Assignment Aquifer High-Value Care 04 80-year-old woman – Medications and value

Assignment: Aquifer High-Value Care 04: 80-year-old woman – Medications and value

Author(s): Susan Merel, MD University of Washington Medicine; Anne Eacker, MD University of Washington Medicine

REASON FOR ADMISSION

HISTORY

You are rounding on Mrs. Miller, a newly admitted 80-year-old patient with a heart failure (HF) exacerbation. She had been discharged from the hospital just 10 days ago after presenting with the same problem after a 5 day hospitalization. Assignment: Aquifer High Value Care 04: 80-year-old woman – Medications and value.

You review her list of chronic problems:

Problem list

• Systolic heart failure due to ischemic cardiomyopathy with EF of 35% on last echocardiogram
• Well-controlled diabetes: A1c of 6.5
• Chronic kidney disease Stage 3
• Recurrent urinary tract infections
• Mild cognitive impairment
• Osteoarthritis

You have found no evidence of infection, Mrs. Miller has not changed her diet, and her EKG is unchanged from previous. On rounds today your attending asks you why you think this patient had a second HF exacerbation so soon after discharge. Assignment: Aquifer High Value Care 04: 80-year-old woman – Medications and value.

Question

Which of the following are likely to contribute to a HF exacerbation requiring readmission? Select all that apply.

• Medication nonadherence
• Residence in a skilled nursing facility
• Chronic kidney disease
• Diabetes
• Hyponatremia
• Medication side effects

References

Flacker J, Park W, Sims A. Hospital discharge information and older patients: do they get what they need? J Hosp Med. 2007;2(5):291-296.

Amabile CM SA. Keeping your patient with heart failure safe: a review of potentially dangerous medications. Arch Intern Med. 2004;164(7):709-720.

Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI. Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J. 2000;139(1 Pt 1):72-7.

DEEP DIVE Aquifer High Value Care 04: 80-year-old woman – Medications and value

References

Journal of Managed Care & Specialty Pharmacy, Volume 22 Issue (5) 2016 May 22 (5): 516-523.

 

Answer Comment

The correct answers are A, C, D, F.

Medication nonadherence (A) and medication side effects (F) are important risk factors for readmission in patients discharged after a hospitalization for HF.

• Medication nonadherence is a pervasive problem; up to 25% of prescriptions ordered are never filled. In one study of elderly patients discharged from a county hospital with medication changes, only about 50% reported getting their prescriptions filled. (See the Expert to learn about the types and prevalence of medication nonadherence.)
• Older patients are likely to take multiple medications and are more susceptible to side effects and adverse drug events than younger patients because of comorbidities, frailty, and age-related physiologic changes in drug metabolism and excretion. Drug-induced HF exacerbations are also common. Medications to consider include non-steroidal anti-inflammatories (NSAIDS), corticosteroids, alpha-blockers, calcium-channel blockers, and tricyclic antidepressants.

Elderly patients with renal failure (C) and diabetes (D) are at increased risk for readmission after an exacerbation of HF. Both conditions make it more difficult to control heart failure.

Hyponatremia (E) is a common condition in the elderly and may make it more difficult to treat heart failure, but has not been shown to be associated with HF readmission.

Advanced age and residence in a skilled nursing facility (B) have not been shown to be risk factors for HF readmission.

 

 

REASON FOR ADMISSION

HISTORY

READMISSION QUESTION

HISTORY

Question

Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.

• Association with increased mortality
• Increased occurrence in patients with depression
• Cost to health care facility
• Cost to the patient

SUBMIT

TEACHING POINT

Early readmission, within 30 days of discharge, is associated with an increased rate of all-cause mortality for community-dwelling elderly patients. Patients over age 80, with five or more comorbidities, or depression are at greater risk of early readmission

References

Lum HD, Studenski SA, Degenholtz HB, Hardy SE. Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. J Gen Intern Med.2012;27(11):1467-74.

Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107(1):13-17.

