Pharmacist discharge summary: Impact of inpatient to community pharmacist handoff at hospital discharge.

BACKGROUND: Community pharmacists are often the initial health professionals whom patients encounter after hospital discharge but are rarely provided relevant discharge information. OBJECTIVES: Implement a pharmacist-to-pharmacist discharge summary (P2PDS) to improve the safety of pharmacist care provision to patients transitioning home from the hospital. PRACTICE DESCRIPTION: Inpatient pharmacists at an academic medical center conduct discharge medication reconciliation and release discharge electronic prescriptions to dispensing pharmacies. PRACTICE INNOVATION: A multidisciplinary intersystem quality improvement project was conducted to demonstrate the impact of clinical information sharing via the P2PDS to community pharmacists. EVALUATION METHODS: With input from community pharmacists, the P2PDS was created and implemented on inpatient units throughout the health system. Outcomes assessed included identification of medication discrepancies, enrollment into reimbursable medication management services, and pharmacist confidence when filling discharge prescriptions. RESULTS: During the study period, community pharmacists identified a total of 388 medication discrepancies in 161 patients; 16% of discrepancies were considered "unintentional." Twenty-five discharging patients were identified for enrollment in medication management services, with 20 of these patients enrolling in all 3 services (medication delivery, synchronization, and medication packaging). The P2PDS increased community pharmacist confidence in discharge medication filling (40% vs. 95%, P < 0.001) and increased the percent of patients receiving community pharmacist medication reconciliation (14%-76%, P < 0.001). CONCLUSION: Enhancing pharmacist communication across practice settings with a P2PDS decreases care fragmentation through identification of medication discrepancies and improves pharmacist confidence in patient care provision.

An altered microbiome in a Parkinson's disease model Drosophila melanogaster has a negative effect on development.

Parkinson's disease (PD) is the second most common neurodegenerative disease, besides Alzheimer's Disease, characterized by multiple symptoms, including the well-known motor dysfunctions. It is well-established that there are differences in the fecal microbiota composition between Parkinson's disease (PD) patients and control populations, but the mechanisms underlying these differences are not yet fully understood. To begin to close the gap between description and mechanism we studied the relationship between the microbiota and PD in a model organism, Drosophila melanogaster. First, fecal transfers were performed with a D. melanogaster model of PD that had a mutation in the parkin (park25) gene. Results indicate that the PD model feces had a negative effect on both pupation and eclosion in both control and park25 flies, with a greater effect in PD model flies. Analysis of the microbiota composition revealed differences between the control and park25 flies, consistent with many human studies. Conversely, gnotobiotic treatment of axenic embryos with feces-derived bacterial cultures did not affect eclosure. We speculate this result might be due to similarities in bacterial prevalence between mutant and control feces. Further, we confirmed a bacteria-potentiated impact on mutant and control fly phenotypes by measuring eclosure rate in park25 flies that were mono-associated with members of the fly microbiota. Both the fecal transfer and the mono-association results indicate a host genotype-microbiota interaction. Overall, this study concludes functional effects of the fly microbiota on PD model flies, providing support to the developing body of knowledge regarding the influence of the microbiota on PD.

The high-value pharmacy enterprise framework: Advancing pharmacy practice in health systems through a consensus-based, strategic approach.

PURPOSE: The high-value pharmacy enterprise (HVPE) framework and constituent best practice consensus statements are presented, and the methods used to develop the framework's 8 domains are described. SUMMARY: A panel of pharmacy leaders used an evidence- and expert opinion-based approach to define core and aspirational elements of practice that should be established within contemporary health-system pharmacy enterprises by calendar year 2025. Eight domains of an HVPE were identified: Patient Care Services; Business Services; Ambulatory and Specialty Pharmacy Services; Inpatient Operations; Safety and Quality; Pharmacy Workforce; Information Technology, Data, and Information Management; and Leadership. Phase 1 of the project consisted of the development of draft practice statements, performance elements, and supporting evidence for each domain by panelists, followed by a phase 2 in-person meeting for review and development of consensus for statements and performance elements in each domain. During phase 3, the project cochairs and panelists finalized the domain drafts and incorporated them into a full technical report and this summary report. CONCLUSION: The HVPE framework is a strategic roadmap to advance pharmacy practice by ensuring safe, effective, and patient-centered medication management and business practices throughout the health-system pharmacy enterprise. Grounded in evidence and expert recommendations, the statements and associated performance elements can be used to identify strategic priorities to improve patient outcomes and add value within health systems.

