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Breast Cancer in Women Over 60

By: Carla Sinner, PharmD

Breast Cancer Risk: 

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The National Cancer Institute estimates that 1 in 8 women living in the United States will be diagnosed with breast cancer in their lifetime.

Gender and age are the most significant risk factors for developing breast cancer, with approximately 95% of all cases occurring in women 40 and older. It is a leading cause of death among women in the United States, second only to skin cancer. 

Breast cancer is considered a disease of aging. The median age of women who develop breast cancer is 62, with over 24% of cases occurring in women between the ages of 70 -84. Additionally, the number of diagnosed invasive breast cancer cases is expected to more than double by 2030 for this age group.

Mammogram Recommendations:

The U.S. Preventive Services Task Force recommends biennial mammogram screenings for women ages 50-74.  However, screening guidelines for women 75 years and older are less clear. The task force does not offer any guidance for or against mammogram screenings for this population due to lack of evidence demonstrating benefits outweighing risks. Thus, the decision to continue having mammograms should be personal, based on current health and medical history. The benefits of continued screenings should be discussed with a physician who can aid in developing a preventative screening plan. For some older, healthy women with a life expectancy greater than 10 years, it may be reasonable to continue getting mammograms once every 2 years; whereas breast cancer monitoring through physical exams may be more beneficial for older women who have serious health issues or reduced life expectancy.

Treatment options for older women:

Even though older women represent the majority of breast cancer patients, treatment-based guidelines for this patient population are limited mainly due to lack of representation in clinical trials which are used to form the basis of the standards of care guidelines. While usual treatment regimens for younger patients often involve a combination of chemotherapy, surgery, and radiation, treatment for older women, who present with early breast cancer, is likely to be considerably less invasive and is mostly dependent upon the type of breast cancer diagnosed. For example, it is estimated that 80% of women in their 70s, and 90% of women in their 80s, have hormone receptor positive breast cancer. These types of tumors can often be treated effectively with surgery and adjuvant hormone therapy without the need for additional radiation or chemotherapy.  

Hormone therapy has been shown to prevent cancer cells from getting the hormones necessary to grow, either by lowering estrogen levels, or by stopping the action of estrogen on tumor cells. The following hormone based therapy is often used to treat breast cancer in post-menupausal women:

  • Aromatase inhibitors, including anastrozole, exemestane, and letrozole, which help lower estrogen levels in the body.  

  • Selective estrogen receptor modulators (SERMs), including tamoxifen and toremifene,which block estrogen receptors on the tumor cells surface.  This prevents estrogen from acting on cancer cells and giving the cells instructions to grow and divide.

A study published in the  August 1st, 2019 edition of “International Journal of Radiation Oncology” looked at women 70 years of age and older with hormone receptor positive, HER-2 negative breast cancer. The research team conducted a matched cohort observational study that included 2995 patients from the National Cancer Database. The study compared overall survival in otherwise healthy women treated with lumpectomy and adjuvant hormone therapy versus lumpectomy followed by radiation therapy. The study found no difference in the 5 year overall survival rate between the two groups. Women who underwent lumpectomy and hormone therapy lived just as long as those who received radiation, although radiation therapy did result in a somewhat reduced risk of recurrence.   (https://www.redjournal.org/article/S0360-3016(19)33556-4/abstract) 

For a small percentage of older women who have advanced metastatic breast cancer or estrogen negative breast cancer, treatment with chemotherapy may warrant consideration. Chemotherapy drugs are often selected based on their ability to target tumor cell genes and proteins as well as the patient’s ability to tolerate the treatment regimen. The risks of potential side effects that can impact the patient’s daily life must be weighed against the benefits of treatment. Women should work closely with their oncologist to develop a personalized treatment plan that addresses the following:

  • Health and life expectancy

  • Risks and benefits of treatment

  • Treatment goals- reduced side effects versus lower likelihood of recurrence

Risk of breast cancer related death:

While older women are more likely to get breast cancer, their risk of dying from the disease is not significantly higher than that of younger women. Studies show more deaths from breast cancer in older women simply because most diagnoses occur in older women; however, the cause of death for many of these women is unrelated to their breast cancer. For women of any age, survival rates are dependent on the stage and subtype of cancer. The facts show many women of advanced age have positive results when treated for breast cancer. 