Centers for Medicare and Medicaid Services. Readmissions Reduction Program.

 

 

Question

Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• Association with increased mortality
• Increased occurrence in patients with depression
• Cost to health care facility
• Cost to the patient

SUBMIT

Answer Comment

The correct answers are A, B, C, D.

All of the above are correct.

Early readmission, within 30 days of discharge, is associated with an increased rate of all-cause mortality (A) for community-dwelling elderly patients initially admitted for any diagnosis. It is more common in patients who:

• Are over age 80
• Have five or more comorbidities
• Have depression (B).

The Affordable Care Act currently requires the Center for Medicare and Medicaid Services (CMS) to reduce payments to hospitals in the setting of “excess readmissions” of patients hospitalized for acute myocardial infarction, heart failure, and pneumonia within 30 days of the first hospitalization. If readmission rates exceed the expected rate, a penalty is charged to the hospital (C). The amount of these penalties will increase in the future, and additional medical conditions will be added.

Even with insurance, Medicare or otherwise, most patients still have to pay (D) some portion of their health care costs. For example, Medicare Part A covers 80% of inpatient costs. The average cost of inpatient care per day in the U.S. is about $2270. Hospital Adjusted Expenses per Inpatient Day 2015.

 

 

 

MEDICATION REVIEW

HISTORY

While you are rounding, Mrs. Miller’s daughter arrives with her mother’s home medications in a grocery bag. You express your appreciation that she was able to bring these in for review. They are as follows:

Scheduled medications

• Aspirin 81 mg po daily
• Calcium carbonate 500 mg po bid
• Furosemide 20 mg po daily
• Glipizide 5 mg po daily
• Lisinopril 10 mg po daily
• Metformin 500 mg po bid
• Metoprolol XL 50 mg po daily
• Multivitamin one tab po daily
• Nitrofurantoin 50 mg po daily
• Pravastatin 40 mg po daily
• Cholecalciferol 800 IU po daily
• Naproxen over-the-counter, patient has been taking 500 mg twice a day for a week.

As needed medications

• Diphenhydramine 25 mg po q 6 hours prn pruritus
• Zolpidem 5 mg po qhs prn insomnia
• Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain

Question

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS:Assignment: Aquifer High-Value Care 04: 80-year-old woman – Medications and value

After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.

• Aspirin
• Nitrofurantoin
• Metoprolol
• Diphenhydramine
• Naproxen
• Vicodin
• Zolpidem

SUBMIT

TEACHING POINT

• Older patients are at increased risk of adverse drug events.
• The Beers Criteria is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly and should be referenced when caring for older patients.

References

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12.

Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516-23.

Steinman MA, Story PS. Managing medications in clinically complex elders: “There’s got to be a happy medium.” JAMA. 2010;304(14):1592-1601.

Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6.

DEEP DIVE

References

Brater DC. Effects of nonsteroidal anti-inflammatory drugs on renal function: Focus on cyclooxygenase-2-selective inhibition. Am J Med. 1999;107(6A):65S-71S.

Question

After a discussion with the patient and her primary care doctor, which of the following medications would be appropriate to consider discontinuing during this hospitalization? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• Aspirin
• Nitrofurantoin
• Metoprolol
• Diphenhydramine
• Naproxen
• Vicodin
• Zolpidem

SUBMIT

Answer Comment

The correct answers are B, D, E, F, G.

Adverse Drug Events in the Elderly

• Older patients are at high risk for adverse drug events due to age-related changes in physiology, including changes in drug metabolism.
• Older patients generally have more comorbid conditions and are prescribed more medications: 40% of adults over age 65 take 5 to 9 medications and 18% take 10 or more.
• Frail elderly patients who take multiple medications are at increased risk for falls, fractures and delirium; these conditions can have serious consequences for an elderly patient’s health and independence.
• As many as 10% of hospital admissions in older adults may be related to adverse drug events.

The Beers Criteria is an evidence-based list developed by experts documenting medications which are potentially inappropriate in the elderly.

