Electronic Tracking System Can Help Diabetes Patient Care

An electronic system with personalized patient information shared by diabetes patients and their primary care providers improved diabetes care and clinical outcomes, found a new study in CMAJ (Canadian Medical Association Journal).

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The study involved 511 patients and 46 family physicians and nurse-practitioners and offered web-based tools integrated with 5 different types of electronic health records, an automated telephone reminder system and a mailing of colour-coded materials to half the study sample. Sixty two per cent of patients improved with the intervention compared with 42.6% in the control group and intervention patients reported greater satisfaction with their diabetes care.

Diabetes affects approximately 7% of the populations of Canada and the US – about 23 million people – and costs $105 billion in direct annual healthcare costs. Most diabetes care is community-based, largely managed by primary care physicians.

The study is one of the first randomized trials to show success in community-based primary care and the first such trial in Canada.

"Despite the technical challenges for both patients and physicians, we have demonstrated that the care of a complex chronic disease can be improved with electronic tracking and decision support shared by family physician and patient," write Dr. Anne Marie Holbrook of McMaster University and coauthors.

The results of the study "provide strong evidence that complex research interventions can and should be implemented in community-based practices," say Dr. Richard Grant and Dr. Blackford Middleton of Harvard Medical School in a related commentary. The next steps are to create patient-centred rather than disease-focused systems to address a wide range of patient concerns and help clinical management of complex diseases outside of a visit to a doctor or nurse.

Source : http://www.sciencedaily.com/releases/2009/07/090706171456.htm

Changes in Medicare Pay Rules Could Have a Redistributive Effect

Two days before the July 4 weekend, the Centers for Medicare & Medicaid Services (CMS) announced a series of proposed changes to the 2010 physician fee schedule. In so doing, the agency stirred a controversy that has been bubbling politely below the surface of the physician community for some time now.

For years, primary care physicians (PCPs) have grumbled, sometimes publicly and certainly among themselves, that Medicare's policies and payments favor proceduralists at the expense of PCPs. The effect, family physicians, general internists, and others argued, was to decenter primary care, resulting in less coordinated care and less preventive care and discouraging a generation of students from entering the profession.

For their part, specialists steadfastly supported calls to restore primary care, including proposals for CMS to boost the relative value units for evaluation and management (E/M) and other cognitive services. However, they were not in favor of this restoration if it resulted in a corresponding devaluing of their services. To make primary care "whole" again, specialists said at the American Medical Association (AMA) House of Delegates meeting last month, real savings needed to be wrung from an inefficient and often wasteful system. This could take a variety of forms, including fewer hospitalizations, fewer inpatient readmissions, lower prescription drug costs, and so on.

What prevented these differences from breaking out into open warfare — PCPs on one side, proceduralists on the other — was not simply physicians' traditional bonhomie, although that was certainly a big factor. It was also the 2 groups' united opposition on another front — the complex, and many would say flawed, methodology that CMS uses each year to update the physician fee schedule. In short, if PCPs and specialists were not always on the same page on some matters, neither side has ever had a good word to say about the Sustainable Growth Rate formula, which, as CMS itself points out, "has yielded negative updates every year beginning in...2002."

Changes May Correct Imbalance

The proposed payment and policy changes do nothing to fix the Sustainable Growth Rate formula, which would take congressional action to accomplish — action that may, in fact, be forthcoming as healthcare reform makes its way through both the House and Senate — but, according to some experts, they do address, if not fully correct, the economic imbalance that PCPs have chafed under for years.

"This is an attempt to make primary care whole again in order to get it back to its rightful position at the center of our healthcare system," Ted Epperly, MD, FAAFP, president of the American Academy of Family Physicians and a family physician in Boise, Idaho, told Medscape Medical News. Dr. Epperly is emphatic, however, that the proposed changes should not be seen as an instance of robbing Peter to pay Paul. "The idea is not to increase one type of physician and decrease another type," he said.

