Clinical Pharmacy Intervention Puts Patients First

It’s not about cost, it’s about injured employee safety and improved claim outcomes

According to the Centers for Disease Control and Prevention (CDC), there were approximately 100,306 deaths due to overdose in the United States during a 12-month period ending in April 2021, up almost 30% over the previous 12 month period. Opioid dispensing peaked in 2012 at more than 255 million before beginning to decline and in 2020 was approximately 142 million. While opioid utilization has decreased significantly, it remains a national concern. But opioid utilization is not the only concern, polypharmacy, the use of five or more medications daily, also presents potential risks to individuals. For years 2015 through 2018, the number of individuals taking three or more prescriptions over the prior thirty days was found to be 24%. Polypharmacy increases the risk of adverse reactions to medications and individuals taking five to nine medications have a 50% chance of an adverse drug interaction. Unfortunately, individuals taking prescription medication(s) are not always aware of how drugs interact with one another, over the counter medications, supplements and even certain foods and beverages. 

Capitalizing on clinical expertise, such as case managers and pharmacists, and leveraging pharmacy utilization with a peer-to-peer discussion enhances pharmacy decision support and helps improve patient safety. A pharmacy utilization assessment combined with peer-to-peer outreach is a powerful combination and effective tool when managing at-risk claims that likely need intervention. Having a multi-disciplinary team including pharmacists and physicians perform an in-depth review to ensure the medi­cations prescribed are appropriate, followed by peer-to-peer discussions with prescribers is the most effective way to secure needed changes to medication regimens. These interventions have delivered positive impacts to patient safety and recovery as well as double-digit reductions in spend through the elimination of inappropriate pharmacy utilization. The assessment should consider recent medical records, pharmacy history and apply evidence-based treatment recommendations, prescription cost, and jurisdictional rules.

Clinicians review the current pharmacy regimen and provide recommendations supporting safety, adherence to evidence-based treatment guidelines and cost effectiveness. The need for pharmacy review with peer-to-peer outreach is often identified by the pharmacy benefit manager (PBM), case manager or claims handler. These reviews will address drug-to-drug interactions, polypharmacy, duplicate therapy, and appropriate utilization. After thorough review, peer-to-peer outreach is initiated to secure an agreement for the recommended changes in the medication regimen.

This case study illustrates how pharmacy intervention improves patient safety

This case involved a 70-year-old male with a work -related back injury dating back to 1994. Over the course of his back injury treatment, he required six surgeries and had a pain pump placed and removed three times. He also developed radiculopathy, major depression, and anxiety through the course of treatment, as well as non-industrial diseases including asthma and chronic obstructive pulmonary disease (COPD).

Over 20 years after the original date of injury, pharmacy intervention was requested. The claims handler had numerous concerns including polypharmacy, high morphine equivalent dosage (MED), which is associated with higher risk of overdose and death, and comorbid conditions.

The injured employee was prescribed 23 total medications for both industrial and non-industrial conditions. The regimen was riddled with red flags for patient safety. The injured employee was prescribed supplemental opioids, fentanyl patches and oral hydrocodone, in addition to a pain pump filled with hydromorphone. The MED was more than 90 milligrams per day. Additionally, the injured employee was prescribed a benzodiazepine in conjunction with high dose opioids as well as a stimulant typically reserved for narcolepsy. The injured employee also required six non-industrial respiratory medications for his asthma, COPD, and emphysema. There were major concerns for respiratory depression and even fatal overdose. Unfortunately, this type of polypharmacy can be common, where over years of treatment, medications are added to treat symptoms rather than a re-evaluation of the regimen itself as a cause.

After a thorough review of the medical records and pharmacy history, peer-to-peer outreach to discuss the pharmacy regimen and safety concerns with both providers prescribing medications was conducted. An agreement to wean or discontinue five of the medications, including the benzodiazepine and both supplemental opioids was secured. The pharmacy intervention  team followed the claim for an additional year. Through months of ongoing collaboration with the providers, the benzodiazepine, fentanyl patches and two other medications were safely weaned. MED was reduced to 40 mg daily – a 56% reduction. All patient safety concerns were addressed with the providers prescribing for treatment of the work-related claim and many were resolved through the work of the pharmacy intervention team.

The goal of clinical pharmacy intervention is to achieve medically appropriate drug utilization, improve patient safety and promote evidence-based prescribing. This may result in improved prescriber compliance, reduction in utilization and/or costs and support a safe and timely recovery.

Successful pharmacy review and peer-to-peer outreach improves pharmacy program outcomes and patient wellbeing through:

• Increased patient safety
• Improved quality of life for the injured employee                              
• Decreased pharmacy utilization over the life of a claim
• Reduced Medicare Set Aside exposure
• Reduced overall claim costs

About the author

Tammy Bradly, Vice President Clinical Product Marketing, Enlyte

Tammy is responsible for strategic planning and product marketing for all clinical and vocational products including Genex’s ClinicalCare24 (nurse triage), case management, return to work, IME, utilization review, physician advisor services and Genex Pharmacy Intervention. Tammy holds several national certifications, including certified case manager (CCM), certified rehabilitation counselor (CRC), certified professional disability manager (CPDM) and critical incident stress management (CISM).

Share This Article: