Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS).

BACKGROUND: Multimorbid patients in nursing homes are prescribed long lists of medication, often without sufficient clinical evaluations beforehand. This results in poor clinical effects of the prescribed medication and significant side-effects, especially in patients with impaired cognition. The aim of this paper is to describe the process, content and implementation of a clinical medication review encompassing clinical testing and collegial support to prescribers. METHODS: The implementation process of a novel approach to medication review in nursing homes was logged thoroughly by structured staff feedback. Staff experienced promotors and barriers to implementation also were collected. The study was part of a cluster randomized controlled trial, in which 36 long-term care units received the COSMOS intervention. Nurses and physicians randomized to the intervention group participated in educational programs, training in clinical evaluation of the patients, and interprofessional medication review with collegial mentoring. RESULTS: The intervention group contained 297 patients from 36 nursing home units. There were 105 staff attendees for the education program. The units were served by 21 different physicians. Clinical medication reviews were performed in all units and all patients were assessed prior to the medication reviews. Of the 240 patients with a logged intervention process, 220 (92%) underwent a medication review. The intervention generated enthusiasm and improved communication among nursing staff and between nursing staff and physicians. The interprofessional discussions helped to facilitate difficult decisions pertaining to treatment levels. Reported barriers were lack of time, low engagement of all nursing staff and physicians, and ethical dilemmas. CONCLUSIONS: Clinical medication reviews were implemented for almost all patients, and every patient was systematically assessed prior to the medication review. The physicians perceived collegial mentoring as an asset, learning from each other facilitated decision making in terms of difficult aspects of prescribing. Knowledge about barriers and promotors can improve implementation of similar interventions in other nursing homes. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02238652 ). Registered July 7th 2014.

Family involvement in managing medications of older patients across transitions of care: a systematic review.

BACKGROUND: As older patients' health care needs become more complex, they often experience challenges with managing medications across transitions of care. Families play a major role in older patients' lives. To date, there has been no review of the role of families in older people's medication management at transitions of care. This systematic review aimed to examine family involvement in managing older patients' medications across transitions of care. METHODS: Five databases were searched for quantitative, qualitative and mixed methods empirical studies involving families of patients aged 65 years and older: Cumulative Index to Nursing and Allied Health Literature Complete, Medline, the Cochrane Central Register of Controlled Trials, PsycINFO, and EMBASE. All authors participated independently in conducting data selection, extraction and quality assessment using the Mixed Methods Appraisal Tool. A descriptive synthesis and thematic analysis were undertaken of included papers. RESULTS: Twenty-three papers were included, comprising 17 qualitative studies, 5 quantitative studies and one mixed methods study. Families participated in information giving and receiving, decision making, managing medication complexity, and supportive interventions in regard to managing medications for older patients across transitions of care. However, health professionals tended not to acknowledge the medication activities performed by families. While families actively engaged with older patients in strategies to ensure safe medication management, communication about medication plans of care across transitions tended to be haphazard and disorganised, and there was a lack of shared decision making between families and health professionals. In managing medication complexity across transitions of care, family members perceived a lack of tailoring of medication plans for patients' needs, and believed they had to display perseverance to have their views heard by health professionals. CONCLUSIONS: Greater efforts are needed by health professionals in strengthening involvement of families in medication management at transitions of care, through designated family meetings, clinical bedside handovers, ward rounds, and admission and discharge consultations. Future work is needed on evaluating targeted strategies relating to family members' contribution to managing medications at transitions of care, with outcomes directed on family understanding of medication changes and their input in preventing and identifying medication-related problems.

Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

BACKGROUND: Dementia patients often show neuropsychiatric symptoms, known as behavioral and psychological symptoms of dementia (BPSD). These are a common motive for medical consultations, hospitalizations, and nursing home stays. Various studies have suggested that the high prevalence of psychotropic drug use to treat BPSD in institutionalized dementia patients may lead to impaired cognitive capacity, rigidity, somnolence, and other complications during the course of the illness. The aim of this study was to design a consensus-based intervention between care levels to optimize and potentially reduce prescription of psychotropic drugs in institutionalized patients with dementia and assess the changes occurring following its implementation. METHODS: Design: Prospective, quasi-experimental, pre/post intervention, multicenter study. SCOPE: 7 nursing homes associated with a single primary care team. INCLUSION CRITERIA: Institutionalized patients diagnosed with dementia and under treatment with 1 or more psychotropic drugs for at least 3 months. SAMPLE: 240 individuals; mean age, 87 years (SD: 6.795); 75% (180) women. INTERVENTION: Creation of evidence-based therapeutic guidelines for psychotropic drug use in the treatment of BPSD by consensus between reference professionals. Joint review (primary care and geriatric care nursing home professionals) of the medication based on the guidelines and focusing on individual patient needs. Primary variable: Number of psychotropic drugs used per patient. ASSESSMENT: Preintervention, immediate postintervention, and at 1 and 6 months. RESULTS: Overall, the number of psychotropic drugs prescribed was reduced by 28% (from 636 before to 458 after the intervention). The mean number of psychotropic drugs prescribed per patient decreased from 2.71 at baseline to 1.95 at 1 month postintervention and 2.01 at 6 months (p < 0.001 for both time points). Antipsychotics were the drug class showing the highest reduction rate (49.66%). Reintroduction of discontinued psychotropic drugs was 2% at 1 month following the intervention and 12% at 6 months. CONCLUSIONS: A consensus guidelines-based therapeutic intervention with a patient-centered medication review by a multidisciplinary team led to a reduction in prescription of psychotropic drugs in institutionalized dementia patients.

Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness.

BACKGROUND: The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure. METHODS: Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession's existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design. DISCUSSION: The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50-70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients' physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources. TRIAL REGISTRATION: The study is registered in the Clinical Trials.gov ( NCT02545257 ). Registration date September 9 2015.

Intervention to improve the appropriate use of polypharmacy for older patients with hip fractures: an observational study.

BACKGROUND: Polypharmacy is frequently observed in hip fracture patients. Although it is associated with an increased risk of hip fracture, polypharmacy often continues after hip fracture recovery. This study aimed to evaluate the effectiveness of an intervention to improve appropriate polypharmacy for elderly patients admitted to the hospital for hip fractures. METHODS: We conducted a retrospective observational study to compare the outcomes of patients receiving the intervention (n = 32) with those of patients who received usual care (n = 132). All hip fracture patients aged 65 years or older and prescribed 5 or more medications at admission from January 2015 to December 2016 were included in the study. The intervention consisted of an assessment by internal medicine physicians of the appropriateness of polypharmacy and the de-prescription of any unnecessary medications during the patients' hospital stay. The primary composite outcome was death or the first occurrence of any new fracture. Comparisons between the intervention and usual care groups were analyzed using binary logistic regression. RESULTS: A total of 164 patients were included in the study. The mean patient age was 84.8 years, and the mean numbers of prescribed medications and potentially inappropriate medications at admission were 8.0 and 1.3, respectively. The mean follow-up period was 8.0 months. The primary composite outcome occurred in 35 (21.3%) patients. The total number of potentially inappropriate medications at discharge was significantly lower in the intervention group than in the usual care group (0.8 ± 0.8 for the intervention group vs 1.1 ± 1.0 for the usual care group; p = 0.03). However, no significant differences in the primary composite outcome were found between the intervention and usual care groups (7 in the intervention group and 28 in the usual care group, odds ratio 1.04, 95% CI 0.41-2.65; p = 1.00). CONCLUSIONS: The intervention to improve appropriate polypharmacy was associated with a reduction in potentially inappropriate medications but not an improvement in clinical outcomes. This intervention, which focused only on polypharmacy, may not effectively improve outcomes for elderly patients with hip fractures. TRIAL REGISTRATION: UMIN-CTR UMIN000025495 . Retrospectively registered 2 January 2017.

Developing a decision rule to optimise clinical pharmacist resources for medication reconciliation in the emergency department.

