Clinical Geriatrics

INTRODUCTION
Research has shown that for every dollar spent on pharmaceuticals, another dollar is spent to manage drug-related problems, costing Americans living in the United States approximately $104.2 billion annually.1-3 The elderly account for 12.7% of the U.S. population, but consume 34% of total prescription medication and 40% of all over-the-counter medicine.4-6 Inappropriate medication use may lead to increased health care services, including physician visits, emergency department visits, and hospitalizations.2 Polypharmacy (use of one or more unnecessary medications)7,8 in older adults is often caused by excessive duration of therapy.9,10 Physicians may be reluctant to discontinue potentially unnecessary medications, especially if they did not initiate the therapy, or if the patient requests therapy to be continued.7,11 Various authors have estimated that between 10% and 20% of hospitalizations among older adults result directly from adverse drug events.12-14

As part of the interdisciplinary team of a long-term care diversion provider, consultant pharmacists collaborate with geriatrician medical directors to review high-risk enrollee medication records. The long-term care diversion programs are designed for community-dwelling, frail elderly who are eligible for nursing home level of care but choose to remain living in the community. Enrollees are assisted by a dedicated care manager to form an individualized care plan that includes home- and community-based services with comprehensive coordination of medical, social, and behavioral health needs.

BACKGROUND
The authors wanted to evaluate the impact of consultant pharmacist collaboration with prescribers in the resolution of potential drug-related problems (DRPs) within Evercare community-based, long-term care programs (Figure). Over the course of 18 months, consultant pharmacists reviewed medication records in three Evercare sites in Florida, Arizona, and Massachusetts. A claims-based query tool identified patients at risk of DRPs, including unnecessary drug use, duplication of therapy, compliance, dosing, duration of therapy, drug-drug and drug-disease interactions, and Preferred Drug List (PDL) compliance. Faxes containing one or more recommendations were sent to prescribers. Returned responses were then tracked for prescriber agreement/disagreement.

Of the 982 medication records that were reviewed, 1191 potential DRPs were identified. Of the DRPs identified, 528 (44%) were for duration of therapy, 286 (24%) were for duplication of therapy, 163 (14%) were for dosing concerns, 107 (9%) were for drug-drug or drug-disease interaction, 102 (9%) were for missing appropriate indication, 54 (5%) were for nonpreferred (non-PDL), and 5 (1%) were for patient compliance issues. These reviews led to 1245 interventions containing one or more recommendations by the pharmacist.

The majority (1141 or 91%) were communicated to the prescribers in the form of faxes; 137 (11%) action plans were developed for the care manager to work with the enrollee, and 9 (1%) phone calls were made to prescribers. Of the 251 recommendations that were accepted, clinicians agreed to discontinue 241 (96%) of the medications; others agreed to switch to a different drug (3%) or change the dosing (2%). Using Beer’s criteria15 and clinical judgment, consultant pharmacists estimated that their interventions prevented serious DRPs in 21 (1%) of the cases reviewed.

DISCUSSION
Consistent with the current literature, the onsite geriatric consultant pharmacists found the four leading problematic medication classes to include gastrointestinal agents, analgesics, antipsychotics, and cardiovascular agents. Potential DRPs identified from these reviews included duration of therapy, duplication of therapy, inappropriate dosing, drug-drug or drug-disease interactions, and clinical indication issues.