The PILL Clinic:The PILL Clinic:Pharmacologic Pharmacologic

Intervention in Late LifeIntervention in Late LifeMarci Salow, PharmDMarci Salow, PharmD

Juliana Millan, MDJuliana Millan, MD

VA Boston Healthcare System GRECCVA Boston Healthcare System GRECC

ObjectivesObjectives

Discuss PILL clinic concept and Discuss PILL clinic concept and developmentdevelopment

Provide overview of patient selection and Provide overview of patient selection and assessment strategiesassessment strategies

Review short-term outcomes Review short-term outcomes

PILL Clinic Concept:PILL Clinic Concept:

Focused & multidisciplinary approach to:Focused & multidisciplinary approach to:

Reducing polypharmacyReducing polypharmacy

Assessing for inappropriate prescribingAssessing for inappropriate prescribing• Reduce risk of ADRsReduce risk of ADRs

Providing patient and provider educationProviding patient and provider education• Assessing patient perceptions about medicationsAssessing patient perceptions about medications

Medication reconciliationMedication reconciliation

Multi-disciplinary TeamMulti-disciplinary Team

GeriatricianGeriatrician

Geriatric FellowGeriatric Fellow

Pharmacist Pharmacist

Pharmacy residentPharmacy resident

Why a PILL clinic?Why a PILL clinic?

Gaps in current systemGaps in current system

Potential inappropriate medication usePotential inappropriate medication use

Why a PILL clinic?Why a PILL clinic?

Non-adherence Non-adherence

PolypharmacyPolypharmacy Increase risk of adverse drug reactions Increase risk of adverse drug reactions

(ADRs)(ADRs) ADRs ~12% of elderly hospital admissionsADRs ~12% of elderly hospital admissions

Why a PILL clinic?Why a PILL clinic?

Medication Use in the ElderlyMedication Use in the Elderly ~12% of the US population is ~12% of the US population is ≥≥65 years65 years 3 out of 4 are taking prescription 3 out of 4 are taking prescription

medicationmedication 2-6 prescription drugs 2-6 prescription drugs 1-3 over-the-counter products1-3 over-the-counter products

50% of all drugs used in US50% of all drugs used in US

Complex Medication Management:Complex Medication Management:Contributing FactorsContributing Factors

Pharmacokineticsand

PharmacodynamicsCHANGES

ADVERSE DRUG

REACTIONS

MULTIPLEMedications

Medical conditionsPrescribersPharmacies

GAPS IN CURRENTSYSTEM

NONADHERENCE

COMPLEX MEDICATION

MANAGEMENT

Patient SelectionPatient Selection

3 criteria for patient selection3 criteria for patient selection

≥≥65 years65 years

≥≥ 14 medications14 medications

≥≥ 1 Beers criteria drug1 Beers criteria drug

Patient SelectionPatient Selection

992 veterans identified by electronic 992 veterans identified by electronic

medication record auditmedication record audit

*Age range 65 – 95

*Prescribed medications 14 – 31

PatientPatient selectionselection

661 patients 661 patients 1+ medications from Beers criteria 1+ medications from Beers criteria

66 providers contacted66 providers contacted 22 responses22 responses 11 agreed to have their patients contacted11 agreed to have their patients contacted

PatientPatient SelectionSelection

Of the 661 patients:Of the 661 patients:

41% - using 2 or more Beers criteria 41% - using 2 or more Beers criteria medicationsmedications

Top DrugsTop Drugs

meclizine

5% temazepam

5%quinine

8%

fluoxetine

9%

diazepam

14%

iron>BID

12%

amitriptyline

7%

ranitidine BID

10%

diphenhydramine

8%

propoxyphene

9%

oxybutynin

13%

PatientPatient SelectionSelection

Phone calls to identified patientsPhone calls to identified patients

Clinic scheduleClinic schedule 4 hours / week4 hours / week

PatientPatient AssessmentAssessment

Pt seen by pharmacist, geriatrician, Pt seen by pharmacist, geriatrician, pharmacy residentpharmacy resident