BACKGROUND: The process of obtaining a complete medication history for patients admitted to the hospital from the ED at hospital admission, without discrepancies, is error prone and time consuming. OBJECTIVES: The goal of this study was the development of a clinical decision rule (CDR) with a high positive predictive value in detecting ED patients admitted to hospital at risk of at least one discrepancy during regular medication history acquisition, along with favourable feasibility considering time and budget constraints. METHODS: Data were based on a previous prospective study conducted at the ED in Belgium, describing discrepancies in 3592 medication histories. Data were split into a training and a validation set. A model predicting the number of discrepancies was derived from the training set with negative binomial regression and was validated on the validation set. The performance of the model was assessed. Several CDRs were constructed and evaluated on positive predictive value and alert rate. RESULTS: The following variables were retained in the prediction model: (1) age, (2) gender, (3) medical discipline for which the patient was admitted, (4) degree of physician training, (5) season of admission, (6) type of care before admission, number of (7) drugs, (8) high-risk drugs, (9) drugs acting on alimentary tract and metabolism, (10) antithrombotics, antihaemorrhagics and antianaemic preparations, (11) cardiovascular drugs, (12) drugs acting on musculoskeletal system and (13) drugs acting on the nervous system; all recorded by the ED physician on admission. The final CDR resulted in an alert rate of 29% with a positive predictive value of 74%. CONCLUSION: The final CDR allows identification of the majority of patients with a potential discrepancy within a feasible workload for the pharmacy staff. Our CDR is a first step towards a rule that could be incorporated into electronic medical records or a scoring system.

New horizons in care home medicine.

Care home medicine has been an under-researched area, but over the last decade there has been a substantial growth in publications. Most of these have focused on the 'geriatric giants' of falls, incontinence and mental health issues (especially dementia, behavioural disturbance and depression) as well as other key topics such as medication use and issues related to death and dying. Other areas of recent interest are around access to health services for care home residents, how such services may most effectively be developed and how the quality of life for residents can be enhanced. While many of the reported studies are small and not always well designed, evidence in several areas is emerging which begins to guide service developments. A common theme is that multi-disciplinary interventions are the most effective models of delivery. The role of care home staff as members of these teams is key to their effectiveness. Recent consensus guidelines around falls prevention in care homes synthesise the evidence and recommend multi-disciplinary interventions, and clarify the role of vitamin D and of exercise in certain populations in the care home. The benefits of pharmacist led medication reviews are beginning to emerge; although studies reviewed to date have not yet led to the 'holy grail' of hospital admission avoidance they point to benefits in reduction of drug burden. Effectiveness may be enhanced when working with GPs and care home nurses. Welcome evidence is emerging that in the UK the rate of prescription of anti-psychotics has fallen. This is clear evidence that changes in practice around care homes can be effected. The poor access to non-pharmacological therapies for care home residents with behavioural disturbance remains a significant gap in service. End-of-life care planning and delivery is an important part of care in care homes, and there is evidence that integrated pathways can improve care; however, the use of palliative care medications was limited unless specialist care staff were involved. Integrated models of care that focus on resident-centred goals and which value the role of care home staff as members of the team working to deliver these goals are most likely to result in improvements in the quality of care experienced by care home residents.

[Feasibility of the implementation of medication reconciliation in Hungary]. / A gyógyszeres terápia egyeztetésének gyakorlata Magyarországon - bevezetési lehetoségek.

INTRODUCTION: For medication safety improvement medication reconciliation was proven to be an effective method transferable between different healthcare providers and ward profiles. AIM: Gaining a better understanding of the process of reconciling medicines. Mapping the driving and restraining forces of introducing medication reconciliation. METHOD: A search of the literature was conducted. 19 databases were searched using 7 different search engines. The relevance of the papers was rated by two independent experts. Data were extracted based on a previously compiled extraction tool. RESULTS: 230 articles were evaluated. Limits and driving forces of implementing medication reconciliation were set out. Often mentioned implementation obstacles were: communication issues, disengagement of the leaders, unpredictable resources and competence problems. Recommendations mainly consisted of process redesign techniques, presentation of cost-effectiveness data and arranging special training for staff. CONCLUSIONS: For improvement of medication safety in Hungarian hospitals implementing medication reconciliation should be considered. The conclusion of ongoing on-site trials as well as limits and success factors identified in this paper should taken into account.

Hospital brings discharge meds to the bedside.

The pharmacy at Strong Memorial Hospital in Rochester, NY, fills about 75% of the prescriptions that patients are given at discharge. Pharmacy technicians coordinate discharge times with unit-based care coordinators and deliver medicine to the bedside. Prescriptions are printed out on the unit and sent to the pharmacy by pneumatic tube. A pharmacist reviews the prescriptions for drug interactions and medication errors and gets corrections made before the patients leave the hospital.

Making pharmacists part of the multidisciplinary team.

Having pharmacists on the multidisciplinary team can help ensure that patients progress well in the hospital and that they follow their medication plan at home and avoid emergency department visits or readmissions. Pharmacists can review medication lists and correct problems as well as ensuring that patients receive the right doses and selections of medication for their ages, weights, and conditions. They can help case managers and social workers deal with complex prescription benefits plans and help with preauthorizations and other issues that can potentially delay filling prescriptions. Pharmacists can use their knowledge of medication to recognize when a patient may not be able to afford a medication and to suggest less expensive alternatives to the physician.

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

BACKGROUND: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES: Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS: On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). CONCLUSIONS: Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

Forecasting preanesthesia clinic appointment duration from the electronic medical record medication list.

BACKGROUND: When scheduling clinic appointments, scheduling patients expected to have different visit durations for different minutes of time reduces patient waiting time and staff idle time. Maintaining an active medication list is an important (and, in the United States, required) component to the meaningful use of electronic medical records. We hypothesized that the count of medications from the medication list would be a better predictor of the time taken by a nurse practitioner to evaluate the patient preoperatively than the American Society of Anesthesiologists' (ASA) physical status and other demographic variables. METHODS: Using 69,654 preoperative visits, we obtained the number of different medications taken by the patient and demographic variables, including ASA physical status, ASA base units, and body mass index. For each independent variable, we applied transformations and calculated the Pearson correlation giving the largest correlation with the log(10) (duration), which followed a normal distribution. RESULTS: Only 18% of the patients had been evaluated previously at the preoperative facility, making use of the prior ASA physical status ineffective for forecasting. The number of medications was a more accurate predictor of appointment duration than any of the other 8 variables (each Bonferroni corrected P < 0.0001), including ASA physical status. CONCLUSIONS: Schedulers can use the number of medications that each patient is taking when choosing the time for preoperative evaluation. This approach can take schedulers only approximately 10 seconds extra per patient when scheduling the appointment.

Transforming the Medication Regimen Review Process Using Telemedicine to Prevent Adverse Events.

BACKGROUND/OBJECTIVES: Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay. DESIGN: Quality improvement study using a stepped-wedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017. SETTING: Four NHs (two urban, two suburban) in Southwestern Pennsylvania. PARTICIPANTS: All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period. INTERVENTION: Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine. MEASUREMENT: Main outcome was incidence of high-risk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations. RESULTS: Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42). CONCLUSIONS: This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.

Framework for Pharmacy Services Quality Improvement-A Bridge to Cross the Quality Chasm.

OBJECTIVE: To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management. BACKGROUND: The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific "components" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management. FINDINGS: There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality; and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes. CONCLUSIONS: Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management. DISCLOSURES: Authors Richard N. Fry and Steven G. Avey are employed by the Foundation for Managed Care Pharmacy, a nonprofit charitable trust that serves as the educational and philanthropic arm of the Academy of Managed Care Pharmacy; author Frederic R. Curtiss performed the majority of work associated with this manuscript prior to becoming editor-in-chief of the Journal of Managed Care Pharmacy. This manuscript underwent blinded peer review and was subject to the same standards as every article published in JMCP.

Hospital referral of older patients to community pharmacy: outcome measures in a feasibility study.

