1 South county medical group-EGPharmacist Initiated Crestor Conversion Elderly Patients With Polypharmacy Kevin McGreevy, PharmD, CDOE, CVDOE

2 Pharmacist Initiated Crestor Conversion2013 ACC/AHA guidelines call for increased use of statin medications Cardiovascular risk reduction is driving force behind recommendations Statins are grouped into intensity levels (low/moderate/high) Multiple statins available, most are low cost generics Crestor is exception (besides little used Livalo) Crestor is typically ~$200 more per month than generic statin Annual savings of ~$2400 per patient

3 Moderate Intensity StatinsACC/AHA guidelines list the following as Moderate Intensity (LDL lowering 30% to <50%) Atorvastatin mg Fluvastatin 40 mg twice a day Fluvastatin XL 80 mg Lovastatin 40 mg Pitavastatin 2-4 mg (Livalo) Pravastatin mg Rosuvastatin 5-10 mg (Crestor) Simvastatin mg

4 Crestor 5 & 10 mg Moderate intensity---Top dollarMultiple cost effective alternatives 6 other generic options with similar clinical effectiveness Highly unlikely that another alternative would not be appropriate for patient Crestor 20 & 40 mg is high intensity Only alternative is atorvastatin mg Much less likely that another option would be appropriate for patient

5 Analysis and ObjectivesPatients on moderate intensity Crestor (5 and 10 mg daily) established Pharmacist reviews charts of patients to determine good candidates for conversion Good candidates are contacted by pharmacist, consent to change established from patient Provider contacted on patients that consented to change and appropriate change made Pharmacist follows up with patient in 8-12 weeks to determine compliance and ensure lipids recheck

6 Results 83 patients with Crestor on medication list recognizedOf those only 32 deemed appropriate for pharmacist intervention Original report included patients once on Crestor but that were no longer taking medication Patient’s split by insurance and assigned to Clinical Pharmacist BCBSRI-Kevin McGreevy, PharmD, CDOE, CVDOE Non-BCBSRI-Julia Manning, RPh, CDOE, CVDOE, AE-C

7 Results Of the 32 targets 19 total patient’s changed13 patient’s refused recommendations Most common reasons include: Failed multiple other treatments, did not want to change No/little cost savings for patient 19 patients agreed to change Providers agreed with all recommendations to change 19 total patient’s changed

8 Results 19 of 32 targets changed Total annual savings of ~$45,60059% conversion rate Total annual savings of ~$45,600 (19 patients) x (~annual savings of $2400) As of now, no patient has been changed back to Crestor

9 Conclusion While opportunity was not as large as originally thought, we were able to show that targeted pharmacist interventions can be effective in reducing medication costs Key to success is acceptance from all parties; pharmacist, providers and patients Going forward, will continue to monitor prescribing of Crestor and expand into High Intensity use

10 Elderly patients with polypharmacyPolypharmacy is defined as the administration of more medications than clinically indicated, representing unnecessary drug use Elderly patients are at high risk to having complications and side effects associated with polypharmacy Polypharmacy drives up both direct medical costs and indirect medical costs with unnecessary prescriptions and costs associated with side effects with these medications

11 BCBSRI recommendationsChanges proposed by BCBSRI Reduce threshold number of medications to be a target 10  5 Focus on high risk medications and anticholinergic cognitive burden (ACB)

12 Number of medications 10 was originally selected due to concern with how many patient’s would need intervention 5 has much more clinical backing to it Concern with flagging patient’s on multiple OTCs

13 High Risk Medications & ACBMedications that should be avoided or used with caution in the senior population Considered by medical experts to have a high risk of side effects when used by seniors and, therefore, may pose a safety concern Derived from Pharmacy Quality Alliance and AGS Beers Criteria

14 Plan Had South County IT run report of patient’s aged 65 or older, taking 5 or more medications and had at least one of the following HRM: Nitrofurantoin (Macrobid, Macrodantin) Brompheniramine(Bromfed), hydroxyzine(Atarax, Vistaril), diphenhydramine(Benadryl) Megestrol (Megace) Premarin tablets, Prempro tablets, estradiol tablets (Estrace) Glyburide (Diabeta, Glynase) Indomethacin (Indocin), Ketorolac (Toradol) Cyclobenzaprine (Flexeril), methocarbamol (Robaxin), carisoprodol (Soma), metazalone (Skelaxin), Amitriptyline (Elavil), clomipramine(Anafranil), imipramine (Tofranil), trimipramine (Surmontil) Desiccated thyroid (Armour Thyroid) Butalbital (Fioricet/Fiorinal) Alprazolam (Xanax), clonazepam (klonopin), lorazepam (Ativan), diazepam(Valium) Zolpidem (Ambien), Zaleplon (Sonata), and Eszopiclone (Lunesta)

15 HRM list This is not complete list of HRMEntire list is very large It does encompass vast majority of HRM prescriptions Having IT run this list slowed project down Larger list would further slow down project

16 Objectives  Healthcare team will utilize EHR to recognize patients over the age of 65 that are currently taking over 5 medications  Patient profiles will be reviewed to flag potential candidates for pharmacy intervention  Flagged patients will be contacted by healthcare team to make appointments with pharmacy team  Pharmacy team will meet with patients to review medications  Goal of meeting will be to reduce redundant and unnecessary medications and to reduce the number of high risk medications/high anticholinergic burden medications in the patient  Pharmacist will contact primary care physician with recommendations  Physician will consider pharmacist recommendation and discontinue medications as necessary  Pharmacist will follow up with patient to ensure compliance and satisfactory treatment response with patient

17 Results thus far IT able to identify patients over the age of 65, on 5 or more medications and taking HRM 109 patients identified as potential candidates for pharmacy intervention Patient’s will be split by insurance and assigned to pharmacist BCBSRI-Kevin McGreevy, PharmD, CDOE, CVDOE Non-BCBSRI-Julia Manning, RPh, CDOE, CVDOE, AE-C

18 Conclusion BCBSRI comments on project were both constructive and realistic While it did slow down progress due to IT limitations, project will be focused as to make the biggest impact on quality, patient safety, and cost containment