Survey completed by patientSurvey completed by patient

Brown bag review of medsBrown bag review of meds

8

33

31

28

0

5

10

15

20

25

30

35

Patient (%)

<10 10 to 15 16 to 20 20 or >

Number of Meds

Prescription Medication

49

38

3

10

0

5

10

15

20

25

30

35

40

45

50

Patient (%)

0 1 to 2 3 to 5 5 to 10

Number of Meds

OTC Medication Use

Patient AssessmentPatient Assessment

Medication reconciliationMedication reconciliation Patient educationPatient education Medication optimizationMedication optimization

Changes to therapyChanges to therapy

PatientPatient SurveySurvey

How many medications do you take?How many medications do you take? How do you take your medications?How do you take your medications? The medications I take include:The medications I take include:

Only prescriptions from VAOnly prescriptions from VA OTC productsOTC products Herbals/vitaminsHerbals/vitamins otherother

PatientPatient surveysurvey

Which of the following statements apply? Which of the following statements apply? True/FalseTrue/False I take too many medsI take too many meds I take meds too many times during the dayI take meds too many times during the day I am taking medication that doesn’t work for I am taking medication that doesn’t work for

meme I am having side effects.I am having side effects.

PatientPatient SurveySurvey

I don’t understand the purpose of my meds.I don’t understand the purpose of my meds. I have a problem getting medication from the I have a problem getting medication from the

pharmacypharmacy I forget to take medication.I forget to take medication. I don’t know what meds I should be taking.I don’t know what meds I should be taking. When I feel better/worse, I sometimes stop When I feel better/worse, I sometimes stop

my meds.my meds.

Medication ReconciliationMedication Reconciliation

1.1. CompareCompare

2.2. ClarifyClarify

3.3. CommunicateCommunicate

4.4. ReconcileReconcile

Medication ReconciliationMedication Reconciliation

1.1. CompareCompare

Brown Bag ReviewBrown Bag Review Discussion with patient and CaregiverDiscussion with patient and Caregiver Electronic medication recordElectronic medication record

MedicationMedication ReconciliationReconciliation

2. 2. ClarifyClarify Actual medication Actual medication

patient is takingpatient is taking Including Including

OTC/herbals/ OTC/herbals/ vitaminsvitamins

Non-VA medsNon-VA meds

CrucialCrucial StepsSteps

3. Communicate & Reconcile3. Communicate & Reconcile

Omissions, inconsistencies, discrepanciesOmissions, inconsistencies, discrepancies

Involve other practitionersInvolve other practitioners

What was that again?What was that again?

““Medication reconciliation is something that at first glance Medication reconciliation is something that at first glance seems like it should be an easy thing to do……It turns seems like it should be an easy thing to do……It turns out it’s not all that easy.”out it’s not all that easy.”R. Croteau MD, JCAHO Executive Director for Strategic InitiativesR. Croteau MD, JCAHO Executive Director for Strategic Initiatives

PatientPatient AssessmentAssessment

AnticholinergicAnticholinergic RiskRisk AssessmentAssessment

More susceptible to anticholinergic effectsMore susceptible to anticholinergic effects Central Central

cognitive changescognitive changesmemory impairmentmemory impairmentconfusionconfusion

Peripheral Peripheral dry mouthdry mouthblurred vision blurred vision constipationconstipation

Increased risk of fallsIncreased risk of falls

Anticholinergic Risk Score

46

13

28

8

0

5

0 5 10 15 20 25 30 35 40 45 50

0

1 to 2

3 to 4

5 to 6

7 to 8

9 to 10

Sco

re

Percentage of Patients

Medication AssessmentMedication Assessment

Medications Medications IndicationIndication DuplicationDuplication Side effects?Side effects? ARS scoreARS score