Background Post-discharge medication use reviews in English community pharmacy aim to improve medicine support to recently discharged patients. However, there is little evidence of their impact on patient outcomes. Objective Identify potential outcome measures to investigate the impact of a hospital to community pharmacy referral service for older patients that utilises post-discharge medication reviews. Method Pharmacists at a district general hospital identified in-patients aged over 65 years who could benefit from a medication use review. Participants were randomised to receive referral for review, or standard discharge care. Participants were followed up at 4 weeks and 6 months via the hospital's patient administration system and by postal questionnaire, regarding readmissions, medication adherence, health related quality of life and enablement. Results Fifty-nine participants were recruited. There were no statistically significant differences in outcomes between intervention and control groups. However there were trends towards shorter length of stay on readmission and improved self-reported physical health for intervention group participants. There were no preventable medication related readmissions involving participants who had received a post-discharge medication use review as part of the study. Conclusion This feasibility study could be scaled up to a full pilot study, followed by an adequately powered randomised controlled trial, in order to further investigate the effects of medication use review referral post-discharge.

Home medicines reviews and residential medication management reviews in Western Australia.

Background Australian government funding for Residential Medication Management Reviews and Home Medicines Reviews commenced in 1997 and 2001 respectively. Limited data are available on their provision in Australia. Objective To investigate the extent and characteristics of Home Medicines Review and Residential Medication Management Review services provided by accredited pharmacists practising in Western Australia. Setting Pharmacists in Western Australia accredited by the Australian Association of Consultant Pharmacy or Society of Hospital Pharmacists of Australia. Method A paper questionnaire was developed and sent to 198 accredited pharmacists in Western Australia in June 2017. Simple descriptive statistics summarised demographic information and other responses. Logistic regression evaluated factors associated with the frequency of provision of Home Medicines Reviews. Main outcome measure Frequency and factors influencing services provided. Results Of 102 (51.5%) questionnaires returned, 67 (65.7%) respondents were female. Many were aged between 31 and 40 years (53; 52.0%). Most were accredited by the Australian Association of Consultant Pharmacy (101; 99.0%) and mainly offered Home Medicines Reviews (70; 68.6%). Home Medicines Reviews provided over the previous 12 months were limited in frequency with one quarter providing either 1-10 (27; 26.5%) or 21-50 (28; 27.5%) reviews. The median "average" preparation, interview and report writing times, plus communication with other health professionals aggregated to 175.0 min (interquartile range: 140.0-235.0 min) for Home Medicine Reviews and 110.0 min (90.0-140.0) for Residential Medication Management Reviews. Pharmacists born overseas and those who were accredited for a longer time were associated with performing 51 or more Home Medicines Reviews annually. Only one-third (36/101; 35.6%) agreed the current payment was appropriate. Most agreed their Home Medicines Reviews (92/96; 95.8%) and Residential Medication Management Reviews (26/28; 92.9%) provided improved patient outcomes. Over 97% of accredited pharmacists intended to continue to remain accredited. Conclusions Wide variations were evident in the times taken for tasks associated with performing reviews. Most respondents considered their medication reviews contributed to improved patient outcomes. The wide variation in times taken for the reviews suggests a tiered structure for service provision, with appropriate payment within each tier, since most consider current remuneration inadequate.

The role of clinical pharmacist trainees in medication reconciliation process at hospital admission.

Background Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the prevalence and potential risk factors involved in medication discrepancies in China. Objective To determine the frequency of medication discrepancies and the associated risk factors and evaluate the potential harmsof errors prevented by pharmacist trainees performing medication reconciliation process. Setting A tertiary hospital in Shanxi, China. Method Medication reconciliation was conducted at admission to four clinical departments including cardiology, nephrology, endocrinology and pneumology department between 2019 Feb 1st and 2019 Aug 31st by clinical pharmacist trainees. All unintentional medication discrepancies were presented to the expert panel to evaluate. Associations between unintentional medication discrepancies and various factors were examined. Main outcome measure The primary outcome was the prevalence of unintentional medication discrepancies as well as the associated risk factors. Results Overall, 331 patients were included (mean age 59.7 ± 15.2 years; 176 men). The reconciliation process identified 511 drug discrepancies, 98 of which were unintentional medication discrepancies; these occurred in 74 patients. The most common unintentional medication discrepancies type was omission (40.8%), followed by incorrect dose (25.5%), and 73.5% could have caused patients moderate to significant harm and complications. 5 or more drugs and 2 or more chronic diseases at admission associated with unintentional medication discrepancies in a logistic regression analysis. Conclusion Medication reconciliation performed by pharmacist trainees upon admission can reduce unintentional medication discrepancies. Patients taking 5 or more drugs and experiencing more than two chronic diseases were found to be particularly at risk.

