Tackling the polypharmacy problem in chronic care management

Research has shown that prescribing for older patients with multiple chronic conditions (MCCs) often leads to medication regimens that are complicated, difficult to adhere to, and contain multiple drug-drug and drug-disease interactions.1 Polypharmacy, the use of multiple medications, is a particular concern for older patients with MCCs and their clinicians; the greater the number of medications prescribed, the greater the likelihood that issues will be present.

Polypharmacy is associated with adverse outcomes including mortality, falls, adverse drug reactions, increased lengths of stay, and readmission to hospital soon after discharge.2-4

Three in 4 Americans aged 65 and over have multiple chronic conditions,5 and polypharmacy is common in these older patients. For example, in a 2012 study of 44 primary care clinics, more than half of patients being treated for hypertension and type 2 diabetes were taking 5 or more medications.6 The Centers for Disease Control and Prevention estimates that 40% of people older than age 60 take 5 medications or more.7

The issues associated with polypharmacy will only grow. The US Department of Health and Human Services predicts that 81 million Americans will have multiple chronic conditions by 2020.9 Rates of diagnosis of chronic illness, with associated polypharmacy, are high and rising.  Contributing factors include6

  • Lower diagnostic criteria for common chronic conditions, e.g., the 2017 revision for hypertension (130/80 or higher, lowered from 140/90)
  • Greater use of quality measures and incentives to help patients reach their target levels or scores
  • The prescribing cascade—prescribing medications to treat the side effects of drugs prescribed to treat the illness

Primary care clinicians are on the front lines managing polypharmacy

With patients being treated for MCCs accounting for more than 75% of primary care visits,8 primary care clinicians often become the de facto care coordinators for multiple specialists and other healthcare providers. A 2018 Quest Diagnostics survey of physicians who treat patients with MCCs highlighted their concerns regarding this scenario.

When asked about their chronic care patients, primary care clinicians see a lot of challenges that need to be addressed more effectively. Key findings include9

  • A large majority of primary care clinicians—85 percent—say that they are too pressed for time to address complex clinical issues
  • Two-thirds of primary care physicians say they do not have time to address social and behavioral issues, such as loneliness or financial issues, that affect their patients’ health
  • Physicians are concerned that these patients are not asking medications as prescribed
  • Only 9 percent of physicians report being “very satisfied” their Medicare patients with MCCs are “getting all the attention they need to care for all medial issues”

Source: Regina Corso Consulting. Chronic care management survey report, February 2018.

The irony is that the patients least able to cope with polypharmacy are the very patients most likely to be dealing with it. The consequences can be dire. Polypharmacy in heart failure treatment, for example, often leads to poor adherence to pharmacological therapies, drug-drug interactions, and adverse effects.10

This presents a dual dilemma for primary care clinicians: how to keep patients adherent as well as protected from the harmful effects of inadvertent drug misuse.

How does one stay on top of polypharmacy?

As an increasing number of older patients are prescribed more medications, primary care clinicians must adopt strategies to monitor patients with MCCs more closely. A dual strategy is one possible approach that addresses both medication adherence and drug misuse.

Consider Chronic Care Management services for Medicare patients.

Research shows that patients with MCCs have better outcomes when they are given tools to promote better self-care and have a skilled resource to help coordinate care between multiple providers.11 Yet resource-strapped practices are often unable to provide these education and coordination services.

A new service available to primary care practices for their Medicare patients, Quest Chronic Care Management (CCM) Services addresses this gap in care by providing management of patients with MCCs between office visits. CCM extends care by providing:

  • A minimum of 20 minutes of monthly, non-face-to-face services to help meet the requirements for reimbursable chronic care management services under CPT 99490*
  • Care coordinator outreach (LPN/RN) to provide care coordination and navigation
  • Development of comprehensive care plans that will be reviewed and approved by a practice physician(s)
  • Medication reconciliation to help guard against error and support patient compliance
  • Physician notification if patient reports an ER visit, hospital discharge, or skilled nursing facility stay
  • Coordination with specialists and home- and community-based service providers

CCM Services help clinicians address polypharmacy with medication reconciliation as well as between-visit check-ins to ease patient confusion or feelings of being overwhelmed.

*The CPT codes provided are based on American Medical Association guidelines and are for informational purposes only. CPT coding is the sole responsibility of the

billing party. Please direct any questions regarding coding to the payer being billed.

