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.

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.

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 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.

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.

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.

Impact of Computer-Based and Pharmacist-Assisted Medication Review Initiated in the Emergency Department.

OBJECTIVES: Whether early medication reconciliation and integration can reduce polypharmacy and potentially inappropriate medication (PIM) in the emergency department (ED) remains unclear. Polypharmacy and PIM have been recognized as significant causes of adverse drug events in older adults. Therefore, this pilot study was conducted to delineate this issue. DESIGN: An interventional study. SETTING: A medical center in Taiwan. PARTICIPANTS: Older ED patients (aged ≥65 years) awaiting hospitalization between December 1, 2017, and October 31, 2018 were recruited in this study. A multidisciplinary team and a computer-based and pharmacist-assisted medication reconciliation and integration system were implemented. MEASUREMENTS: The reduced proportions of major polypharmacy (≥10 medications) and PIM at hospital discharge were compared with those on admission to the ED between pre- and post-intervention periods. RESULTS: A total of 911 patients (pre-intervention = 243 vs post-intervention = 668) were recruited. The proportions of major polypharmacy and PIM were lower in the post-intervention than in the pre-intervention period (-79.4% vs -65.3%; P < .001, and - 67.5% vs -49.1%; P < .001, respectively). The number of medications was reduced from 12.5 ± 2.7 to 6.9 ± 3.0 in the post-intervention period in patients with major polypharmacy (P < .001). CONCLUSION: Early initiation of computer-based and pharmacist-assisted intervention in the ED for reducing major polypharmacy and PIM is a promising method for improving geriatric care and reducing medical expenditures. J Am Geriatr Soc 67:2298-2304, 2019.

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.

The efficacy of a medication review programme conducted in an emergency department.

Background Older age and inappropriate prescribing is related to a greater rate of emergency department visits and hospitalisations. Objective To assess the efficacy of an interprofessional collaboration programme in which a review of the medication of older patients seen in the emergency observation unit was carried out. Setting Emergency departments at four Spanish hospitals. Method Randomised, controlled study. Patients over 65 years of age presenting to the emergency department were randomised to a control or an intervention group. In the intervention group, a pharmacist reviewed the patients' chronic medication and identified any potentially inappropriate prescriptions based on the STOPP/START criteria. Each case was discussed with the emergency specialist and a recommendation to modify the treatment was sent to the general practitioner. Main outcome measure Rate of emergency visits and hospital admissions. Results The adjusted rate ratio of emergency visits and hospital admissions was 0.808 (95% CI 0.617 to 1.059) at 3 months, 0.888 (95% CI 0.696 to 1.134) at 6 months and 0.954 (95% CI 0.772 to 1.179) at 12 months. There was a statistically significant reduction at 3 months in two of the hospitals that participated in the study [adjusted rate ratio at 3 months was 0.452 (95% CI 0.222 to 0.923) in hospital 3 and 0.567 (95% CI 0.328 to 0.983) in hospital 4]. Conclusion Overall, the intervention did not reduce the number of emergency visits and hospital admissions. However, a significant effect was observed in centres were a high acceptance rate of treatment recommendations was achieved.

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.

Use of a tablet computer application to engage patients in updating their medication list.

PURPOSE: Failure to obtain an accurate medication history can adversely affect patient care in the emergency department (ED) and propagate errors into the inpatient and outpatient settings. Obtaining an accurate medication history in the ED is challenging, however, due to limited time, a suboptimal environment for patient interaction, and inadequate information in the electronic health record (EHR). This article describes the development and initial evaluation of the PictureRx Medication History Application, a tablet computer-based program that queries patients' prescription fill data from the Surescripts Medication History service and renders it graphically for review and editing at the point of care. METHODS: A quasi-experimental trial of PictureRx was performed in a large academic ED. Adult patients taking at least 1 prescription medication were prospectively eligible for the intervention. Usual care control patients were retrospectively matched 1:1. The main outcomes were updates to the patients' existing pre-visit medication list in the EHR and patient perceptions of the application. RESULTS: The medication list was updated for 101/244 (41.4%) of the intervention group and for 43/244 (17.6%) of the control group (difference 23.8%, 95% confidence interval, 16.0-31.6%). Similar differences were observed for medication additions, removals, and corrections in dose. Approximately 80% of intervention patients "strongly agreed" that the application was easy to use, aided medication list accuracy, and the graphical features assisted with recall. CONCLUSION: A novel tablet computer-based medication history application was feasible to implement in a busy academic ED. Use of the tool was associated with more updates to patients' EHR medication list.