Medication	Category	Risks
Nitrofurantoin	Antibiotic	Pulmonary toxicity
Diphenhydramine	Anticholinergic	Side effects include somnolence, confusion, constipation and dry mouth
Naproxen	NSAID	Increased risk of gastrointestinal bleeding, acute kidney injury
Hydrocodone/acetaminophen (Vicodin)	Opioid	Associated with delirium and falls in the elderly
Zolpidem	Sedative-hypnotic (nonbenzodiazepine)	Associated with increased risk of falls, fractures, and delirium in older adults

Nitrofurantoin (B), diphenhydramine (D), naproxen (E), Vicodin (F), and zolpidem (G) are all medications which may be appropriate to discontinue:

• Nitrofurantoin is generally an inappropriate medication in the elderly because of its pulmonary toxicity; it is also less effective in patients with a creatinine clearance less than 60 ml/min due to inadequate concentration in the urine. It should not be used for long-term suppression of urinary tract infections in elderly patients. The reason for the nitrofurantoin should be determined and this medication should be stopped or replaced with a safer appropriate antibiotic. If she is taking nitrofurantoin as suppressive therapy to reduce the risk of recurrent UTI’s, the role of suppressive therapy should be reconsidered as the evidence supporting this is not strong.
• Diphenhydramine (Benadryl) should be avoided in all elderly patients because of its strong anticholinergic properties, unless it is necessary for acute treatment of a severe allergic reaction. Side effects include somnolence, constipation, and dry mouth. Anticholinergic drugs (view list) increase the risk of both delirium and falls in elderly patients.
• Naproxen is an NSAID. The American Society of Nephrology recommends that patients of all ages with hypertension, heart failure or chronic kidney disease avoid NSAIDs when possible (read the ASN’s recommendation). NSAIDs should also be avoided in many elderly patients, especially those over age 75 or those taking antiplatelet agents, anticoagulants, or corticosteroids because of the increased risk of gastrointestinal bleeding. See the Deep Dive to learn about the physiologic effects of NSAIDs on the kidney. NSAIDs can also contribute to both hypertension and congestive heart failure exacerbations, and should be avoided in patients with these conditions. Assignment: Aquifer High Value Care 04

Diphenhydramine and NSAIDs are both examples of over-the-counter medications that are inexpensive, but of low value in many patients because of their associated toxicities. It is important to ask about over-the-counter and herbal medications when taking a medication history.

• Zolpidem, which binds the benzodiazepine receptor subunit of the GABA-A receptor complex, is associated with an increased risk of falls, fractures, and delirium in older adults, and is not proven to be very effective in the elderly. Always teach patients about sleep hygiene before considering a sedative-hypnotic.
• Vicodin is an opioid combined with acetaminophen. Opioids can be associated with delirium and falls in the elderly population and should be used with caution. They also carry the risk of addiction.

If the patient has osteoarthritis pain that is refractory to conservative measures, such as exercise, acetaminophen, and physical therapy, judicious use of hydrocodone/acetaminophen is reasonable if it improves her function. Although opioids can be associated with delirium and falls in the elderly population, untreated pain can also contribute to delirium, decreased mobility and decreased quality of life. Opioids should be used with caution in the elderly patient for pain that has been refractory to acetaminophen and non-pharmacologic measures at the lowest effective dose with the goal of improved function. While opioids should be used with caution, they are often appropriate in older adults with refractory pain and would not need to be stopped in this patient if they are used sparingly and improve her function.

Aspirin (A), metoprolol,(C) and lisinopril are indicated in this patient because of her systolic heart failure and ischemic cardiomyopathy.

 

 

 

Question

Which of the following contribute to increased drug costs, particularly for elderly patients? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• Medication price inflation has far exceeded general inflation.
• The number of medications prescribed to patients is rising over time.
• The elderly pay a larger percentage of their prescription medication costs out of pocket.
• Medicare Part D pays 80% of the cost of each prescription medication for those over 65. Assignment: Aquifer High Value Care 04

SUBMIT

Answer Comment

The correct answers are A, B, C.