Optimizing therapyOptimizing therapy Can any medications be discontinued?Can any medications be discontinued? Can any medications be switched?Can any medications be switched? Risk / benefit analysisRisk / benefit analysis

ClinicClinic PatientsPatients

39 patient uniques 39 patient uniques

Age range 64-92Age range 64-92

Average age 75Average age 75

MaleMale

AGE

0

5

10

15

20

25

30

35

40

45

50

64-69 70-74 75-79 80 or >

Age Range

Per

cen

t

Visit Findings

95

41

2623

15

10 10

36

0

10

20

30

40

50

60

70

80

90

100

1

type

per

cen

tag

e

polypharm duplication Age-Drug untreated disease state

ADR drug with no indication DDI Food-Drug

Charlson Comborbidity Index

3 to 433%

1 to 241%

08%5 or >

18%

0

1 to 2

3 to 4

5 or >

InterventionsInterventions

95 total including education, reconciliation, 95 total including education, reconciliation, medication changesmedication changes 14 involving BEERs criteria medications14 involving BEERs criteria medications

~ 3.4 interventions per patient~ 3.4 interventions per patient

Interventions at Initial Visit

3940

8

13

5

39 39

23

7

0

5

10

15

20

25

30

35

40

45

med

revi

ew

disco

ntinued

med

initi

ated

med

icat

ion

dose a

djust

men

t

switc

hed m

eds

educa

tion

med

rec

sched

uled fo

r f/u

refe

rral

Type

Occ

ura

nce

s

Discontinued Medications

14

8

2

8

8

0 2 4 6 8 10 12 14 16

Beers criteria med

Benzodiazepine

Quinine

OTC product

Med without indication

Occurances

Initiated Medications

1

3

2

2

0 0.5 1 1.5 2 2.5 3 3.5

antidepressant

analgesic

anti-gout

bowel regimen

Occurances

InterventionsInterventions

Patient educationPatient education

Medication chart Medication chart Expiration datingExpiration dating Disease state educationDisease state education Medication counselingMedication counseling

• Example: Inhaler use, max dose acetaminophen,Example: Inhaler use, max dose acetaminophen,

NTG useNTG use

PatientPatient SurveySurvey ResultsResults

8% identified number of medications correctly8% identified number of medications correctly

78% use a pillbox78% use a pillbox

21% believe they take too many meds21% believe they take too many meds

92% believe they take meds too many times 92% believe they take meds too many times during the dayduring the day

Patient Survey Results

92

7874

21

12

36

29

0

10

20

30

40

50

60

70

80

90

100

1

Patient Responses

Pa

tie

nt

Pe

rce

nta

ge

too many adm times

pill box

purpose unknow n

believe side effects exist

problem getting meds

too many meds

don't know w hat meds to take

Patient Survey Results

9

8

6

4

0

1

2

3

4

5

6

7

8

9

10

1

Patient Responses

Pa

tie

nt

Pe

rce

nta

ge

stop med if feelworse

ID meds correctly

stop med if feelbetter

forget to take meds

WhatWhat we’vewe’ve learnedlearned soso far…far…

High numbers of patients do not know High numbers of patients do not know what medications they take and why.what medications they take and why.

Frequency of dosing is of concern to Frequency of dosing is of concern to patients and pill burden is less of a patients and pill burden is less of a concern.concern.

WhatWhat we’vewe’ve learnedlearned soso far….far….

Providers need more educationProviders need more education ? Reluctant to refer? Reluctant to refer

Patients need more educationPatients need more education Patients eager to talk about their meds and Patients eager to talk about their meds and

make changesmake changes

FutureFuture DirectionsDirections

Aggressive recruitment of patientsAggressive recruitment of patients Further data analysis Further data analysis

Correlations or patterns?Correlations or patterns? Follow-up review of patients at 1 yearFollow-up review of patients at 1 year

Patient satisfaction surveyPatient satisfaction survey

Questions??Questions??

ReferencesReferences

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