adverse drug events impact on hospital - fhamar 07, 2017 · adverse drug events impact on hospital...

Adverse Drug Events Impact on Hospital Readmissions

Co‐hosted by FHA HIIN and HSAGFacilitatorsEdna Clifton‐HSAG, Florida QIN‐QIOPhyllis Byles‐FHAScott King, PharmD‐Orlando Health Dr. P. Phillips Hospital March 7, 2017

Agenda• Overview Mission to Care FHA HIIN‐goals• Data year to date for high risk medications (HRMs)

• Overview hospital specific reports‐analysis of claims data for HRMs and hospital readmissions

• Open Discussion – Q/A• Conclusions‐Next steps

HIIN Overview

• “Mission to Care” HIIN• Accomplishments of HEN 1.0 & 2.0• Core Topics and Data for HIIN• Resources‐ HRET HIIN & FHA HIIN• Hospital Process and Expectations• Questions/Open Discussion

• 32 states‐1600+ hospitals (largest HIIN collaborative nationally)

FHA HEN:94 Hospitals

HIINs: Where are they?

CMS

Partnership for Patients (PfP)

15 Other HIIN Entities across the Nation AHA/HRET

31 other state organizations across the nation‐1600+

FHA‐Mission to

Care

94 member hospitals

HIINs: How are they related?

FHA HEN Results: 2012‐2016

Prevented 31,342 cases of

harm

Avoided $198 million in

healthcare costs

Where We are Going‐ HIIN

partnershipforpatients.cms.gov

GOALS:

20% Overall Reduction in Hospital Acquired Conditions

(baseline 2014)

12% Reduction in 30‐Day Readmissions

(baseline 2014)

145 Harms/1,000 Discharges2010142 Harms/1,000 Discharges2011132 Harms/1,000 Discharges2012121 Harms/1,000 Discharges2013121 Harms/1,000 Discharges2014

97 Harms/1,000 Discharges2019New Goal

“America’s hospitals embrace the ambitious new goals CMS has proposed,” said Rick Pollack, president and CEO of the American Hospital Association (AHA). “The vast majority of the nation’s 5,000 hospitals were involved in the successful pursuit of the initial Partnership for Patients aims. Our goal is to get to zero incidents. AHA and our members intend to keep an unrelenting focus on providing better, safer care to our patients ‐‐ working in close partnership with the federal government and with each other.”

Historical ComparisonOriginal HEN HEN 2.0 HIIN

Funding Source Affordable Care Act Affordable Care Act Medicare Trust FundProject Timeline 2 base years; 1 optional

year1 base year; no optional year

2 base years; 1 optional year

Project Aim 40% reduction in preventable harm; 20% reduction in readmissions

40% reduction in preventable harm; 20% reduction in readmissions

20% reduction in all cause harm; 12% reduction in readmissions

Number of hospitals 1,378 1,497 ~1710Number/Types of Topics 10 core harm topics plus

readmissionsADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAP/VAE, VTE

10 core harm topics plus readmissionsADE, CAUTI, CLABSI, EED, Falls, OB Harm, Pressure Ulcers, SSI, VAE, VTE

10 core harm topics plus readmissionsADE, CAUTI, CLABSI, C‐diff, Falls, Pressure Ulcers, Sepsis, SSI, VAE, VTE

Number of Primes 26 17 16Data Submission Baseline

2010 2010 2014

Data Measures Mix of national, state, and organizationally defined measures

Nationally defined (standardized) outcome measures

Nationally defined (standardized) outcome measures

Financial Incentives for Strong Quality Processes

‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00% ‐2.00%

‐1.00% ‐1.25% ‐1.50% ‐1.75% ‐2.00% ‐2.00%‐1.00%

‐2.00%

‐3.00% ‐3.00% ‐3.00% ‐3.00%

‐1.00% ‐1.00% ‐1.00% ‐1.00%

‐9%

‐8%

‐7%

‐6%

‐5%

‐4%

‐3%

‐2%

‐1%

0%

2011 2012 2013 2014 2015 2016 2017 2018

PERC

ENT PA

YMEN

T RE

DUCT

ION

IQR VBP Readmission Reduction HACS

National health expenditures=$3.4 Trillion‐in hospitals=$1.1 Trillion (2016)

