Receipt of High Risk Medications Among Elderly Enrollees in Medicare Advantage Plans
Amal Trivedi, MD, MPH, is an alumnus of the Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Physician Faculty Scholars program. He is an assistant professor of health services, policy and practice at Brown University and a hospitalist at the Providence VA Medical Center. His co-author, Danya Qato, PharmD, MPH, is a pharmacist and doctoral candidate in health services research at Brown University. They recently published a study that finds older patients are routinely prescribed potentially harmful drugs, particularly in the South.
Human Capital Blog: Why did you decide to look at this particular topic? And why are some drugs considered high-risk for elderly patients?
Danya Qato and Amal Trivedi: Adverse drug events are an important public health problem. For the elderly, such events are often precipitated by use of potentially inappropriate or high-risk medications. Over the past several decades, clinicians and researchers have sought to identify medications that should be used with caution in the elderly. These high-risk medications should be avoided among people 65 years of age or older because the associated adverse effects outweigh potential benefits or because safer alternatives are available. Elderly patients are susceptible to these medications because they have more chronic illness, greater frailty, and an altered ability to metabolize drugs. The Centers for Medicare and Medicaid Services now require all Medicare Advantage plans to report on the use of high-risk medications among their enrollees.
We undertook this study because successful efforts to reduce high-risk medication use in the elderly require knowledge of how prescribing of these agents varies geographically and the factors that predict their use. Half of persons aged 65 and older use three or more prescription medications a day. Therefore, potentially inappropriate use of medications in the elderly has important implications for health care spending and quality.
HCB: What did your study look at?
Qato and Trivedi: In this study, we examined geographic variation in and predictors of high-risk medication use, as assessed by the Healthcare Effectiveness Data and Information Set (HEDIS) quality indicator in a national sample of more than six million elderly Medicare enrollees in 2009. The National Committee on Quality Assurance developed HEDIS indicators as a tool to measure and compare the quality of care delivered to enrollees in Medicare health plans. Two HEDIS quality indicators, entitled “Drugs to Avoid in the Elderly,” measure the percentage of Medicare enrollees in each health insurance plan who received at least one high-risk medication or at least two different high-risk medications. These measures seek to reduce use of high-risk drugs and, by extension, rates of adverse drug events.
HCB: What did you find?
Qato and Trivedi: Among 6.2 million Medicare Advantage enrollees in 2009, 21.5 percent (more than one in five) received at least one high-risk medication and 4.8 percent received at least two as defined by the HEDIS quality measures. The largest differences in risk were based on gender and geography. After we adjusted for sociodemographic, community-level, and insurance plan level factors, females had a 10.6 higher percentage point rate of receipt of at least one high-risk medication compared to men. Persons residing in the West South Central (e.g. Arkansas, Louisiana), East South Central (e.g. Alabama, Mississippi) and South Atlantic (e.g. Florida, Georgia) census divisions had a 10 percentage point or higher rate of receiving such drugs as compared with those residing in New England. The maxim that for the elderly Medicare population “geography is destiny” is applicable in the case of receipt of high-risk medications. We also observed increased rates of use of these drugs in areas of lower area-level socioeconomic status and among individuals with low personal income.
HCB: Do you have any theories about why there were regional differences?
Qato and Trivedi: The roots of the variation in high-risk medication use are likely complex and result from a number of interconnected factors. These include differences in patient clinical conditions and preferences, provider prescribing norms, and the quality of the health care system in general.
Many questions arise as a result of our analysis. For example, is there something specific about prescribing behavior among physicians in Louisiana (the state with the highest rates) that stands in stark contrast to that of Iowa or Wisconsin (states with the lowest rates)? Is prescribing behavior informed primarily by medical education and training or another factor? Or is increased use of high-risk medications just one of many potential proxies for poorer quality care in the South in general? Further work is needed in order to better understand this geographic variation in high-risk medication use.
HCB: What kind of implications do your findings have for patients, providers and/or policy-makers?
Qato and Trivedi: Clinicians and policy-makers should understand that elderly patients commonly receive high-risk medications, particularly in the southern regions of the U.S. Reducing the use of these agents may improve health outcomes and reduce spending. Patients and their caregivers can and should regularly review the safety and appropriateness of their medications with both their pharmacist and physician.
HCB: Do you plan to look at this subject further?
Qato and Trivedi: In future work, we hope to quantify the health impact of the use of these medications on patient health outcomes. We also hope to utilize qualitative methodologies to further explore the potential sources of regional differences.