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.

Use of an Anti-Infective Medication Review Process at Hospital Discharge to Identify Medication Errors and Optimize Therapy.

BACKGROUND: Medication reconciliation is a major patient safety concern, and the impact of a structured process to evaluate anti-infective agents at hospital discharge warrants further review. OBJECTIVE: The aim of this study was to (1) describe a structured, multidisciplinary approach to review anti-infectives at discharge and (2) measure the impact of a stewardship-initiated antimicrobial review process in identifying and preventing anti-infective-related medication errors (MEs) at discharge. METHODS: A prospective study to evaluate adult patients discharged on anti-infectives was conducted from October 2013 to May 2014. The antimicrobial stewardship program (ASP) classified interventions on anti-infective regimens into predefined ME categories. RESULTS: Forty-five patients who were discharged on 59 anti-infective prescriptions were included in the study. The most common indications for anti-infective regimens at discharge were pneumonia (22%, n = 10), bacteremia (18%, n = 8), and skin and soft tissue infections (16%, n = 7). An ME was identified in 42% (n = 19/45) of anti-infective regimens. Seventy percentage of ASP team recommendations were accepted which resulted in an avoidance of MEs in 68% (n = 13/19) of patients with an ME prior to discharge. CONCLUSION: This study describes the outcomes of a stewardship-initiated review process in preventing MEs at discharge. Developing a systematic process for a multidisciplinary ASP team to review all anti-infectives can be a valuable tool in preventing MEs at hospital discharge.

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.

Obtaining a follow-up appointment before discharge protects against readmission for patients with acute coronary syndrome and heart failure: A quality improvement project.

BACKGROUND: Cardiac patients have a high risk of readmission following hospital discharge. The aim of our project was to examine the factors associated with increased readmission rate, with a view to eventually decrease the rate of readmission for patients admitted to the hospital due to acute coronary syndrome (ACS) or heart failure. METHODS: Patients admitted to the cardiac step-down unit at a single private hospital from 2015 to 2016 were included in our study. Interventions that were employed included: (1) improved pre-discharge follow-up appointment scheduling, (2) medication education by a pharmacist, and (3) timely discharge planning. Our primary outcome of interest was all-cause rate of hospital readmission within 30days. We conducted a multivariate analysis to determine the factors that were predictive of readmission rate. RESULTS: 578 patients were included in the study and 402 were diagnosed with ACS (69.9%). The rate of readmission was 14.2% for patients with heart failure, compared to 7.5% for patients with ACS. Following the bundle of interventions, patients were significantly more likely to receive an appointment (45.6% vs. 75.4%, p<0.001), medication education from a pharmacist (38.5% vs. 56.7%, p=0.006), and a timely discharge (47.1% vs. 76.0%, p<0.001). Readmission rate was comparable following the intervention (8.6% vs. 9.7%), but patients that received an appointment had 0.374 times lower odds of being readmitted (p=0.004). CONCLUSIONS: While our package of interventions did not lead to a significant decline in our readmission rate, patients who received a follow-up appointment prior to discharge were strongly protected against readmission.

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.

The influence of pharmacist-led adherence support on glycaemic control in people with type 2 diabetes.