Readmissions

Baseline Oct‐16 Nov‐16 Dec‐16FL Rate 10.8 10.1 10.3 8.4HRET HIIN Rate 9.0 8.4 8.6 7.4# FL Reporting 76 56 46 22#HRET HIIN Reporting 1,274 591 551 439

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Rate per 100

Source: HRET Comprehensive Data System, February 21, 2017

Florida HEN 2.0 Baseline: 10.0 (74 hospitals)Florida HEN 2.0 Apr‐June 2016: 9.5 (73 hospitals)

Readmissions ‐Medicare

Baseline Oct‐16 Nov‐16 Dec‐16FL Rate 13.7 12.5 12.4 7.6HRET HIIN Rate 11.9 10.5 10.8 9.0# FL Reporting 40 40 36 20#HRET HIIN Reporting 838 447 423 350

0.0

3.0

6.0

9.0

12.0

15.0

Rate per 100


ADEs ‐ opioids


0.0

0.2

0.4

0.6

0.8

Rate per 100


Florida HEN 2.0 Baseline: 0.6 (54 hospitals)

Florida HEN 2.0 Apr‐June 2016: 0.4 (54 hospitals)

ADEs ‐ hypoglycemia


0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Rate per 100




ADEs ‐ excessive anticoagulation


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Rate per 100




Reducing Adverse Drug Events

Edna CliftonAssociate Director Care CoordinationHealth Services Advisory Group (HSAG)

March 7, 2017

Overview

HSAG is contracted by the Centers for Medicare & Medicaid Services (CMS) to work with healthcare providers to:• Improve coordination of care• Reduce hospital readmissions• Improve medication safety by reducing adverse drug events (ADEs) for patients in the community

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Readmissions and Medication Safety

HSAG works with hospitals to reduce ADEs.• ADEs contribute to readmissions and are the leading cause of preventable patient harm.1

• The Department of Health and Human Services (HHS) identified the following medication classes as high priority medication targets for the National Action Plan for Adverse Drug Event Prevention2 (common, preventable, and measurable ADEs):– Anticoagulants – Diabetic agents – Opioids

181. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107–16.2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention.Washington, DC: Author.

ADEs Contribute to Increased Costs and Negatively Impact Patient Care

Add an additional $3.5 billion in healthcare costs; of this, up to $5.6 million per U.S. hospital.3

Prolong hospital stays by 1.7 to 4.6 days.2

Account for 1/3 of adverse events encountered in hospitals.4

19

2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention.Washington, DC: Author.3. Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.4. U.S. Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.Washington, DC. 2010 November. Report No.: OEI-06-09-00090.

$3.5BILLION

ADEs

Emergency Department (ED) Visits for ADEs

20 5. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA.2016;316(20):2115-2125. doi: 10.1001/jama.2016.16201.

Associated with anticoagulants

17.6% of the visits, with48.8% of cases resulting in hospitalization.5

Associated with diabetic agents

13.3% of the visits, with 38.5% resulting in hospitalization.5

Associated with opioids

6.8% of the visits, with 24.6% resulting in hospitalization.5

Engaging With Hospitals to Create and Implement ADE Interventions

• Data reveal that many facilities rank above the state average for high‐risk readmission rates related to one or more of the three high‐risk medication (HRM) classes:

• A hospital’s ADE rate is measured by counting the number of hospital admissions and ED visits related to an ADE from one of the three HRMs.

21

anticoagulants diabetic agents opioids

Florida Medicare Readmissions Within 30 Days Calendar Year 2015

22

148,154 Readmissions Within 30 Days

54,512 Readmissions Within 7 Days

16,246 7‐Day

Readmissions Were on HRMs

Florida Medicare Readmissions Within 30 Days—2015 (cont.)

23

Of the 54,512 readmissions within 7 days,16,246 (29.8%) readmissions were for beneficiaries who were on HRMs.

That is almost 3 out of every 10 readmissions!

Medicare Fee‐For‐Service (FFS) Beneficiaries on HRMs in Florida—2015

24

Anticoagulants 5.59%Diabetic Agents 8.07%

Opioids 7.75%

Diabetic agents are the most common drug type used, closely followed by opioids agents. Fewer beneficiaries use anticoagulants.

Represents beneficiaries with at least 30‐days supply of drug type. Patients may be included in more than one drug type category.

