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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
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
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.
Which of the following are likely to contribute to a HF exacerbation requiring readmission? Select all that apply.
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
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.
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.
Why is readmission to the hospital within 30 days of discharge a concern? Select all that apply.
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
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.
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:
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.
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
As needed medications
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.
SUBMIT
TEACHING POINT
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
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.
SUBMIT
Answer Comment
The correct answers are B, D, E, F, G.
Adverse Drug Events in the Elderly
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:
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.
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.
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.
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 |
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
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.
Always switch back to generics from brand-name hospital formulary medications.
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.
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.
What is the best way to educate your patient about her medications before discharge? Choose the single best answer.
SUBMIT
TEACHING POINT
The teach-back method assesses the patient’s recall and comprehension of any new concept. It is an effective method for both assessing a patient’s understanding of a situation and providing education. It should be used to educate patients about their medications before hospital discharge.
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847.
Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373-1379.
White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs.2013;28(2):137-46.
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication wtih diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
Question
What is the best way to educate your patient about her medications before discharge? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
Answer Comment
The correct answer is A.
Discrepancies between what a patient is prescribed upon discharge from the hospital and what they actually take at home are common and are associated with a higher rate of hospital readmission, as happened in this case. Thoughtful patient education may improve adherence and reduce the chance of readmission. The teach-back method (A), in which a clinician assesses the patient’s recall and comprehension of any new concept, is an effective method for both assessing a patient’s understanding of a situation and providing education if the patient cannot demonstrate understanding. Using teach-back simply involves asking patients to restate information that has been presented to them. It allows the provider to check the patient’s understanding, reinforce important concepts, and engage in open dialogue.
Answers B and C are not the best answers as it is not clear that the nurse and pharmacist will use the teach back method. Ordering home health nursing and having the nurse check to make sure she is taking her medications correctly (D) is a strategy to identify medication nonadherence after it occurs. The best strategy should prevent nonadherence.Assignment: Aquifer High Value Care 04
View guidelines for using teach-back in patient education.
Mrs. Miller receives her discharge instructions:
Mrs. Miller discharge instructions
Click here for a transcript of the video above.
You see Mrs. Miller in clinic with your preceptor three months later. Mrs. Miller has not been rehospitalized, and her heart failure has been stable. She has had one fall without serious injuries and continues to have trouble with her memory.
Your preceptor asks you to review the patient’s diabetes control during this visit. She has been on metformin and glipizide, and a recent HbA1C was 6.5%. She has stage II chronic kidney disease with a recent creatinine of 1.2 mg/dL and eGFR of 45. She watches her diet carefully, and in fact has lost ten pounds in the past year. Her BMI is 25. Aquifer High Value Care 04: 80-year-old woman – Medications and value
What should you do today regarding Mrs. Miller’s diabetes management? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
SUBMIT
The correct answer is B.
Reducing medications in the elderly reduces harm. Elderly patients on more than 4 medications are at higher risk of adverse events such as falls.
Mrs. Miller is a frail, community-dwelling elderly person, with a life expectancy that is likely less than 10 years. See the Expert for more information regarding prognosis in the elderly. Her goal HbA1C should be about 8% based on current guidelines (see guideline #3).
Comorbidities | Goal HbA1C |
Healthy older adults with long life expectancy | 7-7.5% |
Older adults with comorbidities and life expectancy <10 years | 7.5-8% |
Multiple comorbidities and shorter life expectancy, including most patients in long-term care facilities | 8-9% |
Because Mrs. Miller’s HbA1C was 6.5%, and because she had fallen and is at increased risk of falling with hypoglycemia, her glipizide should be stopped, thus answers (A) and (D) are incorrect. In the future, the metformin could be decreased (C) or stopped (E) depending on her A1c and renal function. Her weight should be monitored closely because weight loss in the elderly is a marker of frailty and may reflect difficulties with self-care in a patient with cognitive impairment.
Glipizide should be stopped before metformin because of the risk of hypoglycemia with sulfonylureas and better evidence for efficacy and safety in the older population with metformin.
TEACHING POINT
Reducing medications in the elderly reduces harm. Considering an elderly patient’s life expectancy before offering interventions is an important part of high-value care in this population.
Sue Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342-56.
DEEP DIVE
Yourman L, Lee S. Prognostic Indices for Older Adults: A Systematic Review. JAMA. 2012;307(2);182-192.
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