References:

U.S. Preventive Services Task Force.  (2016). Breast Cancer: Screenings. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=breast%20can

National Cancer Institute.  Study Forecasts New Breast Cancer Cases by 2030. https://www.cancer.gov/news-events/cancer-currents-blog/2015/breast-forecast

BreastCancer.Org. U.S. Breast Cancer Statistics. https://www.breastcancer.org/symptoms/understand_bc/statistics

Breast Friends., (2017) Breast Cancer Signs, Symptoms, and Facts. https://www.breastfriends.org/cancer-facts/breast-cancer-facts/?gclid=Cj0KCQjw8svsBRDqARIsAHKVyqEs0se5AsFMU6UTliXXdrzL5CnIXNZ49s2S-r4iGG98D-gLFth8qmUaAio8EALw_wcB

American Cancer Society. Hormone Therapy for Breast Cancer. Retrieved from https://www.cancer.org/cancer/breast-cancer/treatment/hormone-therapy-for-breast-cancer.html#references

Harvard Women’s Health Watch. (2015).  Good New About Early Stage Breast Cancer for Older Women. Harvard Health Publishing Harvard Medical School. Retrieved from https://www.health.harvard.edu/cancer/good-news-about-early-stage-breast-cancer-for-older-women

Freedman RA.  (2015). What Older Women Should Know About Breast Cancer.  Dana-Farber Cancer Institute. Retrieved from https://blog.dana-farber.org/insight/2015/08/what-older-women-should-know-about-breast-cancer/

Buszek, SM, Lin HY, Bedrosian I, Tamirisa N Babiera GV, Shen Y, Shaitelman SF.  (2019). Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor–Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database. 

DOI: https://www.redjournal.org/article/S0360-3016(19)33556-4/abstract


Continuous Blood Glucose Monitoring Systems Part 1: The evolution of blood glucose monitoring in the diabetic patient.

By: Carla Sinner, PharmD

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According to the American Diabetes Association, one in eleven Americans have diabetes. Of the 23.1 million Americans living with this condition, about 32% are prescribed insulin either as monotherapy or in combination with oral antidiabetic medications to treat their high blood sugar. A cornerstone of effective diabetes management, especially for patients taking insulin, is monitoring blood glucose levels.

The Importance of Glucose Monitoring:

Glucose monitoring is an essential tool to evaluate a patient’s response to therapy and determine if glycemic targets are being achieved.

  1. Glucose monitoring can help detect and alert to episodes of hypoglycemia and hyperglycemia as well as offer insight into how stress, diet, exercise, and medication impact blood glucose fluctuations and levels throughout the day.

  2. It can offer healthcare providers information to optimize medication therapy in an effort to reach overall treatment goals.

Not that long ago, self monitoring blood glucose (SMBG) meters were the only available devices for home blood sugar monitoring for the millions of patients living with diabetes. Since these allow for the patient to decide when to test his or her blood sugar level, the data provided is both intermittent and time specific. Many times overnight and post-prandial blood glucose levels go unchecked, making it difficult for patients and their practitioners to identify fluctuations in blood glucose levels.

Positive Aspects of Continuous Glucose Monitoring Systems:

The introduction of personal continuous glucose monitoring systems has revolutionized diabetes management for both type 1 and type 2 diabetic patients that rely on exogenous insulin for blood glucose control. Because these patients are dependent on exogenous insulin as part of their diabetes management, they are more susceptible to episodes of blood glucose fluctuations and hypoglycemia. Studies have shown that CGM can improve long-term glucose control, increase the amount of time blood glucose levels are in a healthy range, and reduce episodes of hypoglycemia. The American Diabetes Association states, “Our position on CGM is that this new technology can offer diabetic patients a major advance in improving A1C values and reducing the occurrence of disruptive hypoglycemia.”

While the currently available CGM models may differ with respect to device features, they all share similarities in functionality. They are all composed of 3 basic parts: a sensor, a transmitter, and a receiver.

  • The sensor continuously monitors blood glucose readings in the interstitial fluid under the skin.

  • A small wire in the sensor connects to a reusable transmitter that gathers and interprets the glucose level and transmits the reading wirelessly to an insulin pump, smartphone, tablet, or a device monitor depending on the model.

  • Daily activities such as meal times, exercise, or take insulin can also be entered and tracked on the receiver.

Unlike SMBG meters, CGM technology captures blood glucose levels in real time throughout the day, usually in five minute intervals. This allows patients to see how their levels fluctuate over the course of a few hours or even days in response to diet, periods of physical activity or exercise, and medication. CGM systems can identify trends in blood glucose fluctuations as well as episodes of hyper- and hypoglycemia. Depending on the model, an alarm feature may be available to alert the user when blood glucose levels are quickly falling or rising.

Limitations of Personal CGM Systems:

Personal CGM systems are not without limitations. Even though blood glucose levels are continuously monitored, a finger stick is still required on many of the models for the purpose of calibration or treatment decisions. The high cost associated with CGM systems and limited healthcare coverage can be prohibitive, limiting patient access. Researchers and developers continue to work on improving features such as accuracy, easy of use, and increased life span of device sensors, all of which are concerns with many models available on the market today.

Current Impacts on Diabetes Management:

Regardless of some design limitations of currently available CGM systems, the detailed information these systems gather and provide to both patients and their healthcare providers can significantly impact diabetes management. Patients are able to gain valuable insight into their glucose levels and rates of fluctuations. This can help patients, along with their practitioners, to proactively manage their diabetes through drug therapy as well as lifestyle and dietary modifications.