Still, in its report to Congress in March, the Medicare Payment Advisory Commission (MedPAC) noted that any increase in payments for primary care, a step it fully endorsed, "would be budget neutral within the fee schedule." For specialists, this could not have come as welcome news: If the Medicare pie, as MedPAC said, was not getting bigger, then any plans to cut a somewhat larger slice for one group would necessarily mean a reduction for other groups.

Redistributing the Medicare Pie

In fact, this is precisely the effect of the proposed changes announced by CMS on July 1. Through these changes, the agency has taken steps to redistribute the Medicare pie, cutting back on what specialists have traditionally received to give a somewhat bigger slice — 6% to 8% bigger, before the annual update and other changes — to physicians in primary care.

The agency has proposed to do this in 3 major ways.

First, it has taken a harder look at the practice expense component of physician fees, using a new survey designed and conducted by the AMA. The upshot is that, if the proposed rule stands, some groups will see their practice expenses for certain services go down, with a corresponding decrease in fees, and some will see expenses go up, with a corresponding increase in fees. As a result of these changes (and others in the cost of professional liability insurance), for instance, radiologists could see an 11% dip in their fees.

"There are huge radiology expenses not captured in the AMA survey that CMS is using," Bibb Allen, MD, chair of the American College of Radiology Economics Commission, told Medscape Medical News. Among other things, Dr. Allen recommends that CMS "blend" the AMA results with data from the American College of Radiology's own expense surveys, which he says are more representative.

Second, CMS has proposed eliminating payments for consultation codes that, the agency says, are typically billed by specialists at higher rates than the equivalent E/M services. In a trade-off that could end up increasing the value of E/M services provided by PCPs, specialists billing for consultations would be required to use current E/M service codes. The resulting savings from this proposal, CMS says, would be redistributed to boost payments for existing E/M services, a boon for PCPs.

Third, CMS has proposed a change in the way that the Medicare fee schedule "recognizes the cost of professional liability insurance." In much the same way that proposed changes in the expense component would affect physicians' fees, physicians with lower liability insurance costs would see a slight reduction in their fees, and physicians who pay higher professional liability premiums — obstetricians, for example — would see a slight increase in their fees. "While these changes would have a modest impact," CMS says, "they will promote payment equity."

One other proposed change should also be noted. Concerned about what it calls the "rapid growth in high cost imaging services," CMS has proposed reducing payments for such services and redistributing "the resulting savings to increase payments for other services, including primary care services."

The rationale for this proposed action rests on a series of revised assumptions. Currently, CMS assumes, and the fee schedule reflects the fact, that physicians who own the equipment to provide these high-cost services will use it 25 hours a week, or roughly 50% of their weekly office time. In fact, says CMS, surveys show that such equipment is being used much more often, resulting in economies of scale that push per treatment costs lower, "making a reduction in payment appropriate." Following a MedPAC recommendation, CMS proposes that for equipment priced at more than $1 million, it will now assume a 45 hour/week or 90% utilization rate, with a corresponding reduction in fees for such services.

The American College of Radiology, for one, has estimated that that change alone would reduce the technical component fee for computed tomography imaging, magnetic resonance imaging, and intensity-modulated radiation therapy by as much as 40% for 2010.

Source : http://www.medscape.com/viewarticle/705551?src=mpnews&spon=34&uac=133298AG

RU Healthy? Public Health Efforts Take on Text Messaging: Campaigns Adapting to New Technology

With a few quick thumb swipes, San Francisco youth literally have health information at their fingertips. They can receive the information anywhere, anytime without having to log into a computer, make a phone call or pick up a pamphlet. For Bay area youth, getting the "411" on sexual health is as easy as hitting "send" on their cell phones.

Thanks to today's texting trend, the youth are getting answers from SexInfo, a public health text messaging service that was launched in 2006. The service received 4,500 sexual health inquiries in just its first 25 weeks of service, with broken condoms, pregnancy and sexually transmitted diseases topping the subject list. The effort came after local health officials spotted rising rates of gonorrhea and chlamydia among black teens in one of the city's low-income neighborhoods, according to Deb Levine, MA, executive director and founder of Internet Sexuality Information Services Inc., which developed SexInfo in partnership with the San Francisco Department of Public Health. While the initial idea was to create a new Web site, both Levine and colleague Jacqueline McCright, MPH, a community-based STD services manager at the public health department, decided it was time to think outside the box. While visiting high schools for inspiration, the new idea walked right in front of their faces: After the school bell rang, students filed out with cell phones in hand. But they weren't talking -- they were typing.

"That's when we knew we were on to something," Levine told The Nation's Health.

While San Francisco's health workers could be considered pioneers in text messaging, public health has been taking advantage of mobile communication devices to improve surveillance and the delivery of health interventions for some time, said Jay Bernhardt, PhD, MPH, director of the National Center for Health Marketing at the Centers for Disease Control and Prevention. But because text messaging is "multidirectional" -- in other words, because users can send and receive information in real time -- it can be a "real game-changer in public health both domestically and especially globally," said Bernhardt, who added that CDC took a "big step" last year when it co-sponsored the first Texting4Health conference at Stanford University. Mobile communication platforms, he said, are "the next wave of public health communication and surveillance."

While new communication technologies offer great opportunities for public health, Bernhardt noted, lack of access to tools such as the Internet can be a significant barrier, particularly on the global front. Cell phones, however, are the first interactive communication devices cutting across economic, educational and social divides, he said. In turn, text messaging can be used on a number of health fronts, from delivering information to managing chronic diseases to treatment adherence.

"Today, effective public health requires us to provide our information and interventions to our communities where, when and how they need them," Bernhardt told The Nation's Health. "Our communities are using social media and mobile technology as an important part of their lives and if we want to reach them and help them, then we need to communicate with them the way they communicate with each other."

In San Francisco, Levine, McCright and colleagues knew young people were texting each other, but were unsure if youth wanted to receive text messages from their local health department. Fortunately, in focus groups of young black men and women, participants liked the text messaging idea. However, they were insistent that they be the ones initiating the process, Levine said. The resulting SexInfo service allows youth -- or anyone interested -- to text the word "SexInfo" to a five-digit number to receive a message back with codes telling them to text, for example, "B2 if u think ur pregnant," "D4 to find out about HIV" or "F8 if ur not sure u want to have sex." Participants are then texted back basic health information or referrals for in-person visits. According to a SexInfo study published in the March 2008 issue of APHA's American Journal of Public Health, 2,500 of the first 4,500 text inquiries led to access to more information and referrals for testing and screening.

"Things are changing rapidly and we have to do things differently to reach different people," McCright told The Nation's Health. "We can't keep doing the same old things and expecting different results. We have to be creative."

Of course, SexInfo's success depends on smart marketing and continually checking in with young people about cell phone trends, Levine said. To spread the word about SexInfo, health workers passed out cards, put up posters, bought billboards, created public service announcements and ran ads on local television and radio shows, according to McCright. The same aggressive marketing is working for the Kaiser Family Foundation's "KnowIt" text messaging campaign, which allows users to find HIV testing sites in their area. First promoted with the help of an ongoing partnership with MTV in the summer of 2007, the service received 15,000 text requests in its first month alone and more than 200,000 text inquiries in 2008, according to Tina Hoff, vice president and director of the foundation's entertainment-media partnerships. To use the service, cell phone users send a text message with their ZIP codes to KnowIt and within seconds, receive back a text message with information on nearby HIV testing sites. The service relies on a CDC database of HIV testing sites organized by ZIP codes, and in turn, CDC uses the texting service for its own HIV outreach as well, Hoff said.

"Clearly, it's a format for communicating that (young people) are comfortable with," Hoff said. "One of the nice things about new media technologies is that they're really very accessible and not exceedingly costly to implement. But for a campaign like ours to work, it's incumbent to have effective promotion strategies. The resource is only as good as the promotions you can do."

Getting the word out is the focus for Lauren Weber, a community health educator with Arizona's Mohave Department of Public Health, whose insights led to the launch of the department's Stop Smoking Over Mobile Phone, or STOMP, program in fall 2008. The youngest member of the department's Tobacco Use Prevention Program, the 23-year-old joined the team in 2007 and began visiting schools to teach students about tobacco use. Weber said she noticed that there was no educational component for students caught on campus with tobacco. When searching online for a tobacco intervention method that would appeal to students, Weber hit upon the company Healthphone Solutions and its text messaging smoking cessation service. Now, Mohave County is the first to use the Healthphone product in the United States.

Today, Mohave County students caught with tobacco can avoid suspension from school by signing up for the smoking text service. The 26-week program creates a personalized smoking cessation service based on a participant's demographics and quit date. The text messaging service guides users through the preparations for quitting, sends encouraging messages on the quit date, and begins sending multiple texts per day after the quit date. The program is open to anyone interested and about 40 people have taken part so far, said Weber, noting that some participants couple the text messaging program with traditional in-person cessation classes.

"I know I'd rather text than talk," Weber told The Nation's Health. "What better way to reach people than to get them on the phones that they're already using."

For more information on text messaging and public health, visit www.texting4health.org or www.cdc.gov/mobilehealth. For more news from The Nation's Health, visit www.thenationshealth.org.

Source : http://www.medscape.com/viewarticle/704350?src=mp&spon=34&uac=133298AG

CT-Angiography-Identified Vulnerable Plaque Associated With Higher Risk of ACS

Vulnerable plaques identified visually by computed-tomography (CT) angiography are more likely to result in a subsequent acute coronary syndrome during follow-up, a new study has shown [1]. Identifying these unstable coronary plaques, which have areas of low attenuation and have undergone positive remodeling, could be used to aggressively treat patients who are at higher risk for future events, according to researchers.

"Our data suggest that once a patient is identified to be at risk of having an adverse event on the basis of traditional clinical, biochemical, and biomarker risk profiles, imaging may help identify those at greater risk of acute coronary events," write lead investigator Dr Sadako Motoyama (Fujita Health University School of Medicine, Toyoake, Japan) and colleagues in the June 30, 2009 issue of the Journal of the American College of Cardiology.

Speaking with heartwire , Dr Renu Virmani (Cardiovascular Pathology Institute, Gaithersburg, MD), one of the study investigators, said the results show for the first time that high-risk, vulnerable lesions, characterized previously in pathologic studies, are able to identify patients with future symptoms, and this moves the field forward by a "big step."

"This is just the beginning, but it is a good beginning," she said. "It is the first study we have showing us that we can actually identify these lesions and that these are the lesions that are going to produce symptoms in patients. Before that, it's all been a theory. We were able to say these are vulnerable plaques, and we should watch and worry about them, but we had no way of showing these were the ones that would go on to produce symptoms."

More Than 1000 Patients Assessed by CTA

To determine whether the characteristics of atherosclerotic lesions were associated with future acute coronary syndromes, the researchers analyzed the lesions based on the presence of positive vessel remodeling and low-attenuation plaques. Virmani explained that these two characteristics, along with a necrotic core, are thought to be associated with subsequent plaque rupture.

Among the 1059 patients who underwent CT angiography, 45 patients had coronary plaques that had undergone positive remodeling and were classified as low attenuation. After more than two years of follow-up, 10 patients, 22.2%, with both characteristics of vulnerable plaque developed an acute coronary syndrome. On the other hand, just one of the 27 patients with only one feature, either low attenuation or positive remodeling, developed symptoms, while only 0.5% of the 820 patients without any features of vulnerable plaque developed an acute coronary syndrome.

In a multivariable regression analysis, the presence of low-attenuation plaque or positive remodeling was associated with a 23-fold increase in the risk of an acute coronary syndrome (hazard ratio 22.8; 95% CI 6.9-75.2; p<0.001).

Virmani told heartwire that it is not always easy to identify low-attenuation plaque and that there are those who doubt whether visualizing these softer plaques can be done reliably, although the technology is improving. On the horizon are better imaging modalities, including 320-detector-row CT scanners that improve resolution, as well as machines that limit the amount of radiation exposure.