Primary care pharmacy technicians: Effect on pharmacist workload and patient access to clinical pharmacy services.

PURPOSE: Improve patient access to clinical pharmacy services and decrease pharmacist technical task workload in primary care (PC) clinics. SUMMARY: Due to concerns with the amount of technical tasks performed by University of Wisconsin Health PC clinical pharmacists negatively impacting their capacity to care for patients and perform clinical tasks, the pharmacy department piloted a new PC pharmacy technician role that involved completion of technical tasks previously performed by PC pharmacists. PC pharmacist daily technical and clinical activities were identified through shadowing and quantified by a 4-week period of work sampling. A PC pharmacist workgroup determined the technical tasks that would be appropriate for a pharmacy technician to complete and developed the technician workflows. A PC pharmacy technician was implemented during a 3-week pilot, when pharmacist daily technical and clinical activities were quantified through work sampling. Following implementation, a 52.7% (P < 0.001) relative reduction and a 10.2% (P < 0.001) relative increase in pharmacist technical and clinical activities, respectively, were identified. Additionally, a 10% relative increase from the previous 3-month average was observed in the PC pharmacist rolling patient panel size during the pilot period, correlating with an increase of patient access to pharmacist clinical services. CONCLUSION: Up to 17% of PC pharmacist daily activities are technical tasks. Leveraging pharmacy technicians to support pharmacists with completion of these tasks increases patient access to clinical pharmacy services but requires additional staff resources.

Inpatient pharmacists' patient referrals to a transitions-of-care pharmacist: Evaluation of an automated referral process.

OBJECTIVES: To evaluate the impact of a pharmacist screening and automated referral process that identifies patients at risk for readmission due to medication-related problems (MRPs). SETTING: University of Wisconsin (UW) Hospital is 505-bed flagship hospital that is part of UW Health, an academic health system. PRACTICE DESCRIPTION: The integrated pharmacy practice model at UW Health has inpatient pharmacists who perform discharge medication reconciliation. Before enhancing the screening and referral process, a transitions-of-care (TOC) pharmacist identified patients with the use of a low yield report and performed a second postdischarge medication reconciliation on selected patients. PRACTICE INNOVATION: A screening process was developed to identify patients at risk for readmission due to MRPs and allow for direct referral from inpatient pharmacists to a TOC pharmacist for postdischarge follow-up. EVALUATION: Patient characteristics, readmission risk, and readmission rate were compared between inpatient only (before referral) and inpatient plus second medication reconciliation (after referral). MRPs identified during medication reconciliation were quantified and categorized as provider or patient-associated. RESULTS: Before process improvement, 9 patients (5%) received a second medication reconciliation out of 175 patients who received standard-of-care inpatient medication reconcilation. After implementation, 45 patients (24%) received a second medication reconcilation out of 188 referrals. Patients referred for postdischarge follow-up with the TOC pharmacist had an average of 3.2 more medications and 2.7 more chronic conditions than before process implementation (P < 0.01). Both inpatient and TOC pharmacists identified at least 1 MRP in about two-thirds of patients (P = 0.60). Provider-associated MRPs were more commonly identified in both inpatient and postdischarge settings. CONCLUSION: Inpatient pharmacist screening is an effective method for identifying patients for referral to a TOC pharmacist to receive postdischarge follow-up. Despite the robustness of the inpatient medication reconciliation process in identifying provider-associated MRPs, patient-associated MRPs still emerged after discharge that warranted additional pharmacist intervention.

Prospective daily review of discharge medications by pharmacists: Effects on measures of safety and efficiency.

PURPOSE: Results of a pilot project to improve the safety and efficiency of the discharge process by adding daily pharmacist review and preparation of discharge medication orders to an existing discharge medication reconciliation workflow are reported. SUMMARY: Due to patient capacity issues, the pharmacy department of a large tertiary medical center implemented changes to the existing medication discharge workflow. A steering committee was established, with subgroups responsible for workflow development, electronic medical record enhancement, and data collection designated. Patients admitted to 5 hospitalist services, 1 otolaryngology service, and 1 gynecology service were included in pilot testing of a new discharge workflow over a 7-week period. The new workflow included pharmacist daily prospective preparation of discharge medication orders by "pending" (i.e., managing all aspects of) orders for providers to sign. After implementation, a 22% relative reduction (p = 0.046) in pharmacist-identified medication-related problems was documented. Additionally, the proportion of discharges occurring before noon was increased on all services involved in the pilot project, including a significant increase (from 19% to 23%, p = 0.001) on the hospitalist services. Challenges identified during the pilot project included suboptimal initial provider acceptance and added pharmacist workload. On average, an additional 16.2 minutes of pharmacist time per patient was required for ordering of discharge medications throughout a patient stay. CONCLUSION: Implementation of a discharge process that incorporated pharmacist pending of discharge medication orders throughout the patient stay improved measures of safety and efficiency of the discharge process.

Refill-Based Medication Use Quality Measures in Kidney Transplant Recipients: Examination of Proportion of Days Covered and Medication Possession Ratio.

BACKGROUND: The Pharmacy Quality Alliance's definition of proportion of days covered (PDC) and medication possession ratio (MPR) have not been examined as potential quality measures in the kidney transplant recipient population. OBJECTIVES: To (a) describe the frequency distribution of MPR and PDC using mycophenolic acid products in a real-world kidney transplant recipient population and (b) evaluate associations between MPR and PDC with late (> 90 days after transplantation) biopsy-proven acute rejection (BPAR). METHODS: This was a retrospective cohort study combining data from the Wisconsin Allograft Recipient Database with University of Wisconsin (UW) Health Specialty Pharmacy prescription claims and dispensing data from March 10, 2006, to June 30, 2012. Patients who met criteria for persistence filling mycophenolic acid prescriptions at UW Health Specialty Pharmacy in the first year following discharge from kidney transplantation surgery hospitalization were included. Patients were excluded if they were enrolled in a clinical trial, if they had BPAR within 90 days of transplantation, or if they did not have panel reactive antibody data available. PDC and MPR were calculated over 360 days after discharge, and multivariable analyses were performed to determine if there were associations between PDC or MPR with late BPAR within 3 years. RESULTS: This study included 388 patients. The incidence of 3-year late BPAR was 5.1% (n = 20). Characteristics of patients who experienced late BPAR were largely consistent with those who did not experience late BPAR, with the exception of number of hospital readmissions, which was higher among patients who experienced late BPAR. The frequency distribution of PDC and MPR exhibited a skewed left distribution, with a median PDC of 0.972 and a median MPR of 1.000. Higher PDC was associated with lower odds of late BPAR (OR = 0.041, 95% CI = 0.004-0.417) in multivariable analysis, as was a higher MPR (OR = 0.041, 95% CI = 0.004-0.419). CONCLUSIONS: MPR and PDC may be calculated from data available to pharmacies and health plans, and each was associated with 3-year late BPAR among patients who did not experience early BPAR. However, the construct validity of these medication adherence measures requires further study. DISCLOSURES: This study was not funded. The authors report no conflicts of interest and no relevant financial interests related to the products or services discussed in this article. Study concept and design were contributed by Hofmeyer, along with Look and Hager. Hager took the lead in data collection, along with the other authors. Data interpretation was performed by Look, along with the other authors. The manuscript was primarily written by Hofmeyer, assisted by Look and Hager, and revised by all of the authors.

Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework.