CGM is an advanced way for people living with diabetes to keep track of their blood glucose levels in real time and monitor levels over a period of time. These systems will likely evolve to play a vital and central role in diabetes management and blood glucose control, helping patients achieve glycemic targets and maintain near normal blood glucose levels. CGM technology can help patients and healthcare providers make significant improvements in treatment outcomes as well as greatly reduce the incidence of diabetes-related complications.

Stay tuned for Continuous Blood Glucose Monitoring Systems Part 2: How one company is leading the way in technology innovation and advances in patient care.


References:

Russel SJ. (2017). Continuous Glucose Monitoring. U.S. Department of Health and Human Services. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from: https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/continuous-glucose-monitoring

.ADA: American Diabetes Association. (2019). Diabetes Technology: Standards of Medical Care in Diabetes-2019. Diabetes Care. 42(Supplement 1): S71-S80. Retrieved from https://doi.org/10.2337/dc19-S007

Slattery D, Choudhary P. (2017). Clinical Use of Continuous Glucose Monitoring in Adults with Type 1 Diabetes. Diabetes Technol Ther. 1; 19(Suppl 2): S-55–S-61. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444504/

Rodbard D. (2017). Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. Diabetes Technol Ther. 1; 19(Suppl 3): S-25–S-37.. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467105/

American Diabetes Association. (2019). Fast Facts: Data and statistics about diabetes. Retrieved from https://professional.diabetes.org/sites/professional.diabetes.org/files/media/sci_2019_diabetes_fast_facts_sheet.pdf

Healthwise staff. (2018). Continuous Glucose Monitoring: Topic Overview. Kaiser Foundation Health Plan of Washington. Retrieved from https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=abk4683

American Diabetes Association. (2008). Continuous glucose monitoring: The future of diabetes management. Diabetes Spectrum. 21(2): 112-119. Retrieved from https://doi.org/10.2337/diaspect.21.2.112

Primary Care Providers Face A "STEEEP" Hill to Climb

But They Don’t Have to Do It Alone

By Elliot Sternberg, MD

PharmD Live, Chief Medical Officer

The Center for Medicare and Medicaid Services (CMS) has embraced a framework created by the Institute for Health Improvement (IHI) designed to optimize the American healthcare system:

  • Improve Patient Care

  • Reduce Healthcare Costs         

  • Improve Population Health

CMS has aligned its Quality Payment Program metrics to increase (up to 7%), or reduce (down to 7%), physician reimbursements, tied to performance in pursuit of these goals. The Merit-Based Incentive Payment System (MIPS) has 4 performance categories (with weighting noted):

  • Quality 45%

  • Cost 15%

  • Improvement Activities 15%

  • Interoperability 25%

In addition, CMS has created a customized Advanced Payment Model (APM), featuring an overall financial risk component while requiring the use of a  certified electronic health record (CEHRT) to receive a 5% incentive payment for groups of eligible clinicians focusing on specific clinical conditions, care episodes, or populations:

  • Quality 50%

  • Improvement Activities 20%

  • Promoting Interoperability 30%

Though well intended, this initiative has placed a significant burden on primary care providers (PCP) who, for the most part, are paid on a productivity basis. The added administrative burden of detailed documentation, data collection and submission, in the setting of adoption of an electronic health record, has come at significant cost, time and stress for the health care provider and staff. It is not surprising that some older physicians have opted for early retirement, while others have joined larger organizations that can seemingly ease administrative burden.  But the fact still remains - to be paid one must see patients and complete all of the necessary documentation, thus the pressure remains regardless of practice environment.  

Consequently, physicians face  a very “STEEEP” hill to climb in  providing care to an increasingly aging  and complex group of patients:

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Is it any wonder physicians are experiencing burnout? 

In response, healthcare providers should focus their  efforts on realizing their own “Quadruple Aim”: 

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While the solution to these challenges may be complex, one concept rises  to the top:

The Primary Care Provider does not need to climb this very “STEEEP hill alone!”

The PCP should be finding greater personal and professional satisfaction when he/she practices to the maximum of their privileges and license. This strongly suggests the necessity of offloading many mundane tasks.  This can be accomplished through collaboration with ancillary providers (pharmacists, behavioral medicine specialists, dietitians, and educators among others) which will enable the physician to focus on the diagnosis and management of more challenging clinical problems. Embracing a collaborative team approach, supported by effective technology  and clinical apps, will help to overcome many of the STEEEP challenges they are forced to meet. Allowing others to assist will help improve and promote increased patient access, delivery of preventive services and education, and optimization of medication management while providing chronic disease management services between between physician visits. 

 The result?

  • Increased health of the patient and physician population;

  • Enhanced experience of delivering and receiving care;

  • Reduced per capita cost of care while rewarding primary care services.