Systemic vs Focal Disease

Commenting on the results of the study for heartwire , Dr Steven Nissen (Cleveland Clinic, OH) said he was skeptical of the results and the vulnerable-plaque hypothesis, in general. In a recent editorial in the Journal of the American College of Cardiology: Cardiovascular Imaging, Nissen said that many diagnostic techniques designed to detect vulnerable plaques, including thermography, virtual histology, and optical coherence tomography, among others, have promised much but delivered little [2].

Last week, noted Nissen, a CT-angiography study, reported by heartwire , showed that the technology was unable to reliably identify the functional significance of coronary lesions in patients with stable angina and atypical chest pain. To now suggest that CT angiography can identify plaques at risk for rupture is "asking an awful lot from this technology." Also, he said the investigators did not show that the lesion of the coronary artery identified by CT angiography as vulnerable is responsible for the acute coronary syndrome.

"They don't close the loop," said Nissen. "We don't find out that the site that had positive remodeling and low attenuation is the site where the plaque ruptured. Without that, this becomes much more speculative."

In general, Nissen said that he believes the vulnerable-plaque approach is the wrong approach because atherosclerosis is a systemic disease, and if anything is likely to predict outcomes, it's a systemic, not focal, marker. Virmani, on the other hand, strenuously disagrees, telling heartwire that Nissen is "missing the boat" regarding these high-risk focal lesions because evidence shows that patients with coronary events have a focal thrombus formation.

"If you look at acute-myocardial-infarction patients, it occurs in one vessel, in the proximal areas," said Virmani. "Why? Those are the most prone areas. That's where we need to concentrate. His [Nissen's] idea of concentrating on systemic factors, such as LDL cholesterol, diabetes--yes, absolutely, but those are the patients that then have focal lesions. I don't deny that you need hypercholesterolemia for a patient to have focal lesions, but in the patients that are high risk, they do develop them at focal spots."

Did Anybody See My Stolen Horse?

In an editorial accompanying the published study, Dr Eugene Braunwald (Harvard Medical School, Boston, MA) adopts the middle road, hailing the study by Motoyama and colleagues as a landmark trial, while acknowledging the current limitations in the detection of vulnerable plaque [3].

Braunwald notes that widespread clinical application of CT angiography to characterize coronary lesions at risk for future rupture, which he aptly describes as "locking the barn before the horse is stolen," will require more potent measures for the prevention of plaque rupture than are currently available. Dual antiplatelet therapy, possible stenting, or more potent anti-inflammatory drugs are just some of the possibilities, writes Braunwald.

"Nobody is saying we need to start treating these patients," adds Virmani. "Start treating them systemically, just as Dr Braunwald points out in his editorial. Right now, we don't know how to treat these patients. We might need to think of different therapies. Some patients might need anti-inflammatory drugs, or some might need stents, but we won't know until we learn how these lesions behave prospectively."

Dr Mario Garcia (Mount Sinai School of Medicine, New York) told heartwire that low-attenuation plaques with positive remodeling are features identified as characteristics of thin-cap, lipid-rich plaques in intravascular ultrasound (IVUS) correlative studies. He added that while the present study identifies a novel imaging biomarker as a powerful predictor of future ACS, there remain unanswered questions, particularly whether the predictive accuracy of CT is superior to established serum biomarkers such as high-sensitivity C-reactive protein (CRP) and whether the same predictive utility could be extrapolated to asymptomatic subjects at risk.

In addition, like Braunwald and Nissen, Garcia says trials are needed to determine the optimal treatment strategy to follow--for example, intensive medical therapy vs prophylactic PCI--once these "high-risk features" are identified in a patient.

Source : http://www.medscape.com/viewarticle/705017?src=mpnews

Watch Out for This Growing Malpractice Trend

Introduction

Physicians who have created legal entities, such as LLCs (limited liability companies) and professional associations, to limit their liability may mistakenly believe that they are well protected against medical negligence lawsuits.

Although this legal structure does protect physicians in areas ranging from contractual obligations to "slip-and-fall" type claims, new litigation trends suggest that this can now increase liability in medical negligence cases.

Here's why: In many nonphysician business settings, creating legal entities transfers liability and insulates individual actions. Plaintiffs will typically sue corporations rather than individuals, and corporations can buy insurance to protect all of their owners and employees.