ADE Rates Among Medicare FFS Beneficiaries Discharged on HRMs in Florida—2015 (ADEs per 1,000 Discharges)

25

Anticoagulant ADEs 48.42

Diabetic Agent ADEs 28.72

Opioid ADEs 5.53Despite lower frequency of use, patients taking anticoagulants have the highest rate of ADEs per 1,000 discharges among Medicare beneficiaries on HRMs, followed by diabetic agents. Opioids have much lower ADE rates based on claims data.

30‐Day Readmissions Among Medicare FFS Beneficiaries on HRMs in Florida—2015

26

30‐Day All‐Cause Readmission Rate 19.6%

30‐Day HRM Readmission Rate 23.7%

• Readmissions among beneficiaries on HRMs are much more frequent than the general population, suggesting ample opportunity for improvement.

• Percent of 30‐day readmits with an anticoagulant or diabetes agent ADE are much higher than the percent of readmits with an opioid ADE.

Factors That Contribute to ADEs

• Sub‐optimal medication reconciliation• Failure to confirm patient’s understanding of their medication regimen

• Inappropriate medication use by the patient and inappropriate prescribing

• Failure to monitor patient’s therapeutic lab values, drug treatment outcomes, and patient’s adherence

• Poor multidisciplinary communication and polypharmacy

27

What You Can Do to Reduce the Incidence of ADEs

• Target patients who are receiving HRMs – Medicare claims data is used to focus on medication safety improvement efforts

• Goal – Improve medication safety and reduce the incidence of ADEs related to hospital readmissions

28

Best Practices to Reduce the Risk of ADEs

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Best Practice Description

Pharmacist‐led medication reconciliation and medication therapy review

Compares active medication orders to all of the current medications that the patient has been taking, identifies and addresses medication related problems (i.e., duplication of therapy, unnecessary medications, inappropriate dosing, drug‐drug interactions)

Bedside delivery of medications prior to discharge

Prevents delay or interruption in medication therapy following discharge, verifies insurance coverage, manages prior authorizations or drug substitutions (i.e., therapeutic equivalent substitutions based on cost, availability, formulary, insurance)

Pharmacist‐led discharge medication counseling

Provides information on proper medication administration, side effects, disease state education

Post‐discharge follow‐upReinforces the discharge plan, assesses patient retention of information, addresses patient questions and concerns, assesses medication therapy adherence

Medication therapy management (MTM)

Improves medication use, enhances health care professionals collaboration, enhances communication between patients and their health care team, encourages patient involvement

Comprehensive medication history

Assists with obtaining high quality, complete, and accurate medication history

Hospital ADE Report

High‐Risk Medication (HRM) Categories

• Data sources are Medicare FFS Part A and Part D claims.

• Beneficiaries are considered on an HRM if they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest.

• Beneficiaries may qualify as being on a HRM for more than one drug class.

31

High‐Risk Medication (HRM) Categories (cont.)

• Adverse Drug Events (ADEs) are evaluated based on the beneficiary’s HRM drug classification. – If a beneficiary is on an opioid and has a claim identified

as an ADE related to opioid, this is counted in the numerator.

– If a beneficiary is on an opioid and has a claim identified as an ADE related to anticoagulants, this is not counted in the numerator.

• Missing data points or figures indicate there were no applicable data for your hospital during the specified time period.

32

Readmissions

33

Readmissions (cont.)

34

Readmissions for HRM Beneficiaries on an Anticoagulant

35

Readmissions for HRM Beneficiaries on a Diabetic Agent

36

Readmissions for HRM Beneficiaries on an Opioid

37

Readmissions by Drug Category

38

Overall ED Utilization within 30 Days of Discharge from an IP Visit

39

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Anticoagulant

40

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on a Diabetic Agent

41

Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Opioid

42

General Utilization by HRM Beneficiaries

43

General Utilization by HRM Beneficiaries on Anticoagulants

44

General Utilization by HRM Beneficiaries on Diabetic Agents

45

General Utilization by HRM Beneficiaries on Opioids

46

Anticoagulant ADEs by Prescription

47

Drug Class Number of ADEs

Warfarin 838

Direct Factor Xa Inhibitors (New Oral Anticoagulants) 107

Direct Thrombin Inhibitors 42

Heparins and Heparinoid‐Like Agents 27

ICD‐9 Diagnosis Code

Description Count

79092 Abnormal coagulation profile 472

E9342 Anticoagulants causing adverse effect in therapeutic use 255

5789 Hemorrhage of gastrointestinal tract, unspecified 68

59970 Hematuria, unspecified 64

7847 Epistaxis 59

59971 Gross hematuria 44

5693 Hemorrhage of rectum and anus 28

56212 Diverticulosis of colon with hemorrhage 20

4590 Unspecified hemorrhage 20

5781 Blood in stool 19


Description Count

R791 Abnormal coagulation profile 66

T45515A Adverse effect of anticoagulants, initial encounter 50

K922 Gastrointestinal hemorrhage, unspecified 22

R319 Hematuria, unspecified 17

T45511A Poisoning by anticoagulants, accidental (unintentional), initial encounter 13

