How Can We Get the Best Medication History?

(1)

How Can We Get

the Best Medication History?

Stephen Shalansky, Pharm.D., FCSHP Pharmacy Department, St. Paul’s Hospital

Faculty of Pharmaceutical Sciences, UBC

(2)

How Are We Doing Now?

(3)

Completeness of Medication Histories Documented by Various Health Care Professionals

Before-Admission Medications

Health Care Number of Number Proportion Number NOT Professional Med Histories of Meds Documented Documented

Reviewed

___________________________________________________________________

Physicians

Staff 29 5.5 ± 3.6 70 ± 24 1.8 ± 2.2

Residents 22 5.6 ± 2.8 69 ± 29 2.1 ± 2.0

Nurses 63 5.0 ± 3.1 74 ± 31 1.6 ± 2.2

Paramedics 21 5.0 ± 2.6 63 ± 27 2.2 ± 1.9

Pharmacists

With PharmaNet 18 7.0 ± 2.8 76 ± 21 1.6 ± 1.4

Without PharmNet 16 5.5 ± 3.0 77 ± 30 1.4 ± 1.6 ___________________________________________________________________

Lo, Shalansky, Menezes. Can J Hosp Pharm 2004;57:32-38

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Class 1: unlikely to cause patient discomfort or clinical deterioration

Class 2: potential to to cause moderate patient discomfort or clinical deterioration Class 3: potential to to cause severe patient discomfort or clinical deterioration

39% of discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration

54% of patients had an unintended discrepancy

(7)

No significant predictors of unintended discrepancies were identified

(8)

(9)

Is PharmaNet the Answer?

Canada Health Infoway Inc. is leading a

national program towards the implementation of :

–Electronic health records

–Electronic drug profile and prescribing systems

(10)

The Accuracy of a

Prescription Claims Database

for Determining Medication Profiles of Heart Failure Patients

Stephen Shalansky, Janice Yim, Linda Jang, Andrew Ignaszewski, Leon Jung, Catherine Clark

Pharmacy Department and Division of Cardiology, St. Paul’s Hospital UBC Faculties of Medicine and Pharmaceutical Sciences

Burrard Pharmacy, Vancouver

UNIVERSITY OF BRITISH COLUMBIA

(11)

PharmaNet

• Records all prescription transactions

processed by community Pharmacies in British Columbia

• Not limited to specific health plans

• Excluded:

– HIV meds

– meds administered in hospital

• Can be accessed by:

• community pharmacists

• Hospital pharmacist

• Emergency room physicians

• Ministry and researchers can apply for data

(12)

PharmaNet Data

Hospital access:

– Generic drug name and strength – Dosage form

– Manufacturer

– Date and quantity dispensed – Dose and directions

– Prescribing physicians

Also available:

– Cost/billing, drug interactions, allergies, medical conditions, clinical notes, pharmacy

demographics, physician demographics, access

info., etc.

(13)

Use of PharmaNet Data

Clinical, research, policy applications:

– Current medication profiles/medication history – Adherence

– Therapeutic duplication – Drug interactions

– Major source of medication use data for epidemiology research

– Ministry-initiated drug use evaluations

(14)

Objectives

To quantify agreement between the PharmaNet database and:

a) A thorough medication history interview

– Current medication profile:

• the number of outpatient prescription medications currently consumed (Primary)

• the types and doses of outpatient prescription medications currently consumed (Secondary)

b) Medication Event Monitoring System (MEMS)

– medication adherence over a 6 month period (Pilot study).

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Results

Demographics of 194 Patients Interviewed

Male 149 (77%)

Age, median (range) 65 (27-94) Recruitment Site

Heart Function Clinic 162 (83%) Pre-Heart Transplant Clinic 19 (10%) Community Pharmacy 13 (7%) CHF class

Class I 41 (21%)

Class II 66 (34%)

Class III 19 (10%)

Class IV 1 (1%)

Unknown 67 (34%)

Prescription meds (mean ± SD) 7.5 ± 2.9

Total number meds reviewed 1457

(17)

Med Profile Discrepancies

Between PharmaNet and Interview

194 Medication Profiles; 1457 meds

All discrepancies

# of patients with a discrepancy 138 (71.1%)

# of discrepancies 353

Discrepancies in # of active meds

# of patients 109 (56.2%)

# of discrepancies 230

Discrepancies in type of meds

# of patients 115 (59.3%)

# of discrepancies 268

Discrepancies in doses of meds

^a

# of patients 64 (33.0%)

# of discrepancies 85

a for medications listed in both PNet and Interview

(18)

Bland-Altman Agreement Plot

Number of Medications Currently Consumed:

PharmaNet versus Interview

Difference:

PNet - Interview

Number of Prescription Meds Currently Consumed

Mean

difference:

-1.0 meds per patient

Limits of agreement:

-4.7 to 2.8

n = 194

(19)

Medication Class Involved in 353 Discrepancies

Diuretics 76 (21.6%)

Beta-blocker 37 (10.5%)

ACE inhibitor 29 (8.2%)

Supplements 26 (7.4%)

Oral anti-diabetics 23 (6.5%)

Other heart medications 48 (13.6%)

Others 114 (32.3%)

(20)

Reasons for Discrepancies

Number and Type of Medications

n = 1457 meds

Med listed on PNet but incorrectly appeared inactive 205 (14.1%)

Overdue for refill by < 7 days 72 (4.9%) Overdue for refill by >7 but < 30 days 69 (4.7%) Overdue for refill by >30 days 64 (4.4%) Med listed on PNet but incorrectly appeared active 40 (2.7%) Med did not appear anywhere on PNet 23 (1.6%)

Note: dosing discrepancies excluded: all medications involved in dosing discrepancies appeared on PharmaNet

(21)

Reasons for Discrepancies

Number and Type of Medications

Reason for Discrepancy N = 268 Discrepancies

Overdue for refill; pt stated will refill soon 40 (15.0%)

Dosing regimen recently changed 39 (14.6)

Unknown 37 (13.9%)

Medication stopped 31 (11.6%)

…reason unknown 16

…because of SE’s 7

…because of med switching 4

…because symptoms resolved 2

…because of other reasons 2

Supply left from previous refill 30 (11.2%)

Hospital provided medication during hospital stay 21 (7.9%) Medication recently restarted / old Rx 18 (6.7%)

Patient stated non-compliance 14 (5.2%)

Sample medication 11 (4.1%)

Taken only when needed 10 (3.7%)

Other known reasons 17 (6.3%)

(22)

Reasons for Discrepancies

Dosing

N = 85 Discrepancies

Side Effects 11 (12.9%)

Medication not working 9 (10.6%) Reason unknown to patient 8 (9.4%) Other known reasons 33 (38.8%)

Not recorded 24 (28.2%)

(23)

Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot

40.00 60.00 80.00 100.00 120.00

-25.00 0.00 25.00 50.00 75.00 100.00 125.00

% Adherence (average of PNet and MEMS) Discrepancy

(PNet – MEMS)

Mean discrepancy 6.8% +/- 23.7%

Limits of agreement:

-40.6% to 54.2%

N = 45

(24)

Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot

40.00 60.00 80.00 100.00 120.00

-25.00 0.00 25.00 50.00 75.00 100.00 125.00

(PNet – MEMS)

MEMS misadventures in red (N=5)

-40.6% to 54.2%

N = 45

(25)

Adherence: PharmaNet versus MEMS Bland-Altman Agreement Plot

40.00 60.00 80.00 100.00 120.00

-25.00 0.00 25.00 50.00 75.00 100.00 125.00

(PNet – MEMS)

-23.1% to 25.5 N = 40

(26)

Conclusions

• 70% of PharmaNet profiles contained some inaccurate or misleading information

regarding current medication consumption

• Most medications currently consumed appeared somewhere on the PharmaNet profile

• It was often difficult to determine which were still active

• At least some doses were inaccurate for a third of patients interviewed

(27)

Conclusions

• Adherence calculated using refill data from PharmaNet may inaccurate:

• Limits of agreement with MEMS: -23.1% to 25.5

• 5/45 (11%) of patients did not use MEMS appropriately

• Gold Standard for measuring adherence?

(28)

A Couple More Points on Adherence

An accurate list of what was prescribed or filled is not necessarily an accurate list of what is being consumed Initiating medications that the patient was not previously

taking can be dangerous

(29)

Predictors of Nonadherence

Depression

Cognitive impairment Asymptomatic disease

Inadequate discharge planning/follow-up Side effects

Lack of belief in benefit Lack of insight in illness

Poor provider-patient relationship Barriers to care

Missed appointments Complexity of treatment Cost

Osterberg L. N Engl J Med 2005;353:487-97

(30)

Predictors of Nonadherence

Non-Adherent Adherent P value

(N=49) (N=328)

Age 62 ± 10 61 ± 11 0.34

Male 41 (84%) 239 (73%) 0.12

Number of Rx meds 4.0 ± 2.8 6.0 ± 3.4 <0.001

Adverse effects 18 (37%) 151 (46%) 0.22

Use of adherence aids 18 (37%) 180 (55%) 0.02 Alternative medications 49 (20%) 85 (26%) 0.38

Attends clinic 22 (45%) 144 (44%) 0.93

Shalansky SJ, et al. Ann Pharmacother 2002;36:1532-9

(31)

Predictors of Nonadherence

Non-Adherent Adherent P value

(N=49) (N=328)

Age 62 ± 10 61 ± 11 0.34

Male 41 (84%) 239 (73%) 0.12

Number of Rx meds 4.0 ± 2.8 6.0 ± 3.4 <0.001

Adverse effects 18 (37%) 151 (46%) 0.22

Use of adherence aids 18 (37%) 180 (55%) 0.02 Alternative medications 49 (20%) 85 (26%) 0.38

Attends clinic 22 (45%) 144 (44%) 0.93

(32)

More Meds = Better Adherence?