Medicine is different. Plaintiffs generally sue the individual physician rather than the entity, as by law in many states doctors cannot avoid exposure by working through a corporate entity. Therefore, physicians generally buy medical malpractice policies in their own name, rather than in the name of the practice.

However, because medical malpractice premiums have become more expensive, physicians began buying policies with lower limits of insurance. Previously, individual doctors carried as much as $12 million of insurance per claim; now the majority of physicians carry no more than $1 million per claim.

In response, plaintiff lawyers began to seek larger awards by dragging medical entities into lawsuits. Now more than previously, lawyers sue the individual physician and the corporation. That's true even for solo practitioners.

In the past, plaintiff attorneys may have named entities for a variety of reasons, but mainly to ensure that there was underlying coverage. Once coverage was established, entities were commonly dropped from a lawsuit. Now when lawyers sue an entity, they are less likely to let it out of a case, not only because it may provide potential leverage in settlement negotiations, but also because a number of legal theories can render them an effective source of independent recovery.

Be Aware of Everyone Involved

Lawyers often use a vicarious liability theory known as respondeat superior, which translates literally to "let the master answer," to hold entities liable. Under respondeat superior, the master is the corporation or other legal entity that a physician's group may practice under.

"Agency" principles are used to establish all the parties for which the master is responsible. Agency refers to an individual acting or appearing to act on behalf of another, and thus can make a medical practice liable for the acts of its entire professional and nonprofessional staff.

This causes trouble when the individual doctor responsible for an act of negligence does not have enough insurance to cover a claim. The corporation can become jointly and severally liable for paying the remainder of the judgment.

Even if physicians have insurance coverage for themselves and their entities, they must still be aware of the "vicarious" liability that can emerge from using independent contractors, sharing office space, or even using "covering doctors."

Still another negative is that when a practice is sued, it may need to hire its own lawyers to represent it. Legal fees associated with defending an entity can quickly mount, giving plaintiffs' attorneys yet additional leverage to facilitate a settlement. This "double jeopardy" -- suing both the physician and the entity -- can have a devastating effect on medical practices.

How Can Physicians Lessen This Risk?

Buying additional insurance for the entity can reduce the risk for personal liability. However, the cost may be prohibitive. Worse, high insurance limits often result in higher settlements. The more money available, the more money plaintiffs' attorneys may demand.

To lower both cost and exposure, physicians should develop an overall coverage strategy. Four options follow.

First, use 1 policy limit to cover multiple entities, if applicable.

Second, have physicians "share" their respective limits with the corporate limits to avoid bringing additional insurance policies into a lawsuit and largely eliminate a plaintiff's leverage.

Be careful when constructing this, because it can create significant exposure if coverage is not coordinated for every agent of the corporation. Shared coverage will only respond on behalf of the corporation if the claim is related to a physician that is a "named insured" on the underlying policy.

Third, look into creative solutions for insurance. Although state laws and credentialing requirements often govern insurance policy limits for physicians, there is often no similar framework for healthcare entities. As a result, insurers can offer unique solutions, such as high deductibles, aggregate limits, or even policies that only cover legal expenses, but do not insure against losses (settlements or awards).

Fourth, check with your broker before renewing your insurance coverage. Also consider consulting with experts in accounting, healthcare, and insurance law to coordinate your insurance needs with a comprehensive asset protection plan.

If you have a malpractice question that you'd like this column to address, please send your questions to BusOfMedEditor@medscape.net.

