March 9, 2015. The literature is replete with warnings of medication related problems, adverse drug events, and all-cause mortality related to use of antipsychotic medications for patients with dementia.1 As a large portion of the nursing home population have a dementia diagnosis and have historically had a high prevalence of antipsychotic medication use, the US Health and Human Services (HHS) agency has aimed to effect reductions in antipsychotic use for these patients. How are we doing, and what if anything is being done to assess and impact antipsychotic use by patients with dementia who do NOT reside in nursing homes? Those questions were put by Congress to the Government Accounting Office (GAO) who recently published results of their studies in a GAO report entitled “Antipsychotic Drug Use.”2
The report outlines modest progress in the reduction of antipsychotic use for patients with dementia who reside in the nation’s nursing home facilities. At the beginning of 2012, the HHS Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care in Nursing Homes. The Partnership began with a goal of reducing antipsychotic use by 15% by the end of 2012 (from a baseline of 23.8 percent Q42011). The report observes that the goal was not met by 2012, but with continued efforts a 15.1% reduction in antipsychotic use among nursing home patients was noted by the end of 2013. Building on these gains, in September 2014, CMS established a new set of national goals to reduce antipsychotic prescribing an additional 10% by 2015 years end and another 5 % by the end of 2016. If met, this would reflect a 30% reduction in antipsychotic use over four years.
How is this to be done? The National Partnership has incorporated reduction in antipsychotic use as a quality measure for the CMS Star Ratings System which measures quality in nursing home practice. In addition, the Partnership holds regular conference calls with stakeholders and experts in the field to share best practices. CMS has stepped up required training of nursing home surveyors to include antipsychotic reduction strategies, has contracted with state Quality Improvement Organizations (QIOs) to provide training directly to nursing homes, has funded pilots to effect changes in prescribing habits and has published individual nursing homes successes or failures on their Nursing Home Compare site.
In addition to all of the resources being put forth for nursing home patients as described above, CMS requires quarterly care plan meetings, mandated regular trials to reduce antipsychotic use, stiff fines and penalties for inappropriate prescribing, and requires MONTHLY the services of a consultant pharmacist to provide an extensive Comprehensive Medication Review (CMR) to address all issues surrounding medication use for nursing home patients. It would be interesting to learn if all of this focus of resources has resulted in the reduction of the highest costs of healthcare: long term care. Could this same approach have more impact on improving outcomes and reducing costs by focusing on the older adult population who have not yet entered long term care? In the words of the GAO: “HHS has done little to address antipsychotic drug use among older adults with dementia living in settings outside of the nursing home.” The report shows that almost 14% of these patients are receiving routine antipsychotic medications.
For those lucky few Medicare Part D beneficiaries that meet requirements to be placed in the Medication Therapy Management Programs (MTMPs) CMS requires an annual CMR be completed, usually by a pharmacist, to identify, resolve and prevent medication related problems including inappropriate antipsychotic use. At present, only about 10-15% of beneficiaries are targeted by CMS and their health plans, and of those, less than 25% wind up actually receiving the service. What can we do to balance the scales for ambulatory patients with dementia regarding inappropriate antipsychotic use?
The GAO report suggests extension of many of the initiatives listed above to the ambulatory care setting on behalf of patients. GAO says that the National Partnership should extend their interventions to ambulatory settings, and provide education to health care providers in the community relative to appropriate treatment of dementia and use of antipsychotic medications. Specifically, training for care givers at home and in assisted living settings on non-pharmacologic interventions and ways to avoid and reduce patients’ behavioral outbursts could go a long way in stopping the knee-jerk reaction to prescribe an antipsychotic agent.
Other governmental initiatives could increase the availability of medication management for ambulatory patients, such as requiring that more patients be offered Medicare CMR services, that pharmacists’ patient care services be reimbursed under Medicare billing regulations, and a continued push for paying for quality of care rather than quantity of services rendered. We also think that a closer integration among the care team regarding a patient’s medication use is key to properly managing medications. Particularly in the ambulatory setting, patients’ medication use is not as structured as it is in institutional settings – certain prescription medications, over-the-counter preparations and supplements may cause delirium in the older adult, interpreted as worsening dementia and prompts the antipsychotic prescription in the first place.
In addition, the technical and workflow challenges for medication management are much greater in the ambulatory setting. They include the need to aggregate and validate medication information from multiple disparate sources, including the patient; the need to identify, interpret and make risk actionable; and the need to share it among all the members of a patient’s care team. Most care teams do not have access to the expertise of a consulting pharmacist to fill these gaps or offer the support needed. ActualMeds is committed to building the suite of technical solutions and managed services that can provide longitudinal medication and risk information that is integrated with a patient’s care management.
By focusing medication management resources on ambulatory older adults can we slow down the progression to, and shorten the time needed for long term care? We think all stakeholders can benefit from this approach. Rigorous patient-centered medication management can help to avoid ED visits and hospitalizations and the need for long term care for payers, resulting in fewer and more successful transitions of care for providers, and most importantly, improved quality of life for seniors.
BMJ 2014; 349g6420 (http://www.cochrane.org/CD003476/DEMENTIA_atypical-antipsychotics-benefit-people-with-dementia-but-the-risks-of-adverse-events-may-outweigh-the-benefits-particularly-with-long-term-treatment)
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds