2019 HSR&D/QUERI National Conference

4027 — Design of a centrally aggregated medication use evaluation (CAMUE): anticholinergics in dementia

Lead/Presenter: Madeline McCarren,  COIN - Hines
All Authors: Rise P (VA Puget Sound Healthcare Center)

Conducting medication use evaluations (MUEs) across VA can be resource consuming and challenging to coordinate. VA Center for Medication Safety (VAMedSAFE) designed a novel distributive approach termed centrally aggregated MUE (CAMUE), whereby a facility-provided toolkit allows for standardized chart review, analysis, and submission of results to VAMedSAFE for aggregation. We illustrate CAMUE evaluating anticholinergic medication (AChM) use in dementia patients: (a) prescribing patterns of incident outpatient AChM; (b) if non-AChM alternatives were tried first; (c) whether risk-benefit analyses were documented; (d) harms associated with AChM.

A CAMUE toolkit, consisting of a list of target patients, protocol, operations manual, and Microsoft Access database (data collection form, table, pre-programmed report) was electronically provided to each site. The VA Pharmacy Benefits Management (PBM) outpatient prescription database and Corporate Data Warehouse were used to identify dementia patients with incident outpatient AChM prescriptions ( > = 7 days) in CY2016. Hospice/palliative care patients were excluded. Reviewers verified eligibility, reviewed charts (6-month look-back and 30-day follow-up) per instructions, and electronically transcribed de-identified summary measures generated by the Access Report into a Microsoft InfoPath form. VAMedSAFE combined site counts into grand totals and generated descriptive statistics.

Nineteen sites submitted data on 1094 eligible patients for aggregation. Results presented are percent (95 percent confidence interval). Antihistamines were the most common class (31%, 28.6-34.1). Non-pharmacological alternatives to the indication for the index AChM were trialed in 18% (15.9-20.5); non-AChMs were trialed in 36% (32.9-38.5). A risk-benefit assessment of AChMs in dementia was documented in 13% (11.2-15.2) of cases. An untoward event (fall, delirium, worsening dementia) was reported in 15% (12.6-16.7). In these, 32% (25.3-39.7) had the AChM discontinued or dose reduced.

CAMUE is a novel approach offering a standardized tool for efficiently conducting multi-site MUEs. The results suggest that the risk of AChM use in dementia is underappreciated by prescribers, although under-documentation of risk/benefit assessment is also likely.

VAMedSAFE recommended a prescribing tool or decisional support system to alert prescribers to the potential risk.