Pharmacist-led transitions-of-care program reduces 30-day readmission rates for Medicare patients in a large health system.

PURPOSE: This report describes the growth and development of the Pharmacy Transitions of Care (PTOC) program at a Florida health system and examines its impact on 30-day readmission rates for Medicare core-measure patients. SUMMARY: BayCare Health System is a large not-for-profit community health system with 15 hospitals in central Florida. In 2015, the PTOC program was developed to integrate 2 pharmacists into the transitions-of-care space to reduce readmissions, enhance patient care, and improve medication safety. The PTOC program focuses on traditional Medicare beneficiaries 65 years of age or older with the goal of preventing 30-day readmissions. The service model includes integration of a pharmacist into the discharge medication reconciliation process, as well as postacute care telephonic follow-up. Data and outcomes have been carefully tracked since program inception and consistently demonstrate a reduction in 30-day readmissions, with a 63% relative risk reduction during the beginning phases of the program and a ratio of observed to expected readmissions of 0.77. As a result, in less than 3 years the PTOC program has grown from 2 to 23 pharmacists and is a key component of BayCare Health System's patient care strategy. CONCLUSION: Medication reconciliation, clinical interventions, and patient education by pharmacists after hospital discharge reduced 30-day readmission rates for Medicare core-measure patients across a large health system. The adaptability of this program to other health systems and hospitals of varying size to achieve similar outcomes is valuable to share with the profession.

The effect of inpatient pharmaceutical care on nephrotic syndrome patients after discharge: a randomized controlled trial.

Background Clinical pharmacists can play an important role in chronic diseases management, but limited attention has been given to the pharmaceutical care of nephrotic syndrome patients. Objective To evaluate the impact of inpatient pharmaceutical care on medication adherence and clinical outcomes in nephrotic syndrome patients. Setting A tertiary first-class hospital in Shanxi, China. Method We conducted a randomized controlled trial on 61 patients with nephrotic syndrome. The intervention consisted of medication reconciliation, pharmacist visits every day, discharge counseling and education by 2 certificated pharmacist, while the control group received usual care. Assessments were performed at baseline, month-1, month-3 and month-6 after hospital discharge. Main outcome measure medication adherence and patients' clinical outcomes. Results 61 patient completed the trial. Baseline variables were comparable between the two groups. The decline in medication adherence of patients in the intervention group after hospital discharge was restrained effectively at month-6 (p < 0.05). However, the groups did not differ in clinical outcomes, medication discrepancies, adverse drug events and readmission rate. The rate of return visits of the pharmaceutical care group was higher at month-1 and month-6 after discharge (p < 0.05). Conclusion Pharmaceutical inpatient care improved adherence in patients with nephrotic syndrome after hospital discharge, the effect of the intervention on clinical outcomes, medication discrepancies, adverse drug events or readmission was insignificant. These results are promising but should be tested in other settings prior to broader dissemination.

Graphical timeline software for inpatient medication review.

MedHistory is a web-based software module that graphically displays medication usage (y-axis) against time (x-axis). We set out to examine whether MedHistory would improve clinician's interactions with the medical record system. The authors invited house-officers at our institution to complete a survey about inpatient medication administration before and after using MedHistory. Detailed logs were also kept for 1 year after the study period. Compared to the pre-intervention survey, the post-intervention survey found that reviewing medication history was easier (pre: 13.2% vs post: 32.4%, p = .008), that medication review now fit within resident workflow (38.9% vs 75.7%, p < .001), and that there was increased satisfaction with the electronic health records software (2.6% vs 29.7%, p = .002). Additionally, determining the timing (29% vs 50.1%, p = .045) and dosing history (21.1% vs. 43.2%, p = .036) of inpatient medication administration was easier with MedHistory. Anti-infective agents and drugs requiring frequent adjustments were the most commonly reviewed. A graphical timeline of inpatient medications (MedHistory) was met with favorable response across multiple areas, including efficiency, speed, safety, and workflow.