Adverse Drug Events and Readmissions: The Global Picture Kyle E. Hultgren, PharmD Managing Director Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN
4 Learning Objectives Discuss why readmissions associated with adverse drug events are a current national focus Identify the high-risk medication classes that cause ADEs Connect ADEs directly to readmissions as a frequent root cause
Welcome and Overview Welcome! Define terms: readmissions and ADEs Identify highrisk medications Where meds and readmissions meet Self-assessment tool
Center for Medication Safety Advancement Discovery of safe medication use practices Delivering knowledge to all who may benefit Innovation and collaboration between health care practitioners, faculty, staff and students Provide education, research and outreach GOAL: reduce medication errors
Deliverables and Expectations Highlight top 6 high-risk medication classes Think about what medications cause the most harm at your institution Self-assessment completion is encouraged
Step 1: Define the Terms Define terms: readmissions and ADEs Identify highrisk medications Where meds and readmissions meet
Readmissions One in five Medicare patients readmitted within 30 days 35% within 90 days 17 billion dollars annually ADEs implicated in ~7000 deaths Compared to inpatients, little data is available on ADEs for patients post discharge relating to medications. Jencks et al. Rehospitalizations among Patients in the Medicare Fee-for- Service Program. N Engl J Med 2009;360:1418-28. Beckett RD, Sheehan AH, Redden JG. Factors Associated with Resported Preventable Adverse Drug Events: A Restrospective, Case-Control Study. Ann Pharmacotherapy. 2012;46(5):634-641.
Readmissions Why focus on readmissions? Measureable Good marker of care across continuum (from hospital to long term care to home etc.) Improvement in this area targets: Patient self-care and in-home care Communication between patients and providers Jencks et al. Rehospitalizations among Patients in the Medicare Fee-for- Service Program. N Engl J Med 2009;360:1418-28.
Readmissions Penalties for readmissions Section 3025 of Affordable Care Act Hospitals with higher than expected readmission rates for HF, AMI, and Pneumonia targeted In FY13, penalized up to 1% of total Medicare revenues Up to 2% and 3% in FY14 and FY15 Conditions will be added not done here
Readmissions Family caregivers at home performing nursing functions 42 million family caregivers Nearly half perform nursing functions 75% perform medication managment Available from: http://www.uhfnyc.org/publications/880853.
Readmissions Partnership for Patients (PfP) Reduce preventable hospital-acquired conditions by 40% by December 31, 2013 Reduce all hospital readmissions by 20% by December 31, 2013 PfP focus is on anticoagulants, narcotics, sedatives, and insulin U.S. Department of Health & Human Services Partnership for Patients. Health Research & Educational Trust. Implementation Guide to Reducing Harm from High-Alert Medications. Accessed at http://www.hrethen.org/images/downloads/508changepacks/ade_changepackage_508.pdf, August 4, 2012.
Medication Errors 1999 Institute of Medicine (IOM) report 44,000 98,000 people per year die as a direct result of medical errors
Medication Errors 2006 IOM report 1.5 million preventable adverse drug events (ADE) annually in the United States Each costs ~$8,750
But that was 12 years ago 2010 Landrigan et al study in NEJM Randomized sample of 10 NC hospitals 100 admissions per quarter reviewed for medical errors from Jan 2002 through Dec 2007 Results 25.1 harms per 100 admissions No statistical significant drop in rate of harms over 6 years Landrigan, C et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. New England Journal of Medicine. Nov. 25, 2010; vol 363: pp 2124-2134
Medication Errors "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. - National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP)
Adverse Drug Events Injury resulting from medical intervention related to a drug. - Bates DM et al, JAMA 1995.
Adverse Drug Reactions An effect that is noxious and unintended, and which occurs at does used in man for prophylaxis, diagnosis, or therapy. - World Health Organization IMPORTANT: Includes only appropriate use of drugs.
Medication Errors Preventable Adverse Drug Events Adverse Drug Events ADR
Bad practitioner or bad system?