For their own health and welfare, PCPs must explore different ways of meeting the needs of their patient population. Collaborating with others, embracing a team approach and adoptingsophisticated software solutions would be an effective start. 


The MIND (Mediterrean-DASH Intervention for Neurodegenerative Delay) diet and Alzheimer’s Disease.

By: Carla Sinner, PHARM.D

Alzheimer’s disease is the most common cause of dementia across the nation. According to the Alzheimer’s Association, “Every 65 seconds, someone in the United States develops the disease.” There are currently 5.8 million Americans living with this illness, and that number is expected to more than double by 2050. In fact, more people die from Alzheimer’s disease than breast and prostate cancer combined.

Drug Treatment Options Are Limited:

Currently, there are no treatment options available that can cure or alter the disease progression in the brain. While researchers are working to find a breakthrough drug that can reverse or stop the progression of this debilitating disease, healthcare providers must also focus their efforts on disease prevention. Although some risk factors in developing the disease, such as age and genetics, are not controllable, there are a variety of healthy lifestyle choices shown to promote brain health and preserve its function, including a combination of regular exercise, social interactions, mental stimulation, quality sleep, stress management, and healthy diet.

In May 2019, the World Health Organization issued guidelines to aide in globally reducing the risk of dementia. The new recommendations emphasize healthy lifestyle choices including regular physical exercise, abstaining from tobacco, drinking less alcohol, maintaining a normal blood pressure, and eating a healthy diet.

Healthy Dietary Recommendations Can Help Slow Cognitive Decline.

Healthcare providers can help patients lower their risk of cognitive decline as they continue to age by recommending dietary changes that have proven success. One such diet, called MIND, also known as the Mediterranean-DASH Intervention for Neurodegenerative Delay, combines aspects of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet. MIND was developed by Martha Clare Morris, a nutritional epidemiologist, and her research team at Rush University Medical Center in Chicago. While both the Mediterrean and the DASH diets may also offer protection against cognitive decline, the MIND diet was developed specifically to address neurodegeneration and to determine the effect of nutrition on the brain as people age.

Morris and her team designed MIND with an emphasis on natural whole foods and nutrients that promote neuroprotection. Unlike the other two diets, MIND emphasizes berries over other fruits, separates green leafy vegetables from “other” vegetables, and recommends fish at least once weekly. It promotes foods rich in antioxidants as well as foods that have high amounts of omega 3 fatty acids, which may promote overall brain health and function.

Components Of The Mind Diet:

The MIND diet has 15 dietary components broken into two groups including 10 foods that promote brain health and five unhealthy food groups foods to avoid or limit due to high amounts of trans and saturated fats and sugar.

“Brain healthy” foods include:

  • Green, leafy vegetables: at least six servings per week of vegetables like kale, spinach, cooked greens, and salads for their antioxidant effects;

  • All “other” vegetables: at least one serving per day; aim for non-starchy vegetables;

  • Berries: blueberries, blackberries, strawberries, and raspberries for their antioxidant effects at least twice per week;

  • Nuts: especially those high in omega 3 fatty acids, such as walnuts, most days;

  • Olive oil as the main cooking oil;

  • Whole grains: oatmeal, quinoa, brown rice, whole wheat pasta, and 100% whole wheat bread at least three servings per day;

  • Fish: at least one serving per week; aim for fish high in omega 3 fatty acids such as salmon, sardines, trout, tuna, and mackerel;

  • Beans: beans, lentils, and soybeans at least four servings per week;

  • Poultry: chicken or turkey at least twice per week; and

  • A glass of wine daily.

“Unhealthy foods”:

  • Butter and margarine: less than one tablespoon per day;

  • Cheese: less than one serving per week;

  • Red meat: limit to no more than three servings per week; this includes all beef, pork, lamb, and any products made from these meats;

  • Fried food: less than one serving per week;

  • Pastries and sweets: limit to no more than four times per week.

MIND Diet Study Results:

To determine the benefits of the MIND diet with respect to brain health, Morris and her team conducted an observational study which followed 923 individuals, ages 58 to 98, over a period of five years. The study enrolled volunteers already participating in the ongoing Rush Memory and Aging Project in Chicago. Researchers used an optional food frequency questionnaire to observe what people in the study were already eating to assign points based on their food choices in order to calculate a MIND score that correlated to their risk reduction.

The study found that closely adhering to the MIND diet could lower the risk of developing Alzheimer’s by as much as 53%. Of the 923 enrolled participants, only 144 of them developed Alzheimer’s disease. Even when the diet was only modestly followed, the risk of Alzheimer’s was reduced by as much as 35%. According to Morris, “One of the more exciting things about this is that people who adhered even moderately to the MIND diet had a reduction in their risk for AD.”

The study also suggests that the longer a person follows the MIND diet, the better the chance of preventing cognitive decline.

Continuing Dietary Research:

In a follow up study, Morris and her team compared the MIND diet with the DASH and Mediterrean diets. When strictly followed, the DASH and Mediterrean diets offered similar protection against cognitive decline and prevention of Alzheimer’s disease. However, when either diet was only modestly followed, the risk reduction was negligible.

While the observational study did show a strong relationship between adherence to the MIND diet and protection against Alzheimer’s disease, a causal relationship could not be determined due to the limitations of an observational study design.“We devised a diet and it worked in this Chicago study. The results need to be confirmed by other investigators in different populations and also through randomized trials.That is the best way to establish a cause-and-effect relationship between the MIND diet and reductions in the incidence of Alzheimer’s disease,” said Morris.

In order to confirm her results from the previous studies and determine the effectiveness of the MIND diet in preventing Alzheimer’s disease, Morris and her research team are in the process of conducting a three year intervention study consisting of 604 individuals aged 65 to 84. The study includes participants who are considered overweight, have poor eating habits and no cognitive decline. The participants have been randomly separated into two groups: the MIND diet group and the mild calorie restriction group (250 fewer calories per day). The trial concludes in 2021 with the hopes of finding the MIND diet has a direct impact on brain health and Alzheimer’s prevention.

REFERENCES:

Alzheimer’s Association. (2019). 2019 Alzheimer’s disease facts and figures [PDF]. Retrieved from https://www.alz.org/media/Documents/alzheimers-facts-and-figures-infographic-2019.pdf

Smith, M., Robinson, L., Segal, J. (2018). Preventing Alzheimer’s disease: What you can do to prevent dementia. HelpGuide.org. Retrieved from https://www.helpguide.org/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm/

Hunt K. (2019). Eat well, exercise more: New global guidelines to reduce the risk of dementia. CNN Health. Retrieved from https://www.cnn.com/2019/05/14/health/who-guidelines-dementia-intl/index.html

Rush University Medical Center. (2015). New MIND Diet May Significantly Protect Against Alzheimer’s Disease. Retrieved from https://www.rush.edu/news/press-releases/new-mind-diet-may-significantly-protect-against-alzheimers-disease

Rush University Medical Center. (2015). Diet may help prevent Alzheimer’s. Retrieved from https://www.rush.edu/news/diet-may-help-prevent-alzheimer

Morris MC, Tangney CC, Wang Y, Sacks FM, Bennett DA, Aggarwal NT. ( 2015). MIND diet associated with reduced incidence of Alzheimer’s Disease. Alzheimers Dement. 11(9): 1007-1014. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4532650/

Barba, C. (2018). Can you beat Alzheimer’s with diet? An interview with the MIND diet creator. Being patient. Retrieved from https://www.beingpatient.com/can-you-beat-alzheimers-with-diet-an-interview-with-the-mind-diet-creator/

The MIND diet intervention to prevent Alzheimers’s disease. Retrieved from http://mind-diet-trial.org/

Bradford, A. (2016). What is the MIND diet? LiveScience. Retrieved from https://www.livescience.com/57132-mind-diet.html


Polypharmacy Demographics: Studying The Rise in Over Prescribing

By: Courtney Wright, PhamD

Polypharmacy is the utilization of multiple medications for one or more conditions generally regarded as treatment with five or more medications simultaneously. The elderly population is most susceptible to this practice, with nearly 40-50% of elderly patients being prescribed an array of medications to treat multiple conditions.

Swedish Study Shows Increases As Patients Age:

As humans age, comorbid conditions rise. A study in Sweden, conducted over the course of three years, observed the prevalence of polypharmacy in individuals aged 65 and older. During this time period, the prevalence of polypharmacy (5 medications) was 44% and excessive polypharmacy (10 medications) was ~11%. The incidence of polypharmacy increased as well. A one year follow-up to this study showed the risk of polypharmacy development was 20% for adults ages 65-74 and 34% for ages 95 and up. At the three year mark, the data showed the risk of polypharmacy having increased to 53% for patients ages 65-74 and up to 87% for patients 95 years and older.

British Study Found Patients With Higher Education Levels Less Susceptible:

A British study of elderly patients at age 70 reported the number of medications and use increased for most. However, polypharmacy was mostly prevalent in patients with cardiovascular medications. This study also concluded that patients with higher education levels were less likely to experience polypharmacy. Researchers suggested that people with higher education levels may be more inclined to research medications and their side effects, as well as explore alternative therapies.

