unsafe sedative-hypnotics prescribing exists for all

BHS consumers

Increased patient safety

Consistent with the Wellness and Recovery Model Cognitive dysfunction and impaired memory are barriers for client’s

wellness and recovery

Consumer demand Consumers request both providers and clients receive more

education on sedative-hypnotics

UNSAFE SEDATIVE-HYPNOTIC

RX

PATIENTS

Benzodiazepine use disorder

Lack of education re: risks

Attachment/preference to

current regimen

EQUIPMENT

Medical record not integrated across

system

Cumbersome to obtain CURES

access

PROCEDURES

Poor coordination between care

settings

Poor documentation of rationale for

ongoing usePOLICIES

No policy requiring risk assessment

No policy requiring

documentation for ongoing use

PRESCRIBERS

Policy may limit appropriate treatment

Inherited patient on regimen

NON-MEDICAL PROVIDERS

Lack of commitment

or experience with non-

pharmacologic treatment

Home environment not conducive for

sleepLack of education

re: risks

Lack of support for non-

pharmacologic treatment

UNSAFE SEDATIVE-HYPNOTIC PRESCRIBING ROOT CAUSE ANALYSIS

STUDY QUESTION

If we formulate and implement Safer Prescribing of Sedative-Hypnotic Guidelines, then we will reduce the long-term use of sedative-hypnotics?

STUDY POPULATION

Includes all adults (18+) with billed services in the BHS electronic health record Total of 11,921 clients in 2012-2013 Did not include <18 years – sedative-hypnotics accounted for <1%

of total number of prescriptions in this group in FY 2013-2014 Excluded clients who only receive services in locations where they

do not use the BHS prescribing software Excluded inpatient, crisis stabilization, long-term care, private provider

network

Also Evaluated High Risk Subpopulations: Older adults (age 60+): 2752 clients Methadone maintenance: 542 clients

STUDY INDICATOR

Indicator: Number of chronic (≥60 days) prescriptions during a quarter for sedative-hypnotics Reasoning:

Decreasing sedative-hypnotic use could improve health status and functional status of our clients

Sedative-hypnotic prescribing was identified as a problem in our system Did not include short-term use due to treatment guideline

recommendations

Considered number of sedative-hypnotics related deaths Due to low incidence it is difficult to detect change, therefore not

selected

BASELINE DATA FOR BHS – 2012-2013

Q1CY2

012

Q2CY2

012

Q3CY2

012

Q4CY2

012

Q1CY2

013

Q2CY2

013

Q3CY2

013

Q4CY2

013

0%

5%

10%

15%

20%

25%

30%

35%

40%

15.27% 15.16% 15.43% 15.07% 14.71% 15.26% 15.79% 15.89%

14.85%15.64% 15.25% 14.78%

14.03% 14.62%15.80% 15.83%

32.75% 33.33%32.55%

34.09%35.06%

32.20%

34.92% 34.84%

% 18 and Over with SedHyp

% 60 and Over With SedHyp

% 18 and Over on Methadone Maintenance and SedHyp

% o

f Popula

tion P

resc

ribed a

Sedati

ve-H

yptn

oic

Mean = 33.7%

Mean = 15.3%

Mean = 15.1%

BASELINE DATA – 2012-2013

#  Performance Indicator

# Patients with Prescriptions for a Sedative-Hypnotic*

(Numerator)

# Patients with a Billed Mental Health

Service*(Denominator)

Baseline Performance

IndicatorGoal

1 

Percent of clients (age 18+) receiving a sedative-hypnotic

1826 11921 15% 20% reduction from baseline(12%)

2 

Percent of older adult clients (age 60+) receiving a sedative-hypnotic

416 2752 15% 20% reduction from baseline(12%)

3 

Percent of methadone maintenance clients receiving a sedative-hypnotic

183 542 34% 30% reduction from baseline(24%)

* Determined by a mean of the 8 quarters in 2012-2013

IMPLEMENTATION

IMPLEMENTATION CHALLENGES

Technical

Staff

Client

TECHNICAL CHALLENGES

Access to CURES and interpreting CURES reports

Methadone maintenance not on CURES reports

Distributing guideline to staff

Educating staff about the new guideline

Do we have adequate staff to provide non-pharmacologic interventions?

STAFF CHALLENGES

“I’ve been told we have to take you off this medication…by our very mean pharmacist”

Caught in the middle of administrative goals and patient demands

Prescriber hands feeling tied with few pharmacologic options

Difficult to tolerate patient push-back

Time concerns

PATIENT CHALLENGES

Lack of education about risks

Client fears of change

Denial of risk – “This will never happen to me”

“I take my medicine as prescribed”

CLINIC IMPLEMENTATION

CLINIC STAFF AND ADMINISTRATIVE IMPLEMENTATION

Prescriber meeting to discuss cases and peer review Clients taking concomitant opioids or over 60 years Challenging cases Any new, changed, or requested sedative-hypnotic Frequency: every 1 – 4 weeks

Internally auditing and following medication list, doses, and ages for all clients on sedative-hypnotics

PATIENT EDUCATION

Welcome letter for new clients that informs them of Behavioral Health’s status on sedative-hypnotics Safety concerns and long-term treatment is not recommended

Offering EMPOWER handout to those asking about sedative-hypnotics

Sedative-hypnotic patient agreement Reviews risks Sets expectations for both prescriber and patient

Patient education visits with clinical pharmacist to discuss risks and benefits Consistent message across medical team

1 1/2 YEARS OF FOLLOW-UP DATA

PRE- AND POST-IMPLEMENTATION SUMMARY

0%

5%

10%

15%

20%

25%

30%

35%

40%

15.27%

15.16%

15.43% 15.07% 14.71% 15.26%

15.79%

15.89%

14.72%13.93% 13.71%

15.60%

12.64% 12.21%

14.85%

15.64%

15.25%14.78% 14.03% 14.62%

15.80%

15.83%

15.23% 14.67% 14.72%

15.39%13.70% 13.27%

32.75% 33.33%32.55%

34.09%35.06%

32.20%

34.92% 34.84%

31.33%

26.53%

24.68%

26.72%

22.71%

26.18%

% 18 and over on SedHyp

% 60 and over on SedHyp

%18 and over on MM and SedHyp

1. All Medical Staff Meeting Reviewing MMT Death Data2. Registering Medical Staff with CURES3. Form MUIC Subcommittee to Create a Sedative-Hypnotic Guideline

Disseminate and Implement the Sedative-Hypnotic Guideline

Disseminate Guidelineto SFGH psychiatry

BHS PLANS FOR 2015

Continue quarterly measurements and analysis by MUIC

Joint education with primary care and mental health providers

Develop a non-pharmacologic treatment of insomnia toolkit Sleep hygiene patient education handouts

Focus on older adults Patient education materials Assist providers with identifying patients

Shift to non-medication treatments and team approach

QUESTIONS?