Step 2: Identify the Meds Define terms: readmissions and ADEs Identify highrisk medications Where meds and readmissions meet
High Risk Medications http://polypharmacyinitiative.com/drugalert.html
Data Collection Formulate research question: Readmissions ADEs High-risk Medications Search strategy: PubMed & MEDLINE MeSH terms readmissions rehospitalizations ADEs high-risk meds high-alert meds transitions post-discharge Cross-reference
Data Abstraction 300+ abstracts Inclusion criteria Readmitted ADE High-risk meds Exclusion criteria Drug/alcohol abuse Article selection Limited results Analyzed occurrence of most common offending classes
Data Discovery and Delivery Medications Studies Why implicated Hematologic Forster, Budnitz, McDonnel, Beckett, Complexity of dosing and Classen, Ruiz, Roughead, Evans monitoring Patient adherence Drug interactions Dietary interactions Anti-diabetic Budnitz, McDonnel, Beckett, Classen Pharmacology of drugs Complexity of dosing Medication adjustments Narrow therapeutic range Anti-neoplastic Budnitz, McDonnel, Ruiz, Roughead, Pharmacology of drugs Adverse effects Dose scheduling Drug interactions Depressed immune system Analgesics (including narcotics) Cardiovascular Forster, Boockvar, Budnitz, Beckett, Evans Forster, Boockvar, Budnitz, McDonnel, Beckett, Classen, Roughead, Evans Dose mix ups Allergic reactions Enhanced CNS effects Ambiguous directions Patient adherence Polypharmacy Adverse effects Anti-infectives Forster, Budnitz, Beckett, Classen, Evans Patient adherence Overuse/misuse Kill normal flora Adverse effects/allergies Drug interactions
High-Risk Medications Hematologic Complexity of dosing and monitoring Patient adherence Drug interactions Dietary interactions
High-risk Medications Anti-diabetic Pharmacology of drugs Complexity of dosing Medication adjustments Narrow therapeutic range
High-Risk Medications Antineoplastics Pharmacology of drugs Adverse effects Dose scheduling Drug interactions Depressed immune system
High-risk Medications Analgesics (narcotics too) Dose mix ups Allergic reactions Enhanced CNS effects Ambiguous directions
High-risk Medications Cardiovascular Patient adherence Polypharmacy Adverse effects
High-Risk Medications Anti-infectives Patient adherence Overuse Misuse Kill normal flora Adverse effects Allergies Drug interactions
Step 3: Putting it Together Define terms: readmissions and ADEs Identify highrisk medications Where meds and readmissions meet
Errors in Transition Greater than 50% of medication histories taken upon admission have some form of discrepancy requiring resolution Greater than 50% of documented medication errors occur at three times: Admission Transfer Discharge Gleason, et al. Amer J Health Syst Pharm. 2004; 61: 1689-95;
Errors in Transition High risk meds leading to harm Narrow therapeutic window agents Family caregiving Medication histories Information systems Poor communication
UCSF Medical Center, CA 30-day readmissions 22% to 16% Virtual team through email communication Bedside counseling totaling 90 minutes from admission to discharge Binder for heart failure and how to manage Teach-back method* Follow-up phone calls* O Reilly, KB. Reducing readmissions: How 3 hospitals found success. American Medical Association. Accessed at http://www.amaassn.org/amednews/2011/02/07/prsa0207.htm, August 28, 2012.
Piedmont Hospital, GA <70yo 13.05% to 3.97% >70yo 15.9% to 11.2% Medication reconciliation done by pharmacists Identify patients at high risk Schedule follow-up care Follow-up phone call within 72 hours Discharge document (BOOST) O Reilly, KB. Reducing readmissions: How 3 hospitals found success. American Medical Association. Accessed at http://www.amaassn.org/amednews/2011/02/07/prsa0207.htm, August 28, 2012.
Evergreen Hospital Medical Center, WA National heart failure rate: 24.7% 30-day hospital readmission rate: 14% and 6% for patients referred Identify high-risk patients Refer to Evergreen Cardiac Enhancement Center within 3 days 90 minute long initial session Follow-up visits Q2weeks until stable O Reilly, KB. Reducing readmissions: How 3 hospitals found success. American Medical Association. Accessed at http://www.amaassn.org/amednews/2011/02/07/prsa0207.htm, August 28, 2012.
Conclusion ADEs and high-risk meds directly linked to readmissions Identify ADE associated readmissions Understand the relationship Communicate clearly
Next Steps Mitigation strategies Measurement methods and techniques Sharing your stories!
Resources Hospital Engagement Network (PfP) http://www.hret-hen.org/adverse-drugs-events IHI STAAR Initiative http://www.ihi.org/offerings/initiatives/staar/p ages/default.aspx Project RED https://www.bu.edu/fammed/projectred/index.html BOOST http://www.hospitalmedicine.org/am/template.cfm?sec tion=home&template=/cm/htmldisplay.cfm&conten TID=27659
Studies Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med. 2011;365:2022-2012. Forster AJ, Murfff HJ, Peterson JF, et al. Adverse Drug Events Occuring Following Hospital Discharge. J Gen Intern Med. 2005;20:317-323. Boockvar KS, Liu S, Goldstein N, et al. Prescribing Discrepancies Likely to Cause Adverse Drug Events after Patient Transfer. Qual Saf Health Care. 2009;18(1):32-26. McDonnell PJ, Jacobs MR. Hospital Admissions Resulting from Preventable Adverse Drug Reactions. Ann Pharmacotherapy. 2002;36:1331-1336. Beckett RD, Sheehan AH, Redden JG. Factors Associated with Reported Preventable Adverse Drug Events: A Restrospective, Case-Control Study. Ann Pharmacotherapy. 2012;46(5):634-641. Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf. 2010;36(1):12-21. Ruiz B, Garcia M, Aquirre U, et al. Factors predicting hospital readmissions related to adverse drug reactions. Eur J Clin Pharmacol. 2008; 64(7):715-722. Roughead EE, Gilbert AL, Primrose JG, et al. Drug-related hospital admissions: a review of Australian studies published 1988-1996. Med J Aust. 1998; 168(9):405-408. Evans RS, Lloyd JF, Stoddard GJ, et al. Risk Factors for Adverse Drug Events: A 10-Year Analysis. Ann pharmacother. 2005; 39:1161-8.
Questions?