INTRODUCTION: Patients transitioning from the hospital to a skilled nursing home (SNF) are susceptible to medication-related errors resulting from fragmented communication between facilities. Through continuous process improvement efforts at the hospital, a targeted needs assessment was performed to understand the extent of medication-related issues when patients transition from the hospital into a SNF, and the gaps between the hospital's discharge process, and the needs of the SNF and long-term care (LTC) pharmacy. We report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to SNF and LTC pharmacy staff. METHODS: Applying the Intervention Mapping (IM) framework, a targeted needs assessment was performed using quantitative and qualitative methods. Using the hospital discharge medication list as reference, medication discrepancies in the SNF and LTC pharmacy lists were identified. SNF and LTC pharmacy staffs were also interviewed regarding the continuity of medication information post-discharge from the hospital. RESULTS: At least one medication discrepancy was discovered in 77.6% (n = 45/58) of SNF and 76.0% (n = 19/25) of LTC pharmacy medication lists. A total of 191 medication discrepancies were identified across all SNF and LTC pharmacy records. Of the 69 SNF staff interviewed, 20.3% (n = 14) reported patient care delays due to omitted documents during the hospital-to-SNF transition. During interviews, communication between the SNF/LTC pharmacy and the discharging hospital was described by facility staff as unidirectional with little opportunity for feedback on patient care concerns. CONCLUSIONS: The targeted needs assessment guided by the IM framework has lent to several planned process improvements initiatives to help reduce medication discrepancies during the hospital-to-SNF transition as well as improve communication between healthcare entities. Opening lines of communication along with aligning healthcare entity goals may help prevent medication-related errors.

Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy.

Background: While hospital beds continue to decline as patients previously treated as inpatients are stabilized in ambulatory settings, the number of critical care beds available in the United States continues to rise. Growth in pharmacy student graduation, postgraduate year 2 critical care (PGY2 CC) residency programs, and positions has also increased. There is a perception that the critical care trained pharmacist market is saturated, yet this has not been evaluated since the rise in pharmacy graduates and residency programs. Purpose: To describe the current perception of critical care residency program directors (CC RPDs) and directors of pharmacy (DOPs) on the critical care pharmacist job market and to evaluate critical care postresidency placement and anticipated changes in PGY2 CC programs. Methods: Two electronic surveys were distributed from October 2015 to November 2015 through Vizient/University HealthSystem Consortium, American Society of Health-System Pharmacists (ASHP), Society of Critical Care Medicine, and American College of Clinical Pharmacy listservs to target 2 groups of respondents: CC RPDs and DOPs. Questions were based on the ASHP Pharmacy Forecast and the Pharmacy Workforce Center's Aggregate Demand Index and were intended to identify perceptions of the critical care market of the 2 groups. Results: Of 116 CC RPDs, there were 66 respondents (56.9% response rate). Respondents have observed an increase in applicants; however, they do not anticipate increasing the number of positions in the next 5 years. The overall perception is that there is a balance in supply and demand in the critical care trained pharmacist market. A total of 82 DOPs responded to the survey. Turnover of critical care pharmacists within respondent organizations is expected to be low. Although a majority of DOPs plan to expand residency training positions, only 9% expect to increase positions in critical care PGY2 training. Overall, DOP respondents indicated a balance of supply and demand in the critical care trained pharmacist market. In comparing RPD and DOP perceptions of the demand for critical care pharmacists, DOPs perceived demand to be higher than RPDs (mean, 3.2 vs 2.8; P = .032). Conclusion: Although there is a perception of the oversupply of critical care trained pharmacists, a survey of DOPs and CC RPDs found a market with positions available, rapid hiring, stable salaries, and plans for expanded hiring of critical care trained pharmacists.

Creation of a certification requirement for pharmacists in direct patient care roles.

PURPOSE: Steps taken by a large health system to require certification for all pharmacists in direct patient care roles are detailed. SUMMARY: Major supply chain changes and rising payer expectations are reshaping pharmacy practice, resulting in expanded responsibilities for pharmacists and a heightened need for certification in specialized practice areas. In response, the pharmacy leadership team at UW Health, the integrated health system of the University of Wisconsin-Madison, used an iterative process and a "rolling" FAQ format to develop and implement a certification requirement. Key decisions during the process included decisions to accept only rigorous certifications (mainly those offered by the Board of Pharmacy Specialties), to provide institutional support for continuing education-based recertification, and to use an accepted definition of direct patient care in determining which pharmacists need to be certified. The team obtained the support of the UW Health human relations department by drafting a policy and rewriting all pharmacist position descriptions to incorporate the certification requirement. An all-pharmacist forum was held to build staff commitment. As a result of the requirement, 73 pharmacists were required to obtain certification by 2018 at a total cost to UW Health of $44,000; ongoing support of certification maintenance will cost an estimated $40,000 per year. CONCLUSION: Health systems can be successful in establishing uniform certification expectations for pharmacists in direct patient care roles, even across diverse practice settings, by aligning expectations with organizational goals.