Source : http://www.medscape.com/viewarticle/703170

From Agency for Healthcare Research and Quality (AHRQ) Cases from AHRQ WebM&M: Medication Reconciliation Victory After an Avoidable Error

The Case

A 91-year-old woman, previously active and independent, recently developed weight loss, confusion, and falls without injury. She lived alone. Late one night, her family visited and found her on the floor of her home. She was lethargic and incontinent, and her speech was slurred. She did not appear to recognize her family members. She was taken to the hospital and admitted for altered mental status and dehydration. Upon arrival to the ward, the admitting nurse attempted to reconcile her home medications with those ordered on admission. However, the patient was unable to tell the nurse which medications she was taking. A family member was asked to return to the patient's home, gather all of her medications, and bring them to the hospital so that medication reconciliation could be performed. In all, seven prescription medications were returned, including Flexeril 10 mg TID, glipizide 10 mg daily, Neurontin 200 mg TID, lisinopril 10 mg daily, gabapentin 200 mg TID, cyclobenzaprine 10 mg TID, and Lortab 5 mg as needed for pain. Some medications had been filled at a local pharmacy, while others were filled by a mail-order pharmacy. The admitting physician recognized that several of the medications were duplicates (Flexeril is the brand name of cyclobenzaprine; Neurontin the brand name of gabapentin), and he adjusted the medication regimen accordingly.

The day after admission, the patient was more alert and responsive to questions. Her medications were reviewed, and she reported that she was taking all of the medications, as prescribed, from the bottles that were retrieved from her home. Unaware that any of the medications were duplicates, she thought she was taking exactly what her physician had intended.

The Commentary

The direct costs of drug-related morbidity and mortality were estimated to exceed $177 billion in 2000, of which 70% ($121 billion) was attributed to hospital admissions.^[1] The Institute of Medicine reports that up to 1.5 million preventable adverse drug events occur in the United States annually.^[2] Furthermore, potentially inappropriate medication (PIM) use is a significant problem in community-dwelling elders, accounting for an estimated $7.2 billion in health expenditures in 2001.^[3] As a result of continued medication misadventures in the United States, the Joint Commission has established specific National Patient Safety Goals (NPSG) to reduce the impact of medication errors on patient safety.^[4] This case identifies two important aspects in the safe and effective use of medications in the elderly. First, the continued use of PIM in older adults remains a problem and dramatically increases the likelihood of developing a drug-related problem.^[5] Second, medication reconciliation can identify potential and actual drug-related problems when performed across the continuum of care as outlined by the Joint Commission.^[6]

Criteria for PIM in the elderly were first developed by Mark Beers in 1997 and are commonly referred to as "Beers criteria" or the "Beers list."^[7] The Beers criteria were updated in 2003 using a literature review and expert consensus.^[8] The updated Beers list includes drugs to be avoided regardless of disease state or condition and a list of drugs to be avoided in patients with certain diagnoses or conditions. Muscle relaxants like cyclobenzaprine are included on the Beers list of PIM (see Table for a partial list of medications to be avoided in older adults) regardless of condition. Although the case above highlights the potential dangers of therapy duplication, it also illustrates the importance of minimizing use of medications that should be avoided in the elderly population. Studies indicate that 23%-40% of community-dwelling elderly patients use PIM, and that 2.6% of elderly patients take medications that should always be avoided.^[3,9] A study evaluating medication use in older adults identified a threefold increase in the incidence of documented drug-related problems when at least one PIM was used in older adults.^[5] Prescribers and other health care providers must work together to minimize the use of PIM in older adults. It is possible that this medication error could have been avoided if this patient was not taking cyclobenzaprine in the first place.

Table. Selected Potentially Inappropriate Medications to Avoid in Older Adults: Independent of Diagnosis or Conditions.

Generic Drug Name	Concerns
Indomethacin	High risk of developing central nervous system adverse events.
Cyclobenzaprine, methocarbamol, carisoprodol, other muscle relaxants	High risk of anticholinergic adverse events, sedation, and weakness and generally poorly tolerated by the elderly with questionable efficacy.
Amitriptyline, doxepin	High risk of anticholinergic adverse events, sedation, and weakness.
Diazepam, flurazepam, chlordiazepoxide, other long-acting benzodiazepines	Older adults have a higher sensitivity to benzodiazepines, causing sedation, weakness, and increased risk of falls especially when benzodiazepines with a long half-life are used.
Dicyclomine, hyoscyamine, other gastrointestinal antispasmodic drugs	High risk of anticholinergic adverse events, questionable efficacy.
Diphenhydramine, chlorpheniramine, hydroxyzine, other anticholinergic antihistamines	High risk of anticholinergic adverse events, confusion, sedation, risk of falls; nonanticholinergic antihistamines preferred.
Phenobarbital, other barbiturates	Highly addictive, high risk of adverse events including sedation, risk of falls.
Meperidine	Increased risk of confusion, accumulation, neurotoxic active metabolite that may accumulate in older adults.
Fluoxetine	Long half-life that may accumulate causing central nervous system stimulation, sleep disturbances, and agitation.
Mineral oil	Potential for aspiration, safer alternatives available.
Desiccated thyroid	Concerns about cardiac effects, safer alternatives available.

