[Congressional Record Volume 143, Number 55 (Thursday, May 1, 1997)]
[Extensions of Remarks]
[Pages E810-E811]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          MEDICARE MEDICATION EVALUATION AND DISPENSING SYSTEM

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                         Thursday, May 1, 1997

  Mr. STARK. Mr. Speaker, on March 20, I introduced The Medicare 
Medication Evaluation and Dispensing System Act of 1997 [MMEDS]--a bill 
calling for implementation of a computerized information management 
program to review prescriptions for Medicare beneficiaries both before 
and after they are dispensed.
  A recent study appearing in the American Journal of Public Health 
provides another reason MMEDS should be passed this Congress. Based on 
their findings, the authors concluded: ``Increased involvement by 
pharmacists and physicians in systematic drug utilization review is 
warranted''. Overall, the study found inappropriate drug prescribing 
and utilization among the elderly living in board and care facilities. 
Depending on the criterion applied, between 20 percent and 25 percent 
of residents had at least one inappropriate prescription. Approximately 
a quarter of elderly residents received at least one inappropriate 
drug.
  Board and care facilities provide an alternative to nursing homes for 
the elderly; the homes usually do not provide nursing care, but 
assistance with activities of daily living--including drug management. 
Most board and care homes do not use pharmacists for drug-utilization 
review and do not computerize prescription drug data in a readily 
retrievable manner. Thus MMEDS is especially necessary to help bring an 
end to inappropriate drug prescribing for the elderly living in these 
facilities.
  I would like to insert excerpts from the March, 1997, study on 
Inappropriate Drug Prescriptions for Elderly Residents of Board and 
Care Facilities into the Congressional Record:

        [From the American Journal of Public Health, Mar. 1997]

  Inappropriate Drug Prescriptions for Elderly Residents of Board and 
                            Care Facilities

(By Diana L. Spore, PhD, Vincent Mor, PhD, Paul Larrat, PhD, Catherine 
                   Hawes, PhD, and Jeffrey Hiris, MA)


                              Introduction

       Board and care facilities are community-based alternatives 
     to nursing homes, housing elders with physical limitations, 
     cognitive impairment, mental health problems, and chronic 
     physical health conditions. They provide protective 
     oversight, personal care, and assistance with activities of 
     daily living and instrumental activities of daily living in 
     congregate settings. Most facilities do not provide nursing 
     care, but do store drugs and provide assistance with drug-use 
     management in many instances. Board and care homes have been 
     criticized for a lack of medical supervision in drug 
     administration and monitoring, nonexistent drug-management 
     programs, and unskilled staff; however, inappropriate drug 
     use in these settings has been largely unstudied. Use of 
     inappropriate medications can have serious clinical 
     consequences, ranging from adverse drug reactions that affect 
     elders' functional independence and psychosocial well-being 
     to an increased risk of mortality.
       Using the largest multistate sample of board and care homes 
     assembled to date, we examine the prevalence and correlates 
     of inappropriate drug prescriptions among elderly residents. 
     Given that on the long-term care continuum, board and care is 
     midway between living in the community without assistance and 
     residing in nursing homes, we apply the Stuck and Beers 
     criteria to derive estimates of rates for presumptively 
     inappropriate drug prescriptions.


                                results

     Inappropriate Drug Prescriptions
       According to the Stuck and modified Stuck criteria, almost 
     18% of residents were prescribed at least one presumptively 
     inappropriate drug. The most frequently prescribed 
     inappropriate drugs included propoxyphene, long-acting 
     benzodiazepines, dipyridamole, and amitriptyline. 
     Approximately 6.8% of elders were prescribed one or more 
     presumptively inappropriate psychotropics.
       Of those elders prescribed a drug included in the modified 
     Stuck criteria, most (82.4%) were prescribed only one of the 
     problematic drugs; 17.6% were prescribed two or three of the 
     medications; and 38.5% were prescribed inappropriate 
     psychotropics. Multiple prescriptions most frequently 
     involved combinations of propoxyphene or a long-acting 
     benzodiazepine with one other inappropriate drug (e.g., 
     propoxyphene with amitriptyline).
       According to the Beers criteria, almost 25% of residents 
     had an inappropriate prescription. Of those with 
     inappropriate prescriptions, 83.8% were prescribed an 
     entirely contraindicated drug (regardless of dose); 19.3% 
     were prescribed drugs that were problematic due to high 
     dosages; and 40.5% were prescribed inappropriate 
     psychotropics.


                               discussion

       Using a large, multistate sample of board and care homes, 
     this study examined the prevalence and correlates of 
     inappropriate drug prescriptions among elderly residents. 
     Almost one in four residents had at least one presumptively 
     inappropriate prescription. Of those elders prescribed any 
     drugs, 20.2% to 27.4% had inappropriate prescriptions. Rates 
     for inappropriate drug prescriptions are high, but lower than 
     what has been reported for nursing home residents and 
     relatively comparable to rates among community-dwelling 
     elders.
       Only a minority of elderly board and care residents were 
     prescribed more than one inappropriate medication. However, 
     such combinations can cause additive central nervous system 
     effects--such as confusion, excessive drowsiness, and dry 
     mouth--which tend to be more serious problems in the elderly.
       For the most part, board and care homes do not use 
     pharmacists as consultants for drug-utilization review, do 
     not computerize

[[Page E811]]

     drug data in a readily retrievable manner, and do not 
     routinely maintain comprehensive charts documenting 
     residents' clinical or physical status. Thus, we believed 
     that identifying general characteristics associated with 
     inappropriate drug use might prove useful in future efforts 
     to target residents for whom drug-utilization review may be 
     especially warranted. Residents with a larger number of 
     regularly scheduled prescriptions were more likely than 
     others in the sample to receive at least one inappropriate 
     drug. Thus, the number of prescriptions may serve as a simple 
     indicator for targeting residents at higher risk of 
     inappropriate drug use. Indeed, in other arenas, having five 
     or more prescriptions has been used as one indicator of the 
     need for the services of a consultant pharmacist.
       The Health Care Financing Administration recently published 
     a final rule on regulation for drug-utilization review 
     programs for Medicaid-covered prescription drugs. These 
     regulations--which were not targeted specifically for 
     residential care facilities--require that state Medicaid 
     agencies have pharmacist counseling programs to ensure that 
     prescriptions are medically necessary, appropriate, and 
     unlikely to produce adverse side effects. We suggest that 
     state board and care regulations be systematically reviewed 
     with an eye toward incorporating and stimulating the 
     development of pharmacy counseling and drug-utilization 
     review programs that are specific to conditions faced in 
     these facilities.

                          ____________________