Comprehensive Medication Reviews in Long-term Care Facilities: History of Process Implementation and 2015 Results.

BACKGROUND: Since 2013, Part D sponsors have been required to offer comprehensive medication reviews (CMRs) to all beneficiaries enrolled in their medication therapy management (MTM) programs at least annually, including those in long-term care (LTC) settings. Since that time, MTM providers have found that accessing and completing CMRs with beneficiaries is frequently prohibitively complex, since the process often requires a live, face-to-face interactive interview where the beneficiary resides. However, with the migration of the CMR completion rate from a star ratings display measure to an active measure, coupled with the new CMR completion rate cutpoints for 2016, accessing this population for CMR completion has heightened importance. PROGRAM DESCRIPTION: Our proprietary consultant pharmacist (CP) software was programmed in 2012 to produce a cover letter, medication action plan, and personal medication list per CMS standardized format specifications. Using this system, CPs were trained to perform and document CMRs and the interactive interviews. MTM-eligible Part D beneficiaries, identified by several contracted clients as residing in LTC serviced by Omnicare, were provided CMRs and summaries written in CMS standardized format by CPs. Residents with cognitive impairment were identified using 3 data elements in the Minimum Data Set (MDS). OBSERVATIONS: In 2015, 7,935 MTM-eligible beneficiaries were identified as receiving medications from an Omnicare pharmacy. After excluding those who were disenrolled by their prescription drug plans, discharged from the LTC facility, or resided in a LTC facility no longer serviced by Omnicare, 5,593 residents were available for CMR completion. Of these, only 3% refused the CMR offer, and 5,392 CMRs (96%) were completed successfully. Thirty-nine percent of residents had cognitive impairment per MDS assessments; in those instances, CMRs were conducted with someone other than the beneficiary. Based on the CMRs and interactive interviews, 7,527 drug therapy problem recommendations were made to prescribers, about 50% of which resulted in an alteration in therapy, including reductions in polypharmacy and high-risk medications. IMPLICATIONS: The CMR process and written summary in CMS standardized format works effectively for residents in LTC when performed by CPs in the facility, as evidenced by high completion rates and drug therapy problem identification/resolution. Part D plans should further consider using CPs to conduct CMRs in LTC settings. DISCLOSURES: No outside funding supported this research. All authors are employees of Omnicare, a CVS Health Company, and are stockholders of CVS Health. O'Shea and Zarowitz have received research funding (unrelated to the submitted work) from Acadia, AstraZeneca, and Sunovion. The abstract for this article was presented as a research poster at the Academy of Managed Care and Specialty Pharmacy 2016 Annual Meeting; April 21, 2016; San Francisco, California. Study concept and design were contributed by O'Shea and Zarowitz, along with Erwin. O'Shea collected the data, and data interpretation was performed primarily by O'Shea, along with Zarowitz and Erwin. The manuscript was written by O'Shea, along with Zarowitz, and revised primarily by Zarowitz, along with O'Shea and Erwin.

Methotrexate safety improvement in nursing home residents.

OBJECTIVE: Improve the safety of methotrexate use in nursing home residents by reducing methotrexate errors. DESIGN: Concurrent cohort analysis. SETTING: Long term care facilities. PARTICIPANTS: Residents who received methotrexate from January 1, 2007, to December 31, 2009. INTERVENTION: A 3-pronged approach involving modification to dispensing systems and practices, mandatory staff training, and measurement was implemented in June 2008 and monitored through December 2009. Software programming to the pharmacy operating systems occurred forcing a mandatory second clinical review of all methotrexate orders during the pharmacist verification process, before dispensing. Pharmacists were required to call and clarify orders that failed to fulfill prespecified safety criteria before approving the prescription for dispensing. All pharmacists were required to complete a brief, concise, focused, mandatory training program that emphasized the proper use, adverse effects, boxed warnings, appropriate dosing schedules, and new dispensing requirements for methotrexate. MEASUREMENTS: On a daily basis, methotrexate orders from the previous day were summarized and forwarded to a Clinical Intervention Center for analysis and measurement. Prescriptions that triggered preestablished safety concerns were triaged back to their respective pharmacies for verification or modification. The results of the Methotrexate Safety Program were measured by tracking the number of prescriptions filled, number of patients treated, number of sentinel events, and number of safety variances identified. RESULTS: All assigned pharmacists (n = 2293) completed the mandatory training between June and December 2008. In 2009, a total of 369 new employees completed the training. The prescriptions per year and patients treated per year remained comparable, whereas the number of sentinel events decreased from 3 in 2007 and 4 in 2008 to 0 following program implementation. The most prevalent variance was daily dosing of methotrexate when weekly was intended. The measurement process detected and averted 497 variances in 2008 and 693 variances in 2009 that could have resulted in sentinel events. CONCLUSION: Implementation of intensification of dispensing practices, mandatory training, and measurement eradicated sentinel events associated with methotrexate in nursing homes.