Adapted with permission from American Medication Association. Original table © 2003 American Medical Association. In: Fick DM, Cooper JW, Wade WE, et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Intern Med. 2003;163:2716-2725.

The 2008 and 2009 NPSG from the Joint Commission highlight medication reconciliation as a requirement for hospitals. The Joint Commission recognizes that patients are most at risk for medication errors when transitioning across different levels or between different providers of care. The process of medication reconciliation was established to reduce adverse medication events that may occur as a result of this transition.

In the case described above, the medication reconciliation process identified the cause of the admission and resulted in prompt treatment of the patient (in this case, discontinuation of duplicate therapies) as opposed to reducing future medication errors. Communication among health care providers continues to be a focus of the NPSG and the Joint Commission. There appears to have been a breakdown in communication among health care providers and the patient in the case described above. In this situation, the patient should have received counseling and educational material from the pharmacies describing the medication, including the brand and generic name, as well as drug information from a pharmacist that included the purpose and side effects of the prescribed treatment. Furthermore, the use of multiple prescribers and multiple pharmacies could have contributed to the use of duplicate therapies. Using a single pharmacy for medications or a national electronic prescription registry also could have reduced the chance of this error occurring.

Interestingly, the use of technology -- often cited as a primary process to help reduce medication reconciliation errors -- may not be sufficient without further inquiry by a health care provider. A small study determined that 57% of electronic medical record medication histories did not match those obtained telephonically by a nurse.^[10] Furthermore, obtaining medication information from the patient alone may not be enough. Glintborg and colleagues found that patients admitted to a hospital in Denmark failed to report 27% of prescription medications filled in the last month when compared to actual prescriptions identified in the national electronic prescription file.^[11] The same study evaluated self-reported medication use during a home visit and found that 18% of medications filled in the last month were not reported. Although no studies or guidelines describe the best approach to medication reconciliation, a process that uses both electronically available medication records as well as data from direct interviews of patients and/or families appears to be the most logical and accurate approach.

With the increased use of electronic prescribing and real-time data feeds/decision support from third-party organizations, the medication reconciliation process and identification of PIM in the elderly can be enhanced not only upon hospital admission but also in ambulatory care and pharmacy settings. In the case above, it is unclear if the duplicate medications used by the patient were current and recently filled by the patient. If so, a pharmacist or physician with access to the complete medical record and prescription fill history could have identified the duplicate therapy and possibly prevented this hospital admission. Furthermore, a clinician recognizing the importance of avoiding PIM in the elderly might have prevented or mitigated the impact of this error. The focus of medication reconciliation in the hospital has reduced medication errors; however, more emphasis should be placed on accurate medication histories and appropriate prescribing practices in ambulatory care settings.

Take-Home Points

• All health care providers should be aware of medications that are best avoided in general or in specific populations such as the elderly. The Beers list is a useful resource.
• More emphasis should be placed on the implementation of medication reconciliation processes in ambulatory care settings.
• When performing medication reconciliation, multiple sources of information should be used to obtain accurate and complete medication histories (e.g., electronic medical records, pharmacy records, and patient/family history).

Reprint Information

Reprinted with permission of AHRQ WebM&M. Original citation: Cutler TW, Medication Reconciliation Victory after an Avoidable Error: AHRQ WebM&M [online journal]. March 2009. Available at: http://webmm.ahrq.gov/ is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco. The AHRQ WebM&M site was designed and implemented by Silverchair.

Source : http://cme.medscape.com/viewarticle/704150