U.S. Studies Show Population-Based Variations:

While the elderly are most often affected by polypharmacy, recent studies have shown population-based variation. A 2015 study done in the U.S., found differences in racial and geographic patterns in polypharmacy. The study looked at three different regions including: the stroke buckle (coastal plains of the Carolinas and Georgia), the stroke belt (eight Southern states: North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas, Louisiana) and the stroke non-belt (the rest of the continental United States). In this study, researchers looked at age differences as well as race (African Americans versus Caucasians) and sex (male versus female). The results showed female patients living in the southern region had a higher prevalence of polypharmacy than their opposite groups. Polypharmacy prevalence was similar between both ethnic populations; however, African American were less likely to be prone to polypharmacy. Also of note, most patients in the study were being treated for dyslipidemia, hypertension, and diabetes - diseases which often require at least 2-3 medications.

Polypharmacy More Prevalent For Certain Conditions:

Polypharmacy can also occur when patients are suffering from serious illnesses like HIV. There are several patients over the age of 50 years old living with HIV currently. For this group, comorbidities rise at a much higher rate than average. Although antiretroviral regimens have helped decrease the number of required medications, the existence of comorbidities with this illness continues to increase the likelihood for multiple drug treatments.

A retrospective cohort study was conducted between 2004-2006. This study looked at polypharmacy trends in HIV positive versus HIV negative men. The study found that polypharmacy increased in all patients despite age or HIV status; however, prevalence was higher for patients 50 years and older who were HIV positive and had medical insurance. The study also found that higher comorbidity index score equated to higher rates of polypharmacy.

Conclusions:

  • Polypharmacy has been shown to be a greater risk in the elderly population.

  • Studies have also shown the risk increases as people age.

  • Polypharmacy is not equally distributed between regions of the United State either with males or females.

  • Having HIV, or having multiple disease states, increased the likelihood of polypharmacy.

  • While polypharmacy is sometimes appropriate for the standard of care despite demographics, the practice should be avoided when necessary.

How We Can Help:

PharmD Live’s clinical pharmacists have advanced training and knowledge of pharmacology, drug-drug interactions, therapeutic interchanges and informatics. We partner with physicians and prescribers to provide patients with complex medical conditions the best health outcome possible.

Contact us to learn more.

References:

Rawle MJ, Richards M, Davis D, Kuh D. The prevalence and determinants of polypharmacy at age 69: a British birth cohort study. Rawle et al. BMC Geriatrics (2018) 18:118.

Morin L, Johnell K, Laroche ML, Fastbom J, Wastesson JW. The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clinical Epidemiology 2018:10 289–298.

Cashion W, McClellan W, Howard G, Goyal A, Kleinbaum D, Goodman M, Prince V, Muntner P, McClure LA, McClellan A, Judd S. Geographic Region and Racial Variations in Polypharmacy in the United States. Ann Epidemiol, 2015 June; 25(6): 433-438.

Ware D, Palella FJ, Chew KW, Friedman MR, D’Souza G, Ho K, Plankey M. Prevalence and trends of polypharmacy among HIV-positive and -negative men in the Multicenter AIDS Cohort Study from 2004 to 2016. PLoS ONE 13(9): e0203890.


AGS Beers Criteria® (2019 Update): Potentially Inappropriate Medication Use in Older Adults

AGS Beers Criteria® (2019 Update): Potentially Inappropriate Medication Use in Older Adults

By identifying medications that have the potential to harm our elderly patients, we can proactively prevent medication-related harm. Given that more than 90% of older patients use at least one prescription drug, and more than 66% use three or more drugs, it is crucial that we prevent harm by avoiding those drugs which are inappropriate for use in our geriatric population.  

Medication Overload: How Much, is Too Much?

Medication Overload: How Much, is Too Much?

Professionals treating patients with chronic care needs should remain mindful of the increased risks of over medication by working with their patients to ensure a proper review of all medications prescribed. By being cognizant of the possibility for polypharmacy, healthcare professionals can help patients achieve better health outcomes. 

On the Cusp of Change: Social Determinants of Health Garner Attention

Dr. Cynthia C. Nwaubani, BCGP, CMTM

Synopsis: The social determinants of health are being explored by pundits as the root cause of inefficient healthcare spending. This article discusses Health and Human Services Secretary Alex Azar’s recent nod to forthcoming changes in Medicare reimbursement for non-clinical care.

The social determinants of health—economic and social factors that impact health status—have received considerable attention from Health and Human Services (HHS) Secretary Alex Azar. In his November 14th speech at The Hatch Foundation for Civility and Solutions, Secretary Azar names the social determinants of health as the root cause of much of today’s healthcare spending.

Azar states, “We believe we could spend less money on healthcare—and, most important, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs.”

As a clinical pharmacist delivering chronic care management (CCM) services, I have seen many patients whose health conditions are impacted or solely caused by social and economic factors. Ongoing medication therapies, emergency room visits, and extended hospital stays are often underpinned by factors outside of clinical care. The well-being of patients and families is thwarted, health outcomes compromised and a plethora of wasteful spending that ignores root cause and common sense. Asthma patients living in homes contaminated with mold, non-adherence to life-dependent medications due to cost, and diabetics without access to healthy food are commonplace.