Consider clinical drug monitoring for patients with MCCs on long-term opioid therapy.

Older patients undergoing chronic pain management may be at higher risk of medication misuse or harmful drug-drug interactions. In the most recent Health Trends™ report on drug misuse in America, Quest Diagnostics reports that, in 2017, 43% of Medicare patients and 43.5% of patients 65 and older had misused drugs.12

The most common form of misuse was drug mixing, with the most common combination, opioids and benzodiazepines, also the deadliest. Combined, these drugs cause respiratory depression, which in turn causes overdose death.

Clinical drug monitoring can detect misuse in patients, identifying those who are taking a medication not prescribed to them or in danger of deadly drug combinations. Such monitoring is guideline-supported. Opioid prescription and management guidelines issued by the Centers for Disease Control and Prevention (CDC) in 2016 include use of urine drug testing before starting opioid therapy, and consideration of urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit substances.13 Making clinical drug monitoring standard practice for patients on long-term opioid therapy is a strategy that helps protect both patients and the practice. Objective data about what drugs a patient is taking can help prevent or address dangerous misuse.

Greater continuity of care through chronic care management services and greater protection through clinical drug monitoring form a two-prong strategy that can mitigate some of the risks of polypharmacy and protect your practice as well. These actions can also lead to healthier, safer patients who are less overwhelmed and more confident living with multiple chronic conditions. This, in turn, offers clinicians greater reassurance they are providing their patients with the best possible care.

 

References

  1. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “there’s got to be a happy medium.” JAMA. 2010;304(14):1592-1601. doi:10.1001/jama.2010.1482
  2. Milton JC, Hill-Smith I, Jackson SH. Prescribing for older people. BMJ. 2008;336(7644):606-609. doi:10.1136/bmj.39503.424653.80
  3. Caughey GE, Roughead EE, Pratt N, Shakib S, Vitry AI, Gilbert AL. Increased risk of hip fracture in the elderly associated with prochlorperazine: is a prescribing cascade contributing? Pharmacoepidemiol Drug Saf. 2010;19(9):977-982. doi:10.1002/pds.2009
  4. Caughey GE, Roughead EE, Vitry AI, McDermott RA, Shakib S, Gilbert AL. Comorbidity in the elderly with diabetes: identification of areas of potential treatment conflicts. Diabetes Res Clin Pract. 2010;87(3):385-393. doi:10.1016/j.diabres.2009.10.019
  5. Health and Human Services. About the multiple chronic conditions initiative. https://www.hhs.gov/ash/about-ash/multiple-chronic-conditions/about-mcc/index.html?language=en. Accessed December 7, 2018.
  6. Hunt LM, Kreiner M, and Brody H. The changing face of chronic illness management in primary care: a qualitative study of underlying influences and unintended outcomes. Ann Fam Med 2012;10:452-460. doi:10.1370/afm.1380
  7. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: US prescription drug data for 2007-2008. NCHS Data 2010;(42):1-8.
  8. Zamosky L. Chronic disease: a growing challenge for PCPs. Med Econ. http://www.medicaleconomics.com/modern-medicine-feature-articles/chronic-disease-growing-challenge-pcps. August 9, 2013. Accessed December 7, 2018.
  9. Regina Corso Consulting. Chronic care management survey report, February 2018. Survey included 301 physicians who treat patients with chronic conditions and 500 adults 65 and older who have at least two chronic conditions and are on Medicare. Survey was conducted online February 13-21, 2018.
  10.  Mastromarino V, Casenghi M, Testa M, et al. Polypharmacy in heart failure patients. Curr Heart Fail Rep.2014;11(2):212-219.  doi:10.1007/s11897-014-0186-8
  11.  Agency for Healthcare Research and Quality. Chronic disease management can reduce readmissions.  https://innovations.ahrq.gov/perspectives/chronic-disease-management-can-reduce-readmissions. Updated March 26, 2014.  Accessed December 7, 2018.
  12.  Quest Diagnostics. Health Trends™: Drug Misuse in America 2018. https://questdiagnostics.com/dms/Documents/drugprescriptionmisuse/Health_Trends_Report_2018.pdf. Published September  6, 2018. Accessed November 12, 2018.
  13.  Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm  2016;65(1):1-49. http://dx.doi.org/10.15585/mmwr.rr6501e1
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