This presentation by Alixe Bonardi goes over the use of pharmaceutical drugs among adults with developmental disabilities, touching on why adults use drugs, when, and the situations that lead pharmacists to prescribe certain drugs.
Presented at the National Association of State Directors of Developmental Disabilities Services (NASDDDS) Reinventing Quality Conference 2012

Bonardi, Alexandra

Grossman, Gail

Lauer, Emily

English

eScholarship@UMMS

University of Massachusetts Medical School eScholarship@UMMS Commonwealth Medicine Publications Commonwealth Medicine 2012-08-07 Massachusetts Department of Developmental Services Medication Review Alexandra Bonardi University of Massachusetts Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/commed_pubs  Part of the Health Policy Commons, Health Services Administration Commons, Health Services Research Commons, Mental Disorders Commons, and the Pharmacy and Pharmaceutical Sciences Commons Repository Citation Bonardi A, Grossman G, Lauer E. (2012). Massachusetts Department of Developmental Services Medication Review. Commonwealth Medicine Publications. https://doi.org/10.13028/v6xg-dg61. Retrieved from https://escholarship.umassmed.edu/commed_pubs/69 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Commonwealth Medicine Publications by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu.  Massachusetts Department of Developmental Services Medication Review NASDDDS Reinventing Quality August 7, 2012  Alixe Bonardi1, Gail Grossman2 Emily Lauer1 1 University of Massachusetts Medical School 2 Massachusetts Department of Developmental Services Pharmacy (medication) use among adults in the MA DDS population  DDS Medication Review Committee • Clinical Reviews • Population analyses • Training   Medicaid pharmacy claims analyses (2012)  • Study design and validation.  •  Initial results from analysis of data match.   Pharmacotherapy is a common intervention in people with IDD  In MA DDS population analysis, 62% were receiving one or more psychotropic medication (Rate was 47% when anticonvulsants removed)  MA DDS (January 2003 Snapshot ; n=16,212 adults) 4 Rank Brand Name Class # of Prescriptions 1 Depakote Anticonvulsant 18181 2 Risperdal Atypical Antipsychotic 16756 3 Levoxyl Thyroid hormone 12181 4 Zyprexa Atypical Antipsychotic 11175 5 Carbamazepine Anticonvulsant 10743 6 Zoloft Antidepressant 9989 7 Neurontin Anticonvulsant 8678 8 Clonazepam Anticonvulsant 8261 9 Celexa Antidepressant 7839 10 Lorazepam Anxiolytic 7112 Top 10 Rx’s to ‘DMR’ Population over 7 months (2002-2003) 5 Top 11-20 Rx’s to ‘DMR’ Population over 7 mo. Rank Brand Name Class # of Prescriptions 11 Lipitor Cholesterol 6942 12 Phenobarbital Anticonvulsant 6939 13 Fluoxetine HCl Antidepressant 6871 14 Trazodone HCl Antidepressant 6715 15 Phenytoin Na Ext Anticonvulsant 6519 16 Buspirone HCl Anxiolytic 6460 17 Paxil Antidepressant 6253 18 Dilantin Anticonvulsant 5989 19 Seroquel Atypical Antipsychotic 5975 20 Protonix Ulcer/Reflux Disease 5784 NCI: ‘Takes medication for behavior problems’ (2008-2009) Massachusetts All 20 Participating States 21% 24% NCI: ‘Takes medication for anxiety’ (2008-2009) Massachusetts All 20 Participating States 35% 25% MA DDS analysis (2005):  •Avg.  2.75 psychotropic medications (including anticonvulsants)   •61% receiving anticonvulsants also received 1 or more other psychotropic medication  •40% of those on anticonvulsants receive 2 or more types of anticonvulsants concurrently    Polypharmacy is also common 9 Psychotropic Medications per Person over 1 month # of Psychotropics # of people % of population 0 4618 28.5% 1 3117 19.2% 2 2939 18.1% 3 2344 14.5% 4 1508 9.3% 5 907 5.6% 6 456 2.8% 7 193 1.2% 8 72 <1% 9 26 <1% 10 19 <1% >10 13 <1% Range:  0-11 psychotropic medications Psychotropic medication use increases risk of health complications • Weight gain • Abnormal glucose metabolism (diabetes) • Cardiovascular disturbances • Oral health issues • Extra pyramidal symptoms, TD.  Lunsky & Elserafi (2011) Research in Developmental Disabilities Prescribers are not always well prepared to treat the IDD population   Majority of  medical care from community health care providers.    Communication difficulties may challenge ability to monitor response to medication.     Complex medical picture can result in multiple prescribers.     