Nonadherence with medications can increase the use of medical resources. Always ask your patients if they are able to afford their prescriptions. Patients on minimal fixed incomes (most elderly patients) may be unable to afford necessary medications. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Since 1980, prescription medication prices have increased (A) two to three times faster than all consumer prices.

Prescription drug use in the U.S. has been steadily increasing over time. Between 1999 and 2008, the percentage of Americans taking at least one prescription drug increased (B) by 10% and use of five or more drugs increased by 70%; spending for prescription drugs doubled during that time period.

Medicare Part D subsidizes the cost of prescription medications; however, there is a monthly premium, a yearly deductible, and a per prescription co-pay (C), which varies by plan. In addition there is a coverage gap for patients who have more than about $3000 in annual drug costs in 2013. While a patient is in the coverage gap (a.k.a. “donut hole”), he or she pays 79% of the costs of all generic medications and 47.5% of the costs of all brand-name medications. This coverage gap ends at $4750 of drug coverage annually. Because of these costs, not all patients sign up for Medicare Part D.

Medicare Part D does not provide 80% coverage of each prescription (D). Assignment: Aquifer High Value Care 04

References

Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. Centers for Disease Control. NCHS Data Brief. No. 42, September 2010:1-8.

 

 

REASON FOR ADMISSION

HISTORY

READMISSION QUESTION

HISTORY

MEDICATION REVIEW

HISTORY

MEDICATION NON-ADHERENCE

MANAGEMENT

MEDICATION COST

THERAPEUTICS

During her hospitalization, some of Mrs. Miller’s medications have been stopped or changed, and some have been added. Her current medication list in the hospital is as follows:

Hospital Medications	Medications at Home
Scheduled Aquifer High Value Care 04: 80-year-old woman – Medications and value
Aspirin 81 mg po daily	Aspirin 81 mg po daily
Calcium carbonate 500 mg po bid	Calcium carbonate 500 mg po bid
Cholecalciferol 800 IU po daily	Cholecalciferol 800 IU po daily
Furosemide (Lasix) 40 mg po daily	Furosemide 20 mg po daily
Glipizide 5 mg po daily	Glipizide 5 mg po daily
Lisinopril (Prinivil) 10 mg po daily	Lisinopril 10 mg po daily
Metformin 500 mg po bid	Metformin 500 mg po bid
Multivitamin 1 tab po daily	Multivitamin 1 tab po daily
Carvedilol (Coreg) 25 mg po bid	Metoprolol XL 50 mg po daily
Rosuvastatin (Crestor) 10 mg po daily	Pravastatin 40 mg po daily
Omeprazole 20 mg po daily	Nitrofurantoin 50 mg po daily
Naproxen (over-the-counter) patient has been taking 500 mg twice a day for a week
As Needed
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain	Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain
Benadryl 25 mg po q 6 hours prn pruritus
Zolpidem 5 mg po qhs prn insomnia

Question

How could you make this medication list more cost-effective? Document an appropriate discharge medication list here. Aquifer High Value Care 04: 80-year-old woman – Medications and value

Letter Count: 805/1000

SUBMIT

TEACHING POINT

Six Simple Rules for High-Value Medication Prescribing

1. Have a compelling reason for every medication you prescribe. Consider non-pharmacologic alternatives when appropriate.
2. Keep your patient’s medication list as short as possible. Discontinue all non-essential medications and review the list for duplicates.
3. Evaluate affordability before prescribing new medications to patients. This may mean reviewing the patient’s actual copay, generic versus brand name, and the medication tier in their insurance plan. (See High Value Care 06: 65-year-old man – Paying for value: Insurance Part 1.)
4. Make every effort to prescribe generic equivalent medications. Also be aware of lists of less expensive generic prescriptions available at large chain pharmacies, often for as little as $4 per month.
5. Collaborate with pharmacists to avoid drug-drug interactions and help provide lower-cost alternatives.
6. Ask the patient to “teach-back” to show they understand the reason for each medication on the list and how/when to take it. Assignment: Aquifer High Value Care 04

References

Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-92.