Health care expenditures in ulcerative colitis: the perspective of a self-insured employer.

OBJECTIVE: This study was designed to investigate the incidence, prevalence, treatment patterns, disease severity, and direct costs associated with ulcerative colitis (UC) for claimants in health plans offered by a large self-insured employer in the United States. METHODS: Retrospective analysis of medical claims with and without UC identified from a population of approximately 500,000 employees, retirees, and dependents. RESULTS: Costs for UC claimants were more than twice those for the comparator group ($14,486 vs $6158; P < 0.005). Total health care costs for the severe disease cohort were double those of the mild or moderate cohorts ($26,875 vs $12,154 and $12,731), as were inpatient costs ($13,516 vs $3235 and $2244). The annual incremental cost of treating severe disease was $6812 (P < 0.005) compared with mild UC. CONCLUSION: UC is a significant predictor of increased medical costs with severe disease, driven mainly by inpatient costs.

Patterns of cholinesterase-inhibitor use in the nursing home setting: a retrospective analysis.

OBJECTIVE: This study compared dosing and utilization patterns of the cholinesterase inhibitors (ChEIs) donepezil, rivastigmine, and galantamine in the nursing home setting. METHODS: An exploratory, retrospective analysis of prescription claims data from January 1, 2001, to March 31, 2003, was conducted using data from a nationwide network of long-term care facilities in the United States. Nursing home residents with > or =1 new prescription for donepezil, rivastigmine, or galantamine during the index period from June 1, 2001, through March 31, 2002, were identified, and those who received an index prescription for a ChEI >45 days after nursing home admission and remained in the nursing home for > or=1 year after the initiation of ChEI treatment were included in the analysis. Utilization patterns were evaluated based on prescription claims for 1 year after the initiation of therapy. The study end points were the proportions of patients discontinuing or switching ChEI therapy, the proportion reaching an effective daily dose of ChEI therapy, the mean time to effective dose, and the mean daily dosage. RESULTS: : Two thousand eight hundred seventy-three residents of 1417 nursing homes were included in this analysis, of whom 1906 (66.3%) were prescribed donepezil, 507 (17.6%) rivastigmine, and 460 (16.0%) galantamine. The proportion of residents who were prescribed an effective dose at any point during the 1-year study period was significantly greater for donepezil than for rivastigmine or galantamine (99.3%, 72.5%, and 65.1%, respectively; both, P < 0.001). The difference between rivastigmine and galantamine also was statistically significant (P < 0.014). Donepeziltreated residents had a significantly shorter mean time to effective dose than rivastigmine- and galantamine-treated residents (1.5, 76.7, and 99.9 days; P < 0.001). The mean daily dosage of donepezil was above the effective dose throughout the study period, whereas the mean daily dosage was below the effective dose for the first 3 months with rivastigmine and did not approach the effective dose for galantamine until month 12. ChEl therapy was discontinued during the study period by 43.1%, 46.2%, and 47.0% of donepezil-, rivastigmine-, and galantamine-treated residents, respectively. The corresponding proportions of residents switching therapy were 3.3%, 4.7%, and 2.0%. CONCLUSIONS: The results of this study suggest that early effective dosing occurred more often with donepezil than with rivastigmine or galantamine in these nursing home residents. Almost half of residents discontinued donepezil, rivastigmine, or galantamine, whereas rates of switching from one ChEI to another were low.