2004 CAN survey: 53% of medical school deans did not feel their graduates were competent to treat people with N/ID. 1.21.51.72.12.801231 2 3 4-6 7No Psychtropics per PersonAve No. PrescribersThe more practitioners prescribing,the more psychotropic medicationreceived!MA analysis of prescribers (2005) • 50% of prescribers of psychotropics were generalists  • 2,637 practitioners prescribed non-anticonvulsant psychotropics   More prescribers = More meds ! MA DDS Behavioral Supports Current initiatives include: Positive Behavioral Supports (PBS) training and interventions Updated curriculum re. restraints Medication Review Committee Clinical Review Provider Outreach  Training and Continuing Education  Analysis of Health Care and Claims Records Membership:   PhD psychologists (behaviorists) Psych. clinical nurse specialist (CNS) Clinical Pharmacist Internist (MD) Gerontologist (MD)  Neurologist (MD) Psychiatrist (MD)  RNs and NP Hospitalist (MD) * All with significant experience treating adults with IDD  Complex Case Consultation available through referral to the Med. Review Committee  Referral through regional offices  Treatment team invited to participate  Average 2 reviews per meeting  Results sent to regional/area office with request to forward to provider  Direct consult with health care provider when requested. Clinical Reviews – impressions:    Complicated intersection of behavioral and physical issues (e.g. pain)  Earlier signs of age-related issues (dementia, changes in drug metabolism)  Practitioners struggling with prescribing in a community setting (caregiver issues, hesitancy to titrate)  Professional-to-professional outreach from team has included direct consultation, phone consultation.  Clinical Reviews:  One year follow up Of those who were reviewed with recommendation to remove medications – general improvement in function and impression of avoided psychiatric events.  Where recommendations were not followed, individual continued to do poorly.  As a group, those who were identified with emerging dementia showed continued decline in function.   Medication Review Committee guides DDS outreach to prescribers Analyses of DDS Health Care Records to identify ‘top prescribers’ (regionally, by medication, specialty)  Example: identified 191 psychiatric prescribers: 4+ non PRN psychoactive meds in 2012 (11 prescribers serving 15 – 40 people)  Letter sent to prescribers offering consult from clinical pharmacist.  Clinical pharmacist followed up by phone/in person. 2012 Analysis of Medicaid Pharmacy Claims Data is underway Provides information on a larger, more diverse DDS population.  Evaluating the methodology (data match, using Medicaid claims data) in light of new policy/funding models related to pharmacy.   Several recent policy changes may  influencing prescription and claims patterns  in the DDS population Massachusetts Health Reform MassHealth Pharmacy Intiatives MMA - Medicare Part D  Dual eligible population (~ 65% of adults served) Change in formulary (e.g. benzodiazepines) Affordable Care Act – duals integration efforts Medicaid Managed Care Patient Centered Medical Homes (for adults)  MassHealth payment claims analysis – preliminary questions How many adults will the the dataset ‘match’ methodology identify?  Is Medicaid claims data analysis feasible, since duals would only have record of co-pays (if they are claimed by pharmacies)?  Linked dataset DDS- MassHealth • Timeline: ~ 10+ months from initial data request for inter-agency data sharing • Of 20,346 people eligible for Medicaid (from DDS), 15,069 (74%) had 1 or more paid drug claim during the 7 month period.    Adults without claims include:  • not on any medications • private insurance coverage •  dually eligible and had a prescription filled at a pharmacy that did not submit for the small Medicaid co-pay. • Nursing home, ICF/MR, incarcerated. Analysis plan and next steps • Finalize data validation • Analysis of individual and provider-level prescriptions patterns.  • Targeted outreach to providers whose prescription patterns vary substantially from accepted practice (guidelines). • Identify individuals who may be in need of medication review.  • Evaluate prescribing practices across service settings for the purpose of planning broader training or outreach interventions.   Conclusion Massachusetts DDS is pursuing a multi-level approach to ensuring medications are used appropriately to support behavioral needs.   Multidisciplinary team provides expertise for both individual review and for systems’ level interventions.   Analysis of of claims data and health records allows targeted outreach.    Contacts:  DDS Medication Review Committee janice.o’keefe@state.ma.us  2012 CDDER Pharmacy Analysis  alexandra.bonardi@umassmed.edu 

Massachusetts Department of Developmental Services Medication Review

https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1062&amp;context=commed_pubs

Massachusetts Department of Developmental Services Medication Review

Abstract

Similar works

Full text

Available Versions

eScholarship@UMMS