Objectives: 
To determine whether a general practitioner focused intervention aimed at decreasing PIM prescribing in the elderly can decrease the risk of PIM-related hospitalizations.
Poster presented at 2016 ISPOR conference in Washington DC.https://jdc.jefferson.edu/jcphposters/1005/thumbnail.jp

Alcusky, M.

Del Canale, S.

Hegarty, PharmD, Sarah E

Keith, S. W.

Lombardi, M.

Maio, PharmD, MSPH, Vittorio

McRae, PharmD, Jacquelyn

Varga, S.

Vegesna, A.

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsJefferson College of Population Health Posters Jefferson College of Population Health5-24-2016Did a physician-targeted intervention that reducedpotentially inappropriate prescribing to elderlypatients also reduce related hospitalizations?Jacquelyn McRae, PharmDJefferson College of Population Health, Thomas Jefferson University, Jacquelyn.McRae@jefferson.eduSarah E. Hegarty, PharmDDepartment of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, sarah.hegarty@jefferson.eduM. AlcuskyJefferson College of Population Health, Thomas Jefferson UniversityA. VegesnaJefferson College of Population Health, Thomas Jefferson UniversityS. VargaJefferson College of Population Health, Thomas Jefferson UniversitySee next page for additional authorsFollow this and additional works at: http://jdc.jefferson.edu/jcphpostersPart of the Health Services Administration Commons, and the Pharmacy and PharmaceuticalSciences CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inJefferson College of Population Health Posters by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationMcRae, PharmD, Jacquelyn; Hegarty, PharmD, Sarah E.; Alcusky, M.; Vegesna, A.; Varga, S.; Keith, S. W.; Del Canale, S.; Lombardi,M.; and Maio, PharmD, MSPH, Vittorio, "Did a physician-targeted intervention that reduced potentially inappropriate prescribing toelderly patients also reduce related hospitalizations?" (2016). Jefferson College of Population Health Posters. 7.http://jdc.jefferson.edu/jcphposters/7AuthorsJacquelyn McRae, PharmD; Sarah E. Hegarty, PharmD; M. Alcusky; A. Vegesna; S. Varga; S. W. Keith; S. DelCanale; M. Lombardi; and Vittorio Maio, PharmD, MSPHThis poster is available at Jefferson Digital Commons: http://jdc.jefferson.edu/jcphposters/7Add logo here 1. Jefferson College of Population Health, Thomas Jefferson University, Philadelphia PA 2. Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia PA 3. Parma Local Health Authority, Parma Italy RESULTS METHODS OBJECTIVES LIMITATIONS REFERENCES CONCLUSIONS • The RER database does not include inpatient medications (potential underestimation of PIM exposure). • Although adjusted for available confounders, causality of hospitalizations is unknown.   Did a physician-targeted intervention that reduced potentially inappropriate prescribing to elderly patients also reduce related hospitalizations?  McRae JM1, Hegarty S2, Alcusky M1, Vegesna A1, M, Varga S1,Keith SW2, Del Canale S3, Lombardi M3, Maio V1 • A potentially inappropriate medication (PIM) is a drug that may be inappropriate because the risks outweigh the potential benefits.1 • PIM use in the elderly can be especially harmful due to less effective clearance systems, frail bodies, and polypharmacy.2,3 • Maio and colleagues estimated that approximately 20% of elderly Emilia-Romagna residents were prescribed a PIM in 2006.4 • A retrospective, longitudinal analysis of over 1.4 million elderly, Emilia-Romagna residents (2003-2013) demonstrated that individuals exposed to a PIM were 16% more likely to be hospitalized than persons unexposed to PIM.5  • Evidence of the clinical effectiveness of interventions aimed at reducing PIM prescribing in the elderly is limited and has yielded mixed results.6 To determine whether a general practitioner focused intervention aimed at decreasing PIM prescribing in the elderly can decrease the risk of PIM-related hospitalizations.   PIM Exposure & Hospitalizations • Approximately 411 PIM-related hospitalizations were avoided in Parma LHA and elderly residents during post-intervention were at significantly lower risks of PIM-related hospitalizations than pre-intervention.  • We believe that the observed decline in PIM-hospitalizations within Parma LHA was attributable to the decreased exposure to PIMs. • To our knowledge this is the first study to evaluate the effectiveness of a multi-year, PIM awareness program with respect to incident hospitalizations.  • We believe that the observed decreased risk of PIM-related hospitalizations in Parma LHA post-intervention was due to changes in physician behavior. • We urge researchers to continue to evaluate the effectiveness of interventions targeted at increasing awareness of the potential harms of PIM in the elderly.  Table 1. Demographics, 2008 This study was reviewed by the Thomas Jefferson University IRB and determined not to constitute human subjects research.  Intervention • Implemented over a 2 year time period: 2008-2009.7  • Serving residents of the Local Health Authority (LHA) of Parma, Emilia-Romagna region (RER), Italy, one of the 11 regional LHAs. • Aimed to engage 303 general practitioners (GPs) on PIM awareness in the elderly population. • The three components of the intervention included: 1. Circulation of a developed list of PIM to “always be avoided” and a list of alternatives. 2. Annual reviews of incidence of PIM use in the elderly. 3. Educational sessions on PIM use (academic, case reviews). Comparators • We evaluated the effectiveness of the physician-directed PIM intervention by comparing the risk of PIM-related hospitalizations for residents under the care of a general practitioner (GP) in Parma LHA during and after intervention (post-intervention, 1/1/2008-9/30/2011) to residents under the care of a GP in the rest of the RER (Non-Parma). Study Population • Study time period: 01/01/2005 – 09/30/2011. • Elderly individuals (≥65 years old) who were residents of RER for at least one year were included in the cohort.  • Individuals exited the cohort at the earliest time they met one of the following criteria: death, moved out of the region, or hospitalization for more than 30 consecutive days.  Modeling • We developed a time-dependent covariate, repeated-events, Cox Proportional Hazard Model using fully-linked longitudinal administrative claims from the RER database.  • Event of interest: PIM-related hospitalizations, defined as an unplanned, inpatient hospitalization occurring during PIM exposure. • Defined PIM: Drugs that should be “always be avoided”, according to the 2007 Maio Criteria.8  • To estimate PIM exposure we computed the number of days supplied for each medication of interest (using Defined Daily Doses) and added 30 days to capture any residual effects of a PIM.  An individual was considered exposed to PIM from the date the prescription was filled until 30 days after the prescription was expected to end based on DDD. • Adjustments for the outcome included: age, gender, number of non-PIM hospitalizations (in the previous four quarters), number of chronic condition drug groups (CCDGs) (in the previous four quarters).9 Calculations • Demographics were summarized for Parma and Non-Parma at the start of the intervention (01/01/2008).  • Unadjusted PIM exposure and PIM related-hospitalizations were estimated for Parma vs. Non-Parma residents.  • We used Cox modeling to estimate adjusted hazard ratios (HRs) of PIM-related hospitalizations for Parma post vs. pre-intervention.  • We calculated the number of PIM-related hospitalizations avoided in Parma post-intervention vs. pre-intervention (Figure 1).  1. Dunn RL, Harrison D, and Ripley TL. The Beers Criteria as an outpatient screening tool for potentially inappropriate medications. The Consultant Pharmacist. 2010; 26 (10):754-763.  2. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, and Mitchell AA. Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States. JAMA. 2002; 287 (3).  3. Shi S, Morike K, and Koltz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol. 2008; 64:183-199. 4. Maio V, Yuen EJ, Novielli K, et al. Potentially inappropriate medication prescribing for elderly outpatients in Emilia 126 S. W. Keith et al. Romagna, Italy: a population-based cohort study. Drugs Aging. 2006;23(11):915–24.  5. McRae JM, Varga S, Vegesna A, Alcusky M, Hegarty S, Keith S, Del Canale S, Lombardi M, and Maio V. Potentially Inappropriate Medications in the Elderly and Associated Outcomes: What can the US learn from a retrospective Italian cohort study? 