This website allows users to generate a report of drug safety measures within demographic groups at the county, regional and state levels. Select either “Single County View” or ”Multiple County View” to view drug safety measures. Use the selection tool at the top of each page to choose the geographic area and time frame for the report from drop-down lists. When finished, click the “Submit” button. You can print the results by clicking the “Printer Friendly” icon in the upper right hand corner of the page. You can also save the results as a PDF by clicking the “PDF” icon. The table results can be saved to Excel by clicking the “XLS” icon.

Drug-Drug Interaction (DDI) and Potentially Inappropriate Medications (PIM) measures were developed by BearingPoint Consulting under a CMS contract to construct measures that assess and improve patient safety. The DDI measure “describes the percentage of Part D enrollees with claims for drugs potentially interacting.” The PIM measure “describes the percentage of Part D enrollees > 65 years old with > 1 potentially inappropriate medications.”

These indicators are described in detail on the CMS Quality Measures Management Information System.

Eligible Population

Medicare beneficiaries enrolled in a prescription drug plan (PDP) or a Medicare Advantage prescription drug plan (MA-PD).

Exclusions:

• Died during measurement period
• Missing date of service or product ID on any claim
• Actively enrolled in multiple plans concurrently during the measurement period
• Not enrolled for at least 5 of the 6 months during the measurement period

DDI: Drug-Drug Interaction

Percentage of Part D enrollees prescribed selected object or precipitant drugs who have claims for potential drug-drug interactions. An object drug is the drug in which effects or pharmacokinetics are impacted by subsequent administration of another drug (precipitant drug).A precipitant drug triggers the change in effects or pharmacokinetics of another drug being administered (object drug).

PIM: Potentially Inappropriate Medications

Percentage of Part D enrollees (>= 65 yrs old) with >= 1 claims for a Part D drug who have >= 1 potentially inappropriate medications

The eligible population is identified using Medicare Part D enrollment data. Inclusion in the numerator is determined using prescription drug event (PDE) data for Medicare enrollees receiving prescription drug coverage from Medicare Advantage Prescription Drug Plans (MA-PDs) and Prescription Drug Plans (PDPs).

The drug safety measures are limited to Medicare enrollees receiving prescription drug coverage under Medicare Part D from either Medicare Advantage Prescription Drug Plans (MA-PDs) or Prescription Drug Plans (PDPs). The PIM measure is limited to enrollees ages 65 and older.

Each reporting period represents 6 months of PDE (prescription drug event) activity. The initial reporting period uses data from July 1, 2007 through December 31, 2007. The 2nd period uses data from October 1, 2007 through March 31, 2008. Data are updated quarterly.

The report displays data aggregated at the state, county, and region levels. Each region represents a local AHEC (Area Health Education Center/Consortium). North Carolina counties are divided into nine AHEC areas. South Carolina counties are split among four.

North Carolina Regions
Area L AHEC Edgecombe Halifax Nash Northampton Wilson Charlotte AHEC Anson Cabarrus Cleveland Gaston Lincoln Mecklenburg Stanly Union Coastal AHEC Brunswick Columbus Duplin New Hanover Pender	Eastern AHEC Beaufort Bertie Camden Carteret Chowan Craven Currituck Dare Gates Greene Hertford Hyde Jones Lenoir Martin Onslow Pamlico Pasquotank Perquimans Pitt Tyrrell Washington Wayne	Greensboro AHEC Alamance Caswell Chatham Guilford Montgomery Orange Randolph Rockingham Mountain AHEC Buncombe Cherokee Clay Graham Haywood Henderson Jackson McDowell Macon Madison Mitchell Polk Rutherford Swain Transylvania Yancey	Northwest AHEC Alexander Alleghany Ashe Avery Burke Caldwell Catawba Davidson Davie Forsyth Iredell Rowan Stokes Surry Watauga Wilkes Yadkin Southern Reg AHEC Bladen Cumberland Harnett Hoke Moore Richmond Robeson Sampson Scotland	Wake AHEC Durham Franklin Granville Johnston Lee Person Vance Wake Warren

South Carolina Regions
Low Country AHEC Allendale Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Colleton Dorchester Hampton Jasper Orangeburg	Mid-Carolina AHEC Aiken Cherokee Chester Fairfield Kershaw Lancaster Lexington Newberry Richland Union York	Pee Dee AHEC Chesterfield Clarendon Darlington Dillon Florence Georgetown Horry Lee Marion Marlboro Sumter Williamsburg	Upstate AHEC Abbeville Anderson Edgefield Greenville Greenwood Laurens McCormick Oconee Pickens Saluda Spartanburg

The website maps are quartile distribution maps. The counties in the state are divided into four groups based upon their respective rates, ranked from lowest to highest. The lowest 25% are placed in the 1st quartile (lightest blue). The top 25% are placed in the 4th quartile (darkest blue). The map legend displays the ranges represented by each color. These maps allow users to see statewide variations in DDI and PIM rates.

The website tables show DDI and PIM rates for selected geographic area(s), overall and within demographic groups (age, race and sex). The “N” column is the total enrollees (denominator), and the “%” column is the rate. The table allows users to see variations across areas and enrollee groups. The table also allows users to identify statewide or local disparities..

National comparison data are unavailable for the periods reported on this web report. National rates were previously made available, and at that time the NC and SC rates for Drug-Drug Interaction (DDI) and Potentially Inappropriate Medications (PIM) were above the national average. The medications included in DDI and PIM calculations have since changed and are not precisely comparable to the current measures.

The Drug-Drug Interaction (DDI) rate is the percentage of Part D enrollees who were prescribed a drug (precipitant) that impacted the effects (or pharmacokinetics) of another drug the enrollee had already been prescribed (object) and the object and precipitant drug supply days overlap. If the object drug is an MAO inhibitor (MAOI) with a precipitant CNS stimulant or a SSRI within a defined period of time, that is also considered a potential DDI. Drug interactions can result in undesirable side effects such as a reduction in drug effectiveness and, in extreme cases, death. Drug pairs are limited to common potential DDIs with potentially serious, quantifiable adverse effects¹. The measure does not reflect the occurrence of negative DDI events, but the potential of DDI occurring based on prescription claims.

Drug-drug interactions are not necessarily medical errors. A physician may determine that the benefit of the medication outweighs the potential harm of the drug interaction. A limitation of the DDI measure is that the claims cannot indicate whether a patient has discontinued use of the object before the supply ends. The appropriateness of prescription is best determined by a patient’s health care provider.

¹BearingPoint, Inc. “Medication Measures for Part D Task 6 Technical Specifications”
http://www.nmmra.org/resources/Physician/112_1412.pdf (accessed March 2009).

The Potentially Inappropriate Medications (PIM) measure is the percentage of Part D enrollees ages 65 and older who were prescribed drugs that are considered unsafe (potentially inappropriate) for the elderly. PIMs should be avoided in the elderly population because they have no clinical justification, pose unnecessarily high risk to older patients, or can be replaced by safer alternatives. The list of drugs included in this PIM measure is limited to drugs with quantifiable effects compiled by various expert panels conducting studies on inappropriate medication use in the elderly¹.

A limitation of the PIM measure is that it does not adjust for the severity of the potential adverse drug event. A physician may determine that the benefits outweigh the potential harm of the drug. The appropriateness of a prescription is best determined by a patient’s health care provider.

¹BearingPoint, Inc. “Medication Measures for Part D Task 6 Technical Specifications” http://www.nmmra.org/resources/Physician/112_1412.pdf (accessed March 30, 2009).

Object Drug (Brand Names)	Precipitant Drug (Brand Names)
Warfarin (Coumadin, Jantoven)	Levothyroxine (Levoxyl, Levothyroid, Synthroid, Unithroid)
Clonidine (Duraclon, Catapres)	Metoprolol (Lopressor, Metroprolol Tartrate, Toprol XL)
Lisinopril (Prinvil, Zestril)	Spironolactone (Aldactone)
Clonidine (Duraclon, Catapres)	Hydrochlorothiazide-Triamterene (Dyazide, HCTZ/Triamterene, Maxzide)
Lisinopril (Prinvil, Zestril)	Cimetidine (Tagamet, Tagamet HB)

PIM Drug (Brand Names)
Acetaminophen-Propoxyphene (Darvocet, Propacet and Balacet)
Conjugated Estrogens (Cenestin, Enjuvia and Premarin)
Cyclobenzaprine (Amrix, Fexmid, Flexeril)
Promethazine (Adgan, Anergan 50, Antinaus 50, Pentazine, Phenadoz, Phenergan, Phenergan Fortis, Phenoject-50, Promocat, and Promethagan)
Nitrofurantoin (Furadantin, Macrobid, Macrodantin)

The maps and tables allow users to identify variations in drug safety across geographic areas and enrollee groups. Providers, plans, and educators may utilize the reports to identify areas on which to focus educational efforts. A high DDI rate may indicate a need to improve medication documentation in the patient medical record. High DDI rates may identify areas to focus efforts to increase the availability of e-prescribing systems or their functionality. Higher PIM rates can identify areas to offer continuing education on alternative medications for elderly patients.

CCME has a compilation of resources focused on improving drug safety. Please visit our Patient Safety Resources page or contact us at DrugSafety@thecarolinascenter.org.

Click the “Printer Friendly” icon in the top right hand corner of the page. Alternatively, export the results to a PDF by clicking the “PDF” icon and print using Acrobat reader.

For more information about Drug Safety, please visit our Patient Safety Resources page. Please send questions or comments to DrugSafety@thecarolinascenter.org.