Single-Dose Basiliximab Induction in Low-Risk Renal Transplant Recipients.

OBJECTIVES: To compare the efficacy of a single dose of basiliximab with two doses in preventing acute rejection in selected low-risk renal transplant recipients. METHODS: This observational study of 760 kidney transplant recipients considered to be at low immunologic risk (peak panel reactive antibody less than 10%) compared patient and graft outcomes following a single-dose versus a two-dose regimen of basiliximab. MAIN RESULTS: No differences were found in patient survival (92% vs 92%, p=0.6), graft survival (86% vs 83%, p=0.2), acute rejection (cellular [4% vs 7%, p=0.2], antibody-mediated rejection [19% vs 19%, p=0.9]), or opportunistic infections (34% vs 30%, p=0.3) between the single versus two-dose regimens, respectively. In multivariate analyses, the number of doses of basiliximab was not associated with acute rejection or patient/graft survival despite adjustment with Cox regression and propensity scores. However, delayed graft function (DGF), donor age older than 65 years, and human leukocyte antigen mismatch of 3 or higher were associated with acute rejection (hazard ratio [HR] 2.64, 1.91, and 1.57, respectively, p≤0.04), and DGF and diabetes were associated with death/graft loss (HR 2.56 and 1.63, respectively, p≤0.009). PRINCIPAL CONCLUSIONS: A single dose of basiliximab is safe and effective for induction in low-risk kidney transplant recipients.

Antithymocyte globulin is associated with a lower incidence of de novo donor-specific antibodies in moderately sensitized renal transplant recipients.

BACKGROUND: Recent evidence suggests that de novo donor-specific antibodies (dnDSA) are associated with antibody-mediated rejection (ABMR) and graft failure after kidney transplantation. The effects of induction immunosuppression on dnDSA are unknown. METHODS: The study population comprised 114 consecutive moderately sensitized (positive DSA and negative flow crossmatch) recipients who received deceased donor renal transplants between December 2009 and November 2011. Patients were divided into two groups based on induction immunosuppression: antithymocyte globulin (ATG) (n=85) or basiliximab (n=29) and were followed up for 36 months. RESULTS: Patients in the ATG group received a mean dose of 4.98 mg/kg ± 7.9 mg/kg, had a significantly higher PRA, and received more plasmapheresis and IVIG at the time of transplant. The incidence of dnDSA (P=0.02, HR=0.33, 95% CI 0.09-1.24) and ABMR (P=0.002, HR=0.2, 95% CI 0.04-0.87) was significantly lower in the ATG group. In multivariate regression analyses, ATG induction was the single most important variable associated with both ABMR and dnDSA. CONCLUSIONS: In moderately sensitized deceased donor renal transplant recipients, induction with ATG is associated with a reduction in the occurrence of dnDSA and ABMR when compared with basiliximab.

Peripheral administration of antithymocyte globulins: a review of current literature.

Antithymocyte globulin (ATG) preparations are purified gamma-immune globulin products used for the prevention and treatment of transplant organ rejection. Manufacturer labeling recommends administration of the currently available ATG preparations (rabbit antithymocyte globulin and equine antithymocyte globulin) via a high-flow vein; typically this is achieved through a central line. The necessity of maintaining central-line access may delay or prevent the administration of these products and place patients at increased risk of morbidity. Currently, there is limited information on the peripheral administration of ATG preparations. However, data suggest that peripheral administration of ATG is both safe and well tolerated. Peripheral administration of ATG may allow for stable low-risk patients to transition to the outpatient setting, thereby, reducing costs and risks associated with hospitalization. This article reviews the available literature on the safety of peripheral administration of ATG preparations, the clinical considerations, and potential economic implications.