Comprehensive medication review service by embedded pharmacists in primary care: Innovations and impact.

BACKGROUND: Primary care may offer innovations in delivering comprehensive medication reviews (CMRs). OBJECTIVES: This study aimed to (1) describe innovations to improve delivery and impact of CMR, (2) quantify CMR completion rates and patient satisfaction, and (3) characterize medication changes and impact on medication costs. PRACTICE DESCRIPTION: Board-certified ambulatory care pharmacists with collaborative practice agreements embedded in primary care provided CMRs in 5 clinics for eligible university prescription plan retirees. PRACTICE INNOVATION: Innovations included (1) physician review of potential CMR recipient list, (2) use of trained student pharmacists to recruit and set up CMR visits, (3) use of clinical information in a standardized CMR 2-visit approach by embedded pharmacists, and (4) enrollment into disease management programs or referrals to other providers. EVALUATION METHODS: Data from a retrospective cohort were collected. The CMR completion rate and therapeutic interventions were documented. Prescription fill data were available for 6 months before and after the CMR. An anonymous survey assessed patient satisfaction. Frequencies and descriptive statistics characterized completion rate, interventions, and patient satisfaction. The median cost to the plan of deleted versus added medications and per member per month total drug costs before and after the CMR were compared. RESULTS: Among 729 beneficiaries screened, 489 were eligible and 223 (46%) received a CMR. There were 388 medication interventions: the most common intervention was to delete medications (41.0%). One in 4 was enrolled into the pharmacists' disease management programs. Individuals reported 4.68 (SD 0.67) of 5 for helpfulness of the CMR. The ratio of median costs for medication deletions versus additions was $1.46 vs. $1.00. CONCLUSION: Innovations to deliver CMRs capitalized on well-established physician-pharmacist relationships and nonpharmacist personnel to recruit and prepare the intake. Almost half of eligible beneficiaries received a CMR, and the CMRs were impactful for patients and payers. The most prevalent intervention was to discontinue medications for efficacy reasons.

Improving the quality of blood pressure measurements in an outpatient diabetes clinic.

Hypertension is an important modifiable risk factor for cardiovascular disease in patients with diabetes. Despite established guidelines, the percentage of patients meeting the target blood pressure (BP) of <140/90 mm Hg in clinic remains suboptimal. In this project, we sought to improve BP measurement in an outpatient diabetes clinic.Two interventions were performed: (1) Changes were made to the timing of BP measurement during patient intake and (2) An electronic medical record (EMR) alert reminded staff to repeat BP if the initial reading was above target. Baseline data were collected on 4764 patients, with 72.5% meeting their BP target. After implementation of changes to the timing of BP measurement during patient intake, 73.3% of patients met the target (no significant change). However, after implementation of the EMR alert, there was a statistically significant improvement in patients meeting the target BP at 76.8% (p<0.01). This reduction was driven by the high percentage of patients with an initially elevated BP measurement that came down into goal range on repeat measurement. Those who remained above target despite multiple readings could be referred to a new pharmacist-led hypertension clinic to ensure adequate follow-up and medication adjustment.It is important to ensure that in clinic BP measurements are taken correctly and adhere to best practices. Use of a single in-clinic BP measurement may result in overtreatment of hypertension. While timing of BP measurement during patient intake was not important, repeating high BP measurements did improve the number of patients in an outpatient diabetes clinic meeting their BP target.

Evaluation of Clinical Pharmacist Services in a Transitions of Care Program Provided to Patients at Highest Risk for Readmission.

BACKGROUND: An ambulatory transition of care program, including a pharmacist-provided comprehensive medication review (CMR), was implemented. OBJECTIVES: The objectives were to: (1) compare 30-day hospital readmission rates between those who received the pharmacist CMR versus eligible patients not scheduled, (2) describe identified problems and recommendations, and (3) quantify recommendation acceptance rates. METHODS: A retrospective cohort study was conducted between March and October 2016. Inclusion criteria were: LACE score of ≥13, established Michigan Medicine primary care, and discharged from specific inpatient services to home. The primary outcome was 30-day hospital readmission rates. Pharmacist-identified problems, recommendations, and recommendation acceptance rates were examined. χ2 analysis and descriptive statistics were used. RESULTS: 355 discharges met inclusion criteria and pharmacists provided CMRs for 159 patients. The average age was 60 years (standard deviation [SD]: 14.3), the majority were female (54%), and white/Caucasian (69%). There was no significant difference in 30-day readmission rates in patients who received a CMR (p = .96). A mean of 3.1 problems were identified per visit (SD: 1.8, range: 1-10). 509 recommendations were provided and approximately 50% were provider accepted. CONCLUSIONS: Reduced readmission rates were not observed; however, pharmacists identified many areas for intervention in highest risk patients during the transition from hospital to home.