N = 367

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

1 to 3 4 to 6 7 to 9 10 or more

Number of Regularly Scheduled Prescription Medications

Adjusted Odd Ratio

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Proportion Non-Adherent

Adjusted OR for non-adherence Proportion who were non-adherent (unadjusted) N = 111

N = 137

N = 70

N = 49

“Have you changed your daily routine to accommodate your medication schedule?”

(33)

Morisky Score

Non-Adherent Adherent P value (N=49) (N=328)

Do you ever forget to

take your medicines? 29 (59%) 138 (42%) 0.03 Are you careless at time

about taking your medicine? 13 (27%) 72 (22%) 0.47 When you feel better,

do you sometimes stop

taking your medicine? 6 (12%) 7 (2%) <0.001 Sometimes if you feel worse

when you take your medicine,

do you stop taking it? 12 (25%) 27 (8%) <0.001

(34)

Morisky Score

Non-Adherent Adherent P value (N=49) (N=328)

Do you ever forget to

take your medicines? 29 (59%) 138 (42%) 0.03 Are you careless at time

about taking your medicine? 13 (27%) 72 (22%) 0.47 When you feel better,

do you sometimes stop

taking your medicine? 6 (12%) 7 (2%) <0.001

Sometimes if you feel worse when you take your medicine,

do you stop taking it? 12 (25%) 27 (8%) <0.001

(35)

There’s still a place for medication

history interviews!

(36)

Recommendations

Questions for Medication History Interviews

Ask about all medications:

– Prescription

– Over-the-counter

– Anything from a herbalist or health store?

– Herbs

– Vitamins or supplements – Teas

– Traditions remedies (from other countries?)

Name, dosage form, dose, schedule, last dose taken (be specific about prn medications)

Have you recently started any medications, or had the dose changed?

– Side effects/non-adherence more likely

http://www.saferhealthcarenow.ca/en/pdf/GSK%20Reconciling%20Medications%20FINAL%20rev6Nov2005.pdf

(37)

Recommendations

Questions for Medication History Interviews

• Balance open-ended questions with yes/no questions

• Nonbiased questions

• No leading questions

• Vague responses may indicate non-adherence

• Avoid medical jargon

(38)

Recommendations

Questions for Medication History Interviews

• Encourage questions from patient

• Encourage bringing meds and use of medication wallet card

– Give out wallet cards

• Prompt regarding non-pill dosage forms and prns

– Creams, drops, inhalers, spray, samples

• Allergies: ask about symptoms

• Use multiple sources of information:

– Medication labels – Family

– Community pharmacy – Family physician

(39)

Recommendations

Questions for Medication History Interviews

If you have access to prescription refill records:

“Did the doctor change the dose or stop any of your medications recently?”

– Many discrepancies identified in our study resulted from physician-initiated changes or discontinuation

“Have you changed the dose or stopped any of your medications recently?”

– Many of the identified discrepancies were the result of patient-initiated deviations from the written prescription

(40)

Recommendations

Questions for Medication History Interviews

“Do you have trouble taking or remembering to take any of your medications?”

– A substantial number of patients admitted non-adherence with little prompting

“Have any of the medications been causing side effects?”

– Experiencing side effects is one of the common reasons for stopping a medication or changing the dosing of a medication

If you’re pressed for time, focus on:

•Medications with a relatively high incidence of side effects:

•e.g. beta blockers

•Medications that are doses based on symptoms:

•e.g. diuretics

(41)

Recommendations

Questions for Medication History Interviews

Your PharmaNet profile indicates that you may have run out of some medications. Are you still taking any of these?

– Overdue for refills were the most common reason identified for discrepancies

Have you spent any days in the hospital for the past year?

– Hospital providing medications during admission accounted for 8% of the discrepancies in this cohort

(42)

Recommendations

Questions for Medication History Interviews

Adherence:

Review the prescription refill records if possible.

Morisky Questions:

“When you feel better, do you sometimes stop taking your medicine?”

“Sometimes if you feel worse when you take your medicine, do you stop taking it?”

Health Beliefs:

“Have you changed your daily routine to accommodate your medication schedule?”

Don’t assume patients taking few medications are adherent, or patients taking a large number of medications are non-adherent

(43)

Ask the Right Questions!

How much time do you spend using your exercise treadmill each week?