2015 Academy of Managed Care Nexus Conference. Poster presentation.  6. Kaur S, Mitchell G, Vitetta L, et al. Interventions that can reduce inappropriate prescribing in the elderly: a systematic review. Drugs Aging. 2009;26(12):1013–28. 7. Keith SW, Maio V, Dudash K, Templin M, and Del Canale S. A Physician-Focused Intervention to Reduce Potentially Inappropriate Medication Prescribing in Older People. Drugs Aging. 2013; 30:119-127.  8. Emilia Romagna website. Appropriatezza prescrittiva nella popolazione anziana. 2014. Available at: http://salute.regione.emilia-romagna.it/siseps/sanita/prim/files/Farmacipotenzialmenteinappropriatiedalternativi.pdf. 9. Maio V, Yuen EJ, Rabinowitz C, Louis DZ, Jimbo M, Donatini A, Mall S, Taroni F. Using Pharmacy Data to Identify Those with Chronic Conditions in Emilia Romagna, Italy. Journal of Health Services Research and Policy 2005;10(4):232-238   Figure 1. Equations for Hospitalizations Avoided        All Non-Parma,  n(%) Parma,  n(%) N % No. Patients 906,810 100% 816,325 (100%) 90,485 (100%) Exposed to PIM (yes) 76,070 8.4% 68,798  (8.4%) 7,272 (8.0%) Female  522,895 57.7% 470,132 (57.6%)  52,763 (58.3%) Age    65-74 years 459,946 50.7% 414,590 (50.8%) 45,356 (50.1%)    75- 84 years 328,065 36.2% 295,318 (36.2%) 32,747 (36.2%)    >84 years 118,799 13.1% 106,417 (13.0%) 12,382 (13.7%) Hospitalizations, 2007     0 757,427 83.5% 681,609 (83.5%) 75,818 (83.8%)    1-2 134,989 14.9% 121,658 (14.9%) 13,331 (14.7%)    3-4 12,207 1.3% 11,043 (1.4%) 1,164 (1.3%)    5+ 2,187 0.2% 2,015 (0.2%) 172 (0.2%) CCDGs, 2007    0 53,241 5.9% 47,367 (5.8%) 5,874 (6.5%)    1-2 378,357 41.7% 339,836 (41.6%) 38,521 (42.6%)    3-4 334,820 36.9% 302,291 (37.0%) 32,529 (35.9%)    5+ 140,392 15.5% 126,831 (15.5%) 13,561 (15.0%) • In 2005, residents of Parma and Non-Parma were exposed to approximately 8 person years (PYs) of PIM per 100 PYs follow-up time (Figure 2).  • Post-intervention, we observed a decrease in exposure to PIM, appearing a more drastic decline in Parma than Non-Parma.  • Post-intervention there appears to be a decline in PIM-related hospitalizations in Parma consistent with the decline in PIM-exposure (post-intervention).  RESULTS • When the intervention was introduced in 2008, there were 906,810 elderly residents in the Emilia-Romagna region and approximately 1/10th were under the care of a Parma GP.  • The exposure to PIM, previous hospitalizations, and comorbid status, gender, and age strata of residents in Parma and Non-Parma were similar. Demographics Data for this study was retrieved from the Regional database of the Emilia-Romagna Region, provided through a collaborative agreement between the Health Care Authority, Regione Emilia-Romagna, Italy, and Thomas Jefferson University.   Presented at 2016 ISPOR 21st Annual International Meeting, Washington, DC, USA Figure 2. Parma vs. Non-Parma Trends, 2005-2011 Hazard Ratios • Compared with others in the RER during the same periods, Parma residents post-intervention were 7% less likely to have a PIM-related hospitalization than pre-intervention (Table 2). • We estimated that approximately 411 PIM-related hospitalizations were avoided due to the intervention.  HR (95% CI)  P value Post- vs. Pre- Intervention 0.93  (0.89, 0.97) 0.002 Female 0.90 (0.89, 0.91) <0.001 Age 1.08 (1.08, 1.08) <0.001 1+ CCDG 1.50 (1.50, 1.51) <0.001 1+ hospitalization 1.23 (1.23, 1.24) <0.001 Table 2. Cox Model Results INTRODUCTION 

Did a physician-targeted intervention that reduced potentially inappropriate prescribing to elderly patients also reduce related hospitalizations?

Objectives: 
To determine whether a general practitioner focused intervention aimed at decreasing PIM prescribing in the elderly can decrease the risk of PIM-related hospitalizations.
Poster presented at 2016 ISPOR conference in Washington DC.http://jdc.jefferson.edu/jcphposters/1005/thumbnail.jp

Name not available

http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1005&context=jcphposters

Did a physician-targeted intervention that reduced potentially inappropriate prescribing to elderly patients also reduce related hospitalizations?

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