R040 Epistaxis 12

R310 Gross hematuria 11

K921 Melena 9

R042 Hemoptysis 6

K5521 Angiodysplasia of colon with hemorrhage 4

Anticoagulant ADEs by Diagnosis Code1

48

1 Only the top 10 diagnosis codes are shown

Diabetic Agent ADEs by Prescription

49

Drug Class Number of ADEs

Insulin 341

Sulfonylureas

Dipeptidyl Peptidase‐4 (DPP‐4) Inhibitors

Thiazolidinediones

Antidiabetic Combination Agents

Glucagon‐Like Polypeptide‐1 (GLP‐1) Receptor Agonists

104

26

11

8

4

MeglitinidesBiguanides

3

2

Alpha‐Glucosidase Inhibitors 1

Diabetic Agent ADEs by Diagnosis Code2

50


Description Count

25080Diabetes with other specified manifestations, type II or unspecified type,not stated as uncontrolled

284

25082Diabetes with other specified manifestations, type II or unspecified type,uncontrolled

63

E9323 Insulins and antidiabetic agents causing adverse effect in therapeutic use 24

25081Diabetes with other specified manifestations, type I (juvenile type), not stated as uncontrolled

19

79029 Other abnormal glucose 17

2512 Hypoglycemia, unspecified 17

25083Diabetes with other specified manifestations, type I (juvenile type),uncontrolled

12

9623 Poisoning by insulins and antidiabetic agents 4

2511 Other specified hypoglycemia 1


Description Count

E11649 Type 2 diabetes mellitus with hypoglycemia without coma 62

E1169 Type 2 diabetes mellitus with other specified complication 15

E10649 Type 1 diabetes mellitus with hypoglycemia without coma 7

T38X1APoisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter

3

T38X5AAdverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter

2

R7309 Other abnormal glucose 1

2 Only the top 10 diagnosis codes are shown

Opioid ADEs by Prescription

51

Drug Class Number of ADEsOxycodone 22

Hydrocodone Combinations 14

Morphine 7

Codeine and Codeine Combinations 5

Fentanyl 5

Hydromorphone 5

Methadone 2

Opioid ADEs by Diagnosis Code3,4

52


Description Count

96509 Poisoning by opiates and related narcotics, other 16

96500 Poisoning by opium (alkaloids), unspecified 14

E9352 Other opiates and related narcotics causing adverse effect in therapeutic use 11

E8502 Accidental poisoning by other opiates and related narcotics 11

E9500 Suicide and self‐inflicted poisoning by analgesics, antipyretics, and antirheumatics 11

496 Chronic airway obstruction, not elsewhere classified 4

78009 Other alteration of consciousness 3

96502 Poisoning by methadone 3

29281 Drug‐induced delirium 3

E9800Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted

3


Description Count

T40601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter 2

F1123 Opioid dependence with withdrawal 2

T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter 2

T40605A Adverse effect of unspecified narcotics, initial encounter 2

T40602A Poisoning by unspecified narcotics, intentional self‐harm, initial encounter 1

T400X1A Poisoning by opium, accidental (unintentional), initial encounter 1

F1193 Opioid use, unspecified with withdrawal 1

T404X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter 1

T402X5A Adverse effect of other opioids, initial encounter 1

R0681 Apnea, not elsewhere classified 13 Only the top 10 diagnosis codes are shown4 Some opioid ADEs require two diagnosis codes used in combination

Contact to Obtain Your Hospital Report

EmailNina Rose

[email protected]

53

Questions?

54

Thank you!Edna Clifton

813.865.3579 Cell [email protected]

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not

necessarily reflect CMS policy. Publication No FL‐11SOW‐C.3.6‐02172017‐01

adverse drug events impact on hospital - fhamar 07, 2017 · adverse drug events impact on hospital...

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