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Center for Health Equity Research and Promotion

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Safety and value of medications for older adults

Thomas Radomski, MD

Of his transition from his past three years as KL2 scholar focused on low-value tests and procedures among veteran dual users of the VA and Medicare, Dr. Radomski said, “I realized that the paradigm of value as it relates to medications hasn’t been thoroughly explored. There’s a lot out there on medication safety and harms, but the value side of the equation—monetary and non-monetary costs as they relate to benefits and harms—hasn’t been as studied.”

By Center for Research on Health Care University of Pittsburgh
Friday, September 20, 2019

From the University of Pittsburgh Center for Research on Health Care:  https://bit.ly/2kLIvIn


Dr. Thomas R. Radomski
 has recently been awarded a career development K23 grant from the NIH National Institute on Aging for his study titled, “The Development, Validation, and Application of a Claims-Based Metric of Low-Value Prescribing in Older Adults.”

Of his transition from his past three years as KL2 scholar focused on low-value tests and procedures among veteran dual users of the VA and Medicare, Dr. Radomski said, “I realized that the paradigm of value as it relates to medications hasn’t been thoroughly explored. There’s a lot out there on medication safety and harms, but the value side of the equation—monetary and non-monetary costs as they relate to benefits and harms—hasn’t been as studied.”

Older patients are more likely to experience polypharmacy—using multiple medications at the same time, which may lead to drug-drug interactions and complications from taking too many medications at once. In addition to potential side effects, being on multiple medications means more cost and hassle to the patient. Thus, the goals of this study, which began on August 1 and will be completed in 2024, is to decrease unnecessary cost, risk, and burden of medications that senior citizens are prescribed in the United States.

According to Dr. Radomski, health systems and insurers do not have a great way to monitor the aging populations’ use of low-value medications where the harms or costs outweight the potential benefits. Instead, they are likely to focus on the use of a single medication, test, or procedure when assessing value. Therefore, of all the potential medications considered low-value by various professional societies and current research, this project’s panel of experts will determine the top 25–30 medications that are the most important for health systems and insurers to focus on in trying to reduce senior citizens’ medication burden.

In developing this metric, we want to make sure it’s informed by research, reports, and expert guidelines. We also want to make sure that the components of the metric are relevant to prescribers and has validity to patients.

 

Part of the preliminary data of this project was conducting focus groups with patients. Results of these focus groups will add to the review of the literature to aid the expert panel in deciding which candidate medications make the final list. Dr. Radomski and his team interviewed patients 65 years and older taking five or more medications, and caretakers of patients meeting the same criteria. Dr. Radomski said what they found was not unexpected: “Medications that are meant to prevent the onset of a disease, like a cholesterol-lowering medication, don’t resonate with patients as much as a medication with immediate effectiveness.” Patients were also looking for medications that could improve a particular lab value that their physician was tracking. The biggest concern for patients, above cost, were side effects. Caregivers, on the other hand, tended to favor medications that would improve the patient’s mental status and thus devaluing medications that might affect the patient’s mental status. They valued change in home readings, such as blood pressure or blood-glucose readings.

Interviews with prescribing practitioners are in now process to see how they view medication value. This is important because, as Dr. Radomski said, “If an insurance company or health systems says you have to cut back on the use of these medications, or you can’t prescribe these medications, it’s not often well received. It feels very heavy-handed.” These measures ensure that the metric that Dr. Radomski will develop will be clinically sound, informed by guidelines, and acceptable to patients and practicing prescribers.

Once the expert panel—informed by the opinions of patients and physicians—develops the list of 25–30 low-value medications, the second step will be to validate it with claims data from the Department of Veterans Affairs. Looking in the patients charts may provide additional data not apparent from the claims-based metric itself. Validation is a unique step for this project because a lot of currently available metrics measure low-value care like tests, but very few, if any, have actually been validated. Validating the metric will enhance its marketability to insurers and to health systems. After the VA claims data, this metric would be applied to a national sample of millions of patients: the Medicare population. If the metric aligns with patient charts, it would eliminate the need to look at patient charts for finding low-value medications.

Validating the metric will also allow us to check discrepancies between the charts and the diagnostic coding process in order to know if using the diagnostic codes to design the metric is sufficient, or if we need to explore other ways to identify low-value medications.

 

For Dr. Radomski, colleagues, and other health systems, the next step would be to design interventions to decrease use of low-value medications. It would also be beneficial to see how reducing use affects patient outcomes and satisfaction. More and more, insurers are looking for value-based care, which encourages highly evidence-based care delivered at the lowest cost to achieve the best outcome. Developing, validating, and applying this claims-based metric may aid in the de-prescribing of low-value medication among older adults.

Dr. Radomski is aided in this endeavor by his primary mentor, Walid F. Gellad, MD, MPH, and co-mentors Mark Roberts, MD, MPP (Public Health, Chair of Health Policy and Management), Carolyn  T. Thorpe, PhD, MPH (Health Services Researcher at UNC & VA Center for Health Equity and Promotion), and Joseph T. Hanlon, PharmD, MS (Division of Geriatric Medicine). Additional collaborators include Scott Rothenberger, PhD (Center for Research on Health Care Data Center), Megan E. Hamm, PhD (Director of Qualitative, Evaluation, and Stakeholder Engagement Research Services), Julia Driessen, PhD (Assistant Professor of Health Policy and Management), Gary Fischer, MD (Professor of Medicine), RAND, fellows, and research assistants.

Thomas R. Radomski, MD, MS, is an Assistant Professor of Medicine and Clinical & Translational Science and the Director of Academic Programs in Clinical Research for the Institute for Clinical Research Education.


September 20th, 2019

 

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