 

 

The medication list can be made more cost effective by ensuring the list is as short as possible and ensuring that there is a compelling reason for each prescribed medication. When appropriate, non-pharmacologic alternatives and generic equivalent medications should be considered. It will also be important to find out if there are other lower-cost alternative medications used to treat same health condition and have them replace the medications on the list. Lastly, I will collaborate with pharmacists to help suggest lower-cost alternatives.

 

Furosemide (Lasix) 40 mg po daily

Multivitamin 1-tab po daily

Aspirin 81 mg po daily

Lisinopril 10 mg po daily

Pravastatin 40 mg po daily

Metformin 500 mg po bid

Rosuvastatin (Crestor) 10 mg po daily

Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn pain

 

Answer Comment

The table below outlines a suggested higher-value medication list for this patient, with a comparison of actual monthly costs of the initial and the higher-value medication list, without consideration of her prescription drug plan coverage:

Initial hospital medication list	Cost for 30-daysupply ($)	Higher-value medication list	Cost* for 30-daysupply ($)
Aspirin 81 mg po daily	0.30	Aspirin 81 mg po daily	0.30
Calcium supplement with Vitamin D	1.20	Calcium supplement with Vitamin D	1.20
Coreg (carvedilol) 25 mg po bid	164.24	Metoprolol XL 50 mg po daily	17.65
Crestor (rosuvastatin) 10 mg po daily	188.29	Atorvastatin 40 mg po daily	17.00
Furosemide 40 mg po daily	3.37	Furosemide 40 mg po daily	3.37
Glipizide 5 mg po daily	4.00	Glipizide 5 mg po daily	4.00
Metformin 500 mg po bid	4.00	Metformin 500 mg po bid	4.00
Multivitamin	0.90	(discontinued)	–
Prinivil (lisinopril) 10 mg po daily	44.44	Lisinopril 10 mg po daily	4.00
Omeprazole 20 mg po daily	10.25	(discontinued)	–
Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn severe pain, thirty tabs	17.00	Hydrocodone/acetaminophen 5/500 mg po q 6 hours prn severe pain	17.00
Total cost for a one-month supply	$437.99	Total cost for a one-month supply	$68.52

*Costs are based on GoodRx.com using the zip code 98115 and cheapest Costco prices for over-the-counter medications.

Using a Medicare Part D plan, the per-month cost for these medications using the higher value medication list could be reduced to about $20/month out of pocket, including the monthly premium, copay, and annual deductible. However, many patients do not sign up for Medicare Part D due to the cost. Assignment: Aquifer High Value Care 04

Discontinue nonessential medications started during a hospital stay.

• In the hospital, this patient was started on a proton pump inhibitor, omeprazole. Proton pump inhibitors are sometimes started as prophylaxis against stress ulcers, but there is no evidence to support this outside of the intensive care unit, and proton-pump inhibitors are associated with an increased risk of pneumonia and  difficile colitis.

Always switch back to generics from brand-name hospital formulary medications.

• Hospital formularies often contain expensive brand-name medications obtained through special pricing arrangements between the hospital and pharmaceutical companies.
• In this case, generic lisinopril was substituted for the brand name Prinivil and carvedilol was substituted for brand name Coreg. Although brand name Crestor is available as generic rosuvastatin, another high intensity statin, atorvastatin, was less expensive in Mrs. Miller’s town. Aquifer High Value Care 04: 80-year-old woman – Medications and value

If there is no generic for the brand-name drug chosen, consider whether it is appropriate to switch to a drug in the same class that does have a generic option available.

 

 

 

CARE DISCUSSION

CARE DISCUSSION

It is hospital day four. Mrs. Miller’s dyspnea has resolved, and she is near her goal weight. You plan to discharge her later this morning.

Question

What is the best way to educate your patient

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