Sweeping changes to healthcare delivery are expected in 2019, as the journey to a value-based healthcare economy continues. One of these changes will likely be an uptick in chronic care management services provided to Medicare patients with two or more chronic conditions. Addressing the social determinants of health is a compulsory aspect of Medicare-reimbursable CCM services—so it is reasonable to assume more patients will be adequately screened. Community resources (with paper-thin budgets) will likely be tapped for resource provision—healthy meals, transportation or funding for electricity bills. Addressing social determinants of health through CCM services is promising for Medicare patients; however, much work will need to be done to ensure adequate funding for resources.

In his November speech, Azar stated, “Just like how every patient is different in healthcare, every person has unique social service needs—and we are intent on designing models that connect them to the services they need, rather than offering a one-size-fits-all approach.”

A 2014 study by Dr. Seth Berkowitz evaluated the relationship between material need insecurities, control of diabetes mellitus and the use of healthcare resources. Berkowitz concluded, “Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities. In particular, food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus.”

In the context of the study, addressing the social determinants of health is aligned with The Quadruple Aim: improved population health, reduced care cost, satisfied patients and satisfied providers. And Secretary Azar seems to agree: “What if we provided [sic] solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford nutritious food? If that sounds like an exciting idea...I want you to stay tuned to what CMMI is up to.”

Yes, Secretary Azar, our curiosity is piqued!

Dr. Nwaubani is Founder and CEO of PharmD Live, an emerging digital health company focused on pharmacist-led innovative solutions to improve patient outcomes and ease the transition to value-based care. This article originally appeared as a guest post on healthcareguys.com.

MIPS Tips: Procrastinator’s Edition

Dr. Cynthia C. Nwaubani, BCGP, CMTM

The decision to enter the medical profession is personal—and for most of us, it precluded mountains of paperwork and coils of red tape. It had to do with people, healing and working for the greater good. As a pharmacist and CEO, it is easy to envision why business planning so often takes a back seat to patient care.

But as 2018 draws to a close, business plans for 2019 are demanding attention, especially for practices who treat a high volume of Medicare patients. Magnitudinous changes to reimbursement models are imminent, but there is still time to accelerate your MIPS plan and ensure it is aligned with 2019 practice objectives.

Of the myriad of concerns I have heard from stakeholders during past months, reducing physician burden tops the list. Studies show 28% of physician’s time is spent on non-clinical paperwork, translating to lost revenue for practices and increased physician dissatisfaction. It trends as a hashtag on Twitter for good reason—the role of the physician has expanded to include serving as a steward of the healthcare economy—no small task. And, success in the new healthcare model relies on between-visit care, which adds exponential demands on physician time.

If diving into the 2019 QPP requirements on CMS.gov feels daunting, read on. Caveat—consider this a conversation starter rather than an exhaustive list.

Quick Tips to get MIPS ready:

  1. Check your eligibility status. CMS requirements change from year to year, so this may vary over time. Remember, you can participate as an individual clinician or as part of a group. According to CMS.gov, “to be excluded from MIPS, clinicians or groups would need to meet one of the following three criterion: have ≤ $90K in Part B allowed charges for covered professional services, provide care to ≤ 200 beneficiaries, or provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).

  2. Choose your track: MIPS or APMs.

  3. Select six measures based on your patient population; focus on quality measures, as they will have the greatest impact on your final MIPS score. Improving patient care means quality measures will become increasingly stringent over time. Cost measures are weighted at 30% for the 2019 performance year and will increase over time—a cost-reduction strategy is a crucial element of a successful long-term plan.

  4. Innovate. In the context of the profound paradigm shift, physicians open to innovating their care models are most likely to thrive. CMS’ approval of several codes for chronic care management services via telehealth is a nod to the critical nature of innovation. Explore partnering with a third party CCM provider, such as PharmD Live, to shoulder between-visit care, adding value for patients and serving as a seamless extension of your practice.   

  5. Earn. In 2018, physicians could earn up to 5 extra points for caring for complex patients. CPT codes 99487 and 99489 allow reimbursement for CCM for complex patients, which can be outsourced to a third party vendor, such as PharmD Live, to optimize clinical and financial outcomes.

As January 1 approaches, explore evidence-based solutions, such as implementing pharmacist-led CCM services to meet and track quality measures. Clinical pharmacists are equipped to manage complex medical pictures, and make high-level clinical decisions to support your care plan.  

Ready or not, change is coming.


