Evaluation of a pharmacist-led pilot service based on the anticholinergic risk scale.

OBJECTIVES: To determine primary care physician (PCP) acceptance rates of electronic medication therapy recommendations based on anticholinergic burden for high-risk elderly patients, and to evaluate potential associations between recommendation acceptance and patient-provider characteristics. SETTING: Two medical clinics within Dean Health System, an integrated health care organization comprising ambulatory surgery centers, medical clinics, community pharmacies, specialty pharmacies, a health plan, and a pharmacy benefits management company. PRACTICE INNOVATION: In this pilot service, the medical records of patients at least 60 years old who met the following criteria were evaluated bimonthly: 1) PCP visit within 2 weeks; (2) three or more inpatient hospitalizations or emergency department visits in the past year; and (3) ten or more active medications. Anticholinergic Risk Scale (ARS) scores of eligible patients were calculated, and medication therapy recommendations were sent electronically to PCPs for patients with an ARS score greater than 3. Post-visit recommendation outcomes were recorded. EVALUATION: Descriptive statistics were utilized to characterize patients, physicians, and recommendations. A generalized linear mixed effects model with physician specific random effects was employed to evaluate recommendation acceptance rates, and odds ratios were calculated to quantify associations between baseline patient/provider characteristics and the likelihood of recommendation acceptance. Changes in aggregate ARS scores were evaluated with the use of a paired t test. RESULTS: Fifty-nine patients were included in this pilot, with 89 medication therapy recommendations made to 21 PCPs. An overall recommendation acceptance rate of 50% (95% confidence interval [CI] 37%-63%) was observed. There were no significant associations identified between baseline patient/provider characteristics and medication recommendation acceptance. CONCLUSION: High recommendation acceptance rates were achieved with the combination of objective anticholinergic risk assessment and algorithm-driven medication therapy recommendations. The lack of identified associations between patient/provider characteristics and recommendation acceptance supports the future scalability of this novel service.

Incidence and cost of medications dispensed despite electronic medical record discontinuation.

OBJECTIVE: To determine the incidence and cost of medications dispensed despite discontinuation (MDDD) of the medications in the electronic medical record within an integrated health care organization. SETTING: Dean Health System, with medical clinics and pharmacies linked by an electronic medical record, and a shared health plan and pharmacy benefits management company. PRACTICE DESCRIPTION: Pharmacist-led quality improvement project using retrospective chart review. PRACTICE INNOVATION: Electronic medical records, pharmacy records, and prescription claims data from patients 18 years of age or older who had a prescription filled for a chronic condition from June 2012 to August 2013 and submitted a claim through the Dean Health Plan were aggregated and cross-referenced to identify MDDD. MAIN OUTCOME MEASURES: Descriptive statistics were used to characterize demographics and MDDD incidence. Fisher's exact test and independent samples t tests were used to compare MDDD and non-MDDD groups. Wholesale acquisition cost was applied to each MDDD event. RESULTS: 7,406 patients met inclusion criteria. For 223 (3%) patients with MDDD, 253 independent events were identified. In terms of frequency per category, antihypertensive agents topped the list, followed, in descending order, by anticonvulsants, antilipemics, antidiabetics, and anticoagulants. Nine medications accounted for 59% (150 of 253) of all MDDD events; these included (again in descending order): gabapentin, atorvastatin, simvastatin, hydrochlorothiazide, lisinopril, warfarin, furosemide, metformin, and metoprolol. Mail-service pharmacies accounted for the highest incidence (5.3%) of MDDD, followed by mass merchandisers (4.6%) and small chains (3.9%). The total cost attributable to MDDD was $9,397.74. CONCLUSION: Development of a technology-based intervention to decrease the incidence of MDDD may be warranted to improve patient safety and decrease health care costs.

Improving patient feedback about and outcomes with antidepressant treatment: a study in eight community pharmacies.

OBJECTIVE: To determine (1) whether telephone follow-up using a standardized telemonitoring tool can influence the nature and extent to which antidepressant users provide feedback to pharmacists, (2) whether patient characteristics are associated with the extent of patient feedback, and (3) how patient feedback affects subsequent outcomes after controlling for patient characteristics. DESIGN: Randomized, controlled, experimental design. SETTING: Eight Wisconsin community pharmacies within a large managed care organization. PATIENTS: 60 patients presenting new antidepressant prescriptions. INTERVENTIONS: Three monthly telephone calls from pharmacists providing structured education and monitoring. MAIN OUTCOME MEASURES: Frequency of patient feedback to pharmacists, antidepressant knowledge, beliefs, percentage of missed doses, depression symptom scores, and perceptions of progress. RESULTS: Compared with usual care patients (n=32), pharmacist-guided education and monitoring (PGEM) patients (n=28) provided significantly more feedback to pharmacists regarding different aspects of their antidepressant therapy even after controlling for patient characteristics. Regression results also showed that patient feedback was significantly associated with greater antidepressant knowledge, positive antidepressant beliefs, and perceptions of progress after 3 months. Patient feedback was unrelated to nonadherence and depressive symptoms. CONCLUSION: Structured education and monitoring by pharmacists significantly improves the level of patient feedback to pharmacists, and such feedback may help pharmacists identify and address their patients' misconceptions, concerns, and progress with antidepressant therapy.

Pharmacist telemonitoring of antidepressant use: effects on pharmacist-patient collaboration.

OBJECTIVE: To explore the impact of telephone-based education and monitoring by community pharmacists on multiple outcomes of pharmacist-patient collaboration. DESIGN: A randomized, controlled, unblinded, mixed experimental design. SETTING: Eight Wisconsin community pharmacies within a large managed care organization. PATIENTS: A total of 63 patients presenting new antidepressant prescriptions to their community pharmacies. INTERVENTIONS: Patients were randomized to receive either three monthly telephone calls from pharmacists providing pharmacist-guided education and monitoring (PGEM) or usual pharmacist's care. Usual care is defined as that education and monitoring which pharmacists may typically provide patients at the study pharmacies. MAIN OUTCOME MEASURES: Patient's frequency of feedback with the pharmacist, antidepressant knowledge, antidepressant beliefs, antidepressant adherence at 3 and 6 months, improvement in depression symptoms, and orientation toward treatment progress. RESULTS: Of the 60 patients who completed the study, 28 received PGEM and 32 received usual pharmacist's care. Results showed that PGEM had a significant and positive effect on patient feedback, knowledge, medication beliefs, and perceptions of progress. There were no significant group differences in patient adherence or symptoms at 3 months; however, PGEM patients who completed the protocol missed fewer doses than did the usual care group at 6 months (P < or = .05). CONCLUSION: Antidepressant telemonitoring by community pharmacists can significantly and positively affect patient feedback and collaboration with pharmacists. Longer-term studies with larger samples are needed to assess the generalizability of findings. Future research also needs to explore additional ways to improve clinical outcomes.