Background Adherence to treatment is important to achieve target outcomes, particularly for those with type 2 diabetes. Pharmacists are well placed to enhance adherence, however evidence of the impact on clinical outcomes is not well known. Objective To determine the impact of an adherence support service on adherence scores and subsequent clinical biomarkers (HbA1c). Setting Community pharmacies providing a Medicines Use Review (MUR) Service in a New Zealand locality. Methods Records of patients receiving MURs between 2007 and 2012 were obtained from a single locality. Data extraction included: individual characteristics, the adherence score assigned at every consultation, pathology records. Patients receiving oral hypoglycaemic medications (n = 86) were included in the final analysis using generalised estimating equations to explore change in HbA1c over time, and whether this was related to the adherence score. Main Outcome Measures (a) change in adherence scores and (b) association between adherence sores and HbA1c. Results A total of 350 records were obtained, of those, 115 of 350 people had follow up MUR visit/s and could be analysed for changes in adherence. Most people (110/115) showed sustained or improved adherence scores with follow up visits. For those receiving oral hypoglycaemic medications (n = 86); where poor adherence scores were recorded, their HbA1c levels were higher and continued to increase by ~ 0.1% (1 mmol/mol) every 10 weeks, B = 0.11, p = 0.009. Conversely, those with high adherence scores showed an overall decrease in HbA1c levels. Conclusion MURs may positively influence medication adherence. This improved adherence shows a measurable decline in HbA1c levels.

Impact of a pharmacy team-led intervention program on the readmission rate of elderly patients with heart failure.

PURPOSE: The results of a study to determine whether pharmacy team-led postdischarge intervention can reduce the rate of 30-day hospital readmissions in older patients with heart failure (HF) are reported. METHODS: A retrospective chart review was performed to identify patients 60 years of age or older who were admitted to an academic medical center with a primary diagnosis of HF during the period March 2013-June 2014 and received standard postdischarge follow-up care provided by physicians, nurses, and case managers. The rate of 30-day readmissions in that historical control group was compared with the readmission rate in a group of older patients with HF who were admitted to the hospital during a 15-month intervention period (July 2014-October 2015); in addition to usual postdischarge care, these patients received medication reconciliation and counseling from a team of pharmacists, pharmacy residents, and pharmacy students. RESULTS: Twelve of 97 patients in the intervention group (12%) and 20 of 80 patients in the control group (25%) were readmitted to the hospital within 30 days of discharge (p = 0.03); 11 patients in the control group (55%) and 7 patients in the intervention group (58%) had HF-related readmissions (p = 0.85). CONCLUSION: In a population of older patients with HF, the rate of 30-day all-cause readmissions in a group of patients targeted for a pharmacy team-led postdischarge intervention was significantly lower than the all-cause readmission rate in a historical control group.

Changes in medicine prescription following a medication review in older high-risk patients with polypharmacy.

Background The more (inappropriate) drugs a patient uses, the higher the risk of drug related problems. To reduce these risks, medication reviews can be performed. Objective To report changes in the prescribed number of (potentially inappropriate) drugs before and after performing a medication review in high-risk polypharmacy patients. A secondary objective was to study reasons for continuing potentially inappropriate drugs (PIDs). Setting Dutch community pharmacy and general medical practice. Methods A retrospective longitudinal intervention study with a pre-test/post-test design and follow-up of 1 week and 3 months was performed. The study population consisted of 126 patients with polypharmacy and with additional risk for drug related problems that underwent a medication review in five community pharmacies. The medication review was performed by the pharmacist in close cooperation with the general practitioner of each corresponding patient. Main outcome measure Number of (potentially inappropriate) drugs, and appropriateness of prescribed medicines. Results The average number of drugs a patient used 1 day before the review was 8.7 (SD = 2.9), which decreased (p < 0.05) to 8.3 (SD = 2.7) 1 week after the review, and to 8.4 (SD = 2.6) 3 months after the review. The average number of PIDs was initially 0.6 (SD = 0.8) per patient and decreased to 0.4 (SD = 0.6, p < 0.05). Twenty-two of the 241 initial drug changes (9%) were deprescribed during follow-up. Registered reasons for continuing PIDs are clinical or patients' preferences. Conclusions Performing medication reviews in polypharmacy patients seems useful to continue at least in high-risk patients in The Netherlands. The time-consuming reviews could be limited to patients who are willing to change their medication.