Impact of delayed prescription fill on readmission rates for chronic obstructive pulmonary disease and heart failure.

OBJECTIVES: In an effort to reduce reimbursement penalty from the Centers for Medicare & Medicaid Services, hospitals have looked to evaluate the effectiveness of existing programs as well as adopt innovative practices to reduce 30-day readmission rates. The objective of this study was to evaluate the impact of delaying prescription fill on 30-day readmission rates for patients with heart failure (HF) and chronic obstructive pulmonary disease (COPD). Identifying an association between delaying prescription fill and readmission rate would validate programs that provide patients with their medications before discharge. METHODS: A retrospective chart review was performed for all patients admitted to Henry County Medical Center with an HF or COPD exacerbation from January to October 2016. Outpatient pharmacies were contacted for each patient to determine time of prescription fill. Time of fill was compared with time of discharge, and patients were separated into 2 subgroups: those who filled within 48 hours of discharge and those who filled after 48 hours. The primary outcome was 30-day readmission rate, and a secondary end point was to identify patient characteristics associated with delayed prescription fills. RESULTS: A total of 104 patients were included in the study. COPD patients experienced a lower readmission rate when delaying prescription fill at least 48 hours (P = 0.23). HF patients experienced a higher readmission rate when delaying prescription fill at least 48 hours (P = 0.48). No baseline characteristics were associated with a significantly higher rate of delaying prescription fill. CONCLUSION: Delaying discharge prescription fills resulted in a nonsignificant increase in the rate of HF readmission but did not increase the rate of readmission for COPD. Rate of delaying prescription fill was not statistically greater for any of the baseline characteristics.

Drug therapy problems and medication discrepancies during care transitions in super-utilizers.

OBJECTIVES: First, to investigate the prevalence and types of drug therapy problems and medication discrepancies among super-utilizers, and associated patient characteristics. Second, to examine the outcomes of pharmacist recommendations and estimated cost avoidance through care transitions support focused on medication management. DESIGN: Retrospective analysis of the pharmacist-led interventions as part of the SafeMed Program. SETTING: A large nonprofit health care system serving the major medically underserved areas in Memphis, Tennessee. PARTICIPANTS: Three hundred seventy-four super-utilizing SafeMed participants with multiple chronic conditions and polypharmacy. INTERVENTION: Comprehensive medication review, medication therapy management, enhanced discharge planning, home visits, telephone follow-up, postdischarge medication reconciliation, and care coordination with physicians. MAIN OUTCOME MEASURES: Types of drug therapy problems, outcomes of pharmacist recommendations, estimated cost avoided, medication discrepancies, and self-reported medication adherence. RESULTS: Prevalence of drug therapy problems and postdischarge medication discrepancies was 80.7% and 75.4%, respectively. The most frequently occurring drug therapy problems were enrollee not receiving needed medications (33.4%), underuse of medications (16.9%), and insufficient dose or duration (11.2%). Overall 50.8% of the pharmacist recommendations were accepted by physicians and patients, resulting in an estimated cost avoidance of $293.30 per drug therapy problem identified. Multivariate analysis indicated that participants with a higher number of comorbidities were more likely to have medication discrepancies (odds ratio 1.23 [95% CI 1.05-1.44]). Additional contributors to postdischarge medication discrepancies were difficulty picking up and paying for medications and not being given necessary prescriptions before discharge. CONCLUSION: Drug therapy problems and medication discrepancies are common in super-utilizers with multiple chronic conditions and polypharmacy during transitions of care, and greater levels of comorbidity magnify risk. Pharmacist-led interventions in the SafeMed Program have demonstrated success in resolving enrollees' medication-related issues, resulting in substantial estimated cost savings. Preliminary evidence suggests that the SafeMed model's focus on medication management has great potential to improve outcomes while reducing costs for vulnerable super-utilizing populations nationwide.

SafeMed: Using pharmacy technicians in a novel role as community health workers to improve transitions of care.

OBJECTIVES: To describe the design, implementation, and early experience of the SafeMed program, which uses certified pharmacy technicians in a novel expanded role as community health workers (CPhT-CHWs) to improve transitions of care. SETTING: A large nonprofit health care system serving the major medically underserved areas and geographic hotspots for readmissions in Memphis, TN. PRACTICE INNOVATION: The SafeMed program is a care transitions program with an emphasis on medication management designed to use low-cost health workers to improve transitions of care from hospital to home for superutilizing patients with multiple chronic conditions and polypharmacy. EVALUATION: CPhT-CHWs were given primary responsibility for patient outreach after hospital discharge with the use of home visits and telephone follow-up. SafeMed program CPhT-CHWs served as pharmacist extenders, obtaining medication histories, assisting in medication reconciliation and identification of potential drug therapy problems (DTPs), and reinforcing medication education previously provided by the pharmacist per protocol. RESULTS: CPhT-CHW training included patient communication skills, motivational interviewing, medication history taking, teach-back techniques, drug disposal practices, and basic disease management. Some CPhT-CHWs experienced difficulties adjusting to an expanded scope of practice. Nonetheless, once the Tennessee Board of Pharmacy affirmed that envisioned SafeMed CPhT-CHW roles were consistent with Board rules, additional responsibilities were added for CPhT-CHWs to enhance their effectiveness. Patient outreach teams including CPhT-CHWs achieved increases in home visit and telephone follow-up rates and were successful in helping identify potential DTPs. CONCLUSION: The early experience of the SafeMed program demonstrates that CPhT-CHWs are well suited for novel expanded roles to improve care transitions for superutilizing populations. CPhT-CHWs can identify and report potential DTPs to the pharmacist to help target medication therapy management. Critical success factors include strong CPhT-CHW patient-centered communication skills and strong pharmacist champions. In collaboration with state pharmacy boards and pharmacist associations, the SafeMed CPhT-CHW model can be successfully scaled to serve superutilizing patients throughout the country.

Polycyclic aromatic hydrocarbon-DNA adducts and survival among women with breast cancer.

Polycyclic aromatic hydrocarbons (PAH) are mammary carcinogens in animal studies, and a few epidemiologic studies have suggested a link between elevated levels of PAH-DNA adducts and breast cancer incidence. An association between PAH-DNA adducts and survival among breast cancer cases has not been previously reported. We conducted a survival analysis among women with newly diagnosed invasive breast cancer between 1996 and 1997, enrolled in the Long Island Breast Cancer Study Project. DNA was isolated from blood samples that were obtained from cases shortly after diagnosis and assayed for PAH-DNA adducts using ELISA. Among the 722 cases with PAH-DNA adduct measurements, 97 deaths (13.4%) from all causes and 54 deaths (7.5%) due to breast cancer were reported to the National Death Index (NDI) by December 31, 2002. Using Cox proportional hazards models and controlling for age at diagnosis, we did not find evidence that all-cause mortality (hazard ratio (HR)=0.88; 95% confidence interval (CI): 0.57-1.37), or breast cancer mortality (HR=1.20; 95% CI: 0.63-2.28) was strongly associated with detectable PAH-DNA adduct levels compared with non-detectable adducts; additionally, no dose-response association was observed. Among a subgroup with treatment data (n=520), adducts were associated with over a two-fold higher mortality among those receiving radiation, but mortality for adducts was reduced among hormone therapy users. Results from this large population-based study do not provide strong support for an association between detectable PAH-DNA adducts and survival among women with breast cancer, except perhaps among those receiving radiation treatment.

Dietary flavonoid intake and breast cancer survival among women on Long Island.

BACKGROUND: Laboratory research and a growing number of epidemiologic studies have provided evidence for a reduced risk of breast cancer associated with dietary intake of certain classes of flavonoids. However, the effects of flavonoids on survival are not known. In a population-based cohort of breast cancer patients, we investigated whether dietary flavonoid intake before diagnosis is associated with subsequent survival. METHODS: Women ages 25 to 98 years who were newly diagnosed with a first primary invasive breast cancer between August 1, 1996, and July 31, 1997, and participated in a population-based, case-control study (n=1,210) were followed for vital status through December 31, 2002. At the case-control interview conducted shortly after diagnosis, respondents completed a FFQ that assessed dietary intake in the previous 12 months. All-cause mortality (n=173 deaths) and breast cancer-specific mortality (n=113 deaths) were determined through the National Death Index. RESULTS: Reduced hazard ratios [age- and energy-adjusted hazard ratio (95% confidence interval)] for all-cause mortality were observed among premenopausal and postmenopausal women for the highest quintile of intake, compared with the lowest, for flavones [0.63 (0.41-0.96)], isoflavones [0.52 (0.33-0.82)], and anthocyanidins [0.64 (0.42-0.98)]. No significant trends in risk were observed. Results were similar for breast cancer-specific mortality only. CONCLUSION: Mortality may be reduced in association with high levels of dietary flavones and isoflavones among postmenopausal U.S. breast cancer patients. Larger studies are needed to confirm our findings.

Active and passive cigarette smoke and breast cancer survival.

PURPOSE: The association between active and passive cigarette smoking before breast cancer diagnosis and survival was investigated among a cohort of invasive breast cancer cases (n = 1273) participating in a population-based case-control study. METHODS: Participants diagnosed with a first primary breast cancer between August 1, 1996, and July 31, 1997, were followed-up until December 31, 2002, for all-cause mortality (n = 188 deaths), including breast cancer-specific mortality (n = 111), as reported to the National Death Index. RESULTS: In Cox models, the adjusted hazards ratios (HRs) for all-cause mortality were slightly higher among current and former active smokers, compared with never smokers (HR, 1.23; 95% confidence interval [95% CI], 0.83-1.84) and 1.19 (95% CI, 0.85-1.66), respectively). No association was found between active or passive smoking and breast cancer-specific mortality. All-cause and breast cancer-specific mortality was higher among active smokers who were postmenopausal (HR, 1.64; 95% CI, 1.03-2.60 and HR, 1.45; 95% CI, 0.78-2.70, respectively) or obese at diagnosis (HR, 2.10; 95% CI, 1.03-4.27 and HR, 1.97; 95% CI, 0.89-4.36, respectively). Associations between smoking and all-cause and breast cancer-specific mortality did not differ by cancer treatment. CONCLUSIONS: These data do not provide strong evidence for an association between smoking and all-cause or breast cancer-specific mortality, although smokers who are postmenopausal or obese at diagnosis may be at higher risk.

Fruits, vegetables, and micronutrient intake in relation to breast cancer survival.

OBJECTIVE: To determine whether fruit, vegetable, and micronutrient intake 1 year prior to breast cancer diagnosis is associated with a reduction in the subsequent risk of all-cause or breast cancer-specific mortality. METHODS: Follow-up data from 1,235 invasive breast cancer cases age 25-98 years from the Long Island Breast Cancer Study Project were analyzed. At the 1996-1997 case-control interview, respondents completed a food frequency questionnaire, which assessed dietary intake of fruits, vegetables, and vitamin supplement use in the previous 12 months. All-cause mortality (n=186 deaths) and breast cancer-specific mortality status (n=125 deaths, 67.2%) were determined through December 31, 2002. RESULTS: Hazard ratios (HRs) for all-cause mortality were insignificantly reduced for intake of any fruits, fruit juices, and vegetables (HR=0.68, 95% CI: 0.42-1.09) and leafy vegetables (HR=0.72, 95% CI: 0.41-1.24) among post-menopausal women only. Both of these associations were more pronounced among those with ER+PR+ tumors (HR=0.54, 95% CI: 0.27-1.10, and HR=0.66, 95% CI: 0.33-1.31, respectively). Similar associations were observed for breast cancer-specific mortality. CONCLUSIONS: In a cohort of women diagnosed with breast cancer, higher intake of fruits, vegetables, and micronutrients was associated with a non-significant survival advantage in post-menopausal women only.