Leveraging Pharmacist-Led Chronic Care Management (CCM) Services to Decrease Acute Care Stays for Diabetic Patients

Dr. Cynthia C. Nwaubani, BCGP, CMTM

As the national healthcare model has transitioned from volume-based to value-based care, the role of the physician has also shifted. In the value-based care model, physicians are held accountable to deliver the best outcome at the lowest cost. The role of the physician has been redefined to include stewardship of the healthcare economy. November is Diabetes Awareness Month; we will examine the significance of this shift and the impact on the diabetic patient. The American Diabetes Association reports an annual cost of $327B for diagnosed cases of diabetes. One of seven healthcare dollars spent is on diabetic care. Because a significant portion of this spend is derived from costs of acute care, redesigning care delivery to keep diabetic patients out of acute care has been a focus of private and public payers. Chronic care management services—reimbursable by the country’s largest payer, Medicare—were borne from those efforts.

Because complex chronic conditions, such as diabetes, require significant care between office visits—developing a comprehensive patient-centered care plan, care coordination, transitions of care management and increasing access to care via telehealth and 24/7/365 clinician availability are elements of CCM.   

PharmD Live’s CCM services were designed to prevent acute care stays through effective management of the chronic condition. Here’s how PharmD Live’s CCM services are implemented:  

A dedicated clinical PharmD Live pharmacist collaborates with the physician to create a comprehensive care plan, using a patient-centric approach. Patient education and disease-state management plays a paramount role in care. The clinical pharmacist addresses the patient’s ongoing adherence to the care plan, ensures referrals are made to specialists for diabetes-related care (such as podiatrists for foot exams), identifies root cause of shifting bloodwork trends, addresses impact from social determinants of health and ensures diabetes supplies are stocked. Clinical pharmacists rely on PharmD Live’s software, with an advanced clinical rules engine which ensures consistent, timely care and real time communication with practice electronic health records (EHR). PharmD Live  pharmacists provides services virtually, telephonically or via home visit.

PharmD Live tracks quality metrics and provides streamlined billing reports to practice administrators. PharmD Live, a telehealth company committed to improving patient outcome and helping physicians earn quality bonus payments and avoid financial penalties, serves as a seamless extension of physician practices. To fortify your value-based care strategy, schedule a capabilities presentation with Ellery Plowman.



Diabetic Patients in Value-Based Care: Creating the Win for Patients and Physicians

By: Dr. Cynthia Nwaubani, BCGP, CMTM

National Diabetes Month presents the opportunity to examine the process of improving diabetic health outcomes and boosting quality metrics. As a clinical pharmacist and medication expert, I understand the complexities of diabetes and believe it is critical to examine changes through the continuum of care as the national healthcare paradigm has shifted and the market has welcomed innovations. Changes in CMS (the Centers for Medicare and Medicaid Services) reimbursement models have allowed chronic care management (CCM) to be re-engineered; however, the cumbersome process involved in a shift of this magnitude has dictated the pace of change thus far.

As you may know, both tracks of the Medicare Access and CHIP Reauthorization Act’s  (MACRA) Quality Payment Programs, MIPS (Merit-Based Incentive Payment System) and APMs (Alternative Payment Models), tie Medicare reimbursements to patient health outcomes. Physicians are charged financial penalties or awarded financial incentives for reporting on six chosen quality metrics.

The diabetic population, which includes more than 30M Americans, and the prediabetic population, which includes 84M Americans, will comprise a significant portion of the patient population whose health outcomes will be tracked through quality metrics. Meeting quality metrics relies on between-visit care, which has historically added to physician workloads and detracted from practice bottom lines. Compounding the issue of outcome accountability and physician burden is the human tendency to delay physician visits until they reach critical status, creating administrative and physician burden derived from same-day visits.

The Institute for Healthcare Improvement’s (IHI) Triple Aim (which some have expanded to the Quadruple Aim and included physician satisfaction) emphasizes improved patient care and better population health while reducing per capita costs. During the past several years, CMS has made significant changes to reimbursement of chronic care management services to improve population health, hold physicians accountable, and control spiraling healthcare costs based on the Triple Aim. Many physicians I have spoken with agree: in theory, pharmacist-led CCM services are a promising solution to challenges in population health management. But, in practice, how do these services help physicians manage diabetic patient health, meet quality measures and avoid burnout?

Here’s how:

Clinical pharmacists are uniquely qualified to make high-level decisions regarding patient care, including management of the health complexities of diabetic patients. As medication experts, pharmacists can reconcile medication lists from various specialists between primary care visits. Clinical pharmacists serve as a patient resource for questions and concerns around-the-clock, including weekends and holidays, ensuring patients have the appropriate referrals and resources to care for all diabetic issues and complications. Clinical pharmacists are equipped to identify root cause and adjust patient therapy as needed. PharmD Live’s proprietary software relies on an advanced clinical rules engine and artificial intelligence to assist in identifying and managing care and medication side effects.

PharmD Live, a telehealth company committed to improving patient outcome and helping physicians earn quality bonus payments and avoid financial penalties, serves as a seamless extension of physician practices. To fortify your value-based care strategy, schedule a capabilities presentation with Ellery Plowman.