Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial

Abstract

Introduction Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community‐dwelling persons living with dementia (PLWD). Methods Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti‐dementia medications. Results Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (−0.35; 95% CI, −0.49 to −0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS‐active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti‐dementia medication regimens were modified more frequently. Conclusion The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. Highlights Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti‐dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.

Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia

“…In this prespecified secondary analysis, Care Ecosystem participation was associated with a large reduction in total Medicare spending. These findings are consistent with results of the Care Ecosystem trial that demonstrated significant treatment effects on patient outcomes (quality of life, ED visits, and potentially inappropriate medication use) . Even though Care Ecosystem participants appeared to start at a higher level of total costs in the year before enrollment, their costs quickly stabilized by 6 months and they maintained a significant treatment effect on costs out to 12 months.…”

“…The Care Ecosystem is a collaborative dementia care model that uses a multidisciplinary care team centered around an unlicensed, specially trained, dementia care team navigator to provide telehealth-enabled support to patients with dementia and their primary caregiver . The Care Ecosystem was studied in a large randomized clinical trial, which demonstrated that program participation improved patient quality of life, reduced ED use, reduced caregiver depression and caregiver burden, and reduced the use of potentially inappropriate medications . The effect of Care Ecosystem on health care dollars spent has not previously been reported due to delays in claims data access.…”

“…10 The Care Ecosystem was studied in a large randomized clinical trial, which demonstrated that program participation improved patient quality of life, reduced ED use, reduced caregiver depression and caregiver burden, and reduced the use of potentially inappropriate medications. 2,19 The effect of Care Ecosystem on health care dollars spent has not previously been reported due to delays in claims data access. In this study, we linked Medicare claims to trial data to examine the effect of the Care Ecosystem model on total health care costs.…”

Implementation and Review of the Care Ecosystem in an Integrated Healthcare System

“…The HP-CMA "dose" of phone contacts with the CTN was less than that of the original CE model, which was primarily due to the higher caseloads at our site and relatively milder stage of dementia. Furthermore, whereas prior versions of the CE included an embedded pharmacist, the HP-CMA did not have the ability to provide the CE's formal medication review service on every patient [ [12] and instead deferred medication management questions to either the nurse or participating neurologist. In addition, data relating to outcomes and survey data were obtained by mailing information either traditionally or via email to participating dyads whereas UCSF research coordinators conducted formalized telephone surveys with participants.…”

The Maelstrom of Medications—Optimization of Prescribing During the Course of Dementia

“…They have been shown to reduce the use of potentially inappropriate medications. 6 The point of diagnosis is an ideal time to facilitate a proactive connection to wrap-around services that address the medical, neuropsychological, and social aspects of dementia. Scaling up these programs so that they are available to far more people living with dementia and their caregivers within current payment and delivery models will undoubtedly be challenging; failure to do so will stymie efforts to reign in the use of dangerous psychoactive medications that have questionable benefit.…”