pharmacist assisting at routine medical discharge: project pharmd preeyaporn sarangarm, pharmd...
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Pharmacist Assisting at Routine Medical Discharge:
Project PhARMDPreeyaporn Sarangarm, PharmD
Stanley Snowden, PharmDLisa Koselke, PharmD
Thomas Dilworth, PharmDMatthew London, PharmD
Christian Sanchez, PharmD
1PGY1 Pharmacy Practice ResidentsUniversity of New Mexico Hospital
Background Approximately 20% of patients experience
an adverse event after discharge Up to 60% are medication related and
preventable Results in costly healthcare utilization
Pharmacist discharge counseling has shown mixed results in reducing health care utilization Hospital readmissions ED visits
2
Background The American College of Clinical
Pharmacists reviewed the literature between 2001 and 2005 surrounding clinical pharmacy services (CPSs) For every dollar spent on CPSs $4.81 was
saved No study has examined the cost-
effectiveness of an inpatient pharmacist discharge service
3Perez A et al. Pharmacotherapy. 2008;28(11): 285e-323e.
Background Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) July 2007 Inpatient Prospective Payment System (IPPS)
linked to compliance with HCAHPS Patient Protection and Affordable Care Act of 2010
HCAHPS will be one of the measures used to calculate Value-based incentive payments (October 2012) Value-based incentive purchasing
Patient perception has a significant effect on hospital income
Earnings of $4980 per bed linked to one point gain in satisfaction
Patients with higher satisfaction ratings of hospital services are less likely to enter into malpractice suits
4
Background When chronic disease states are treated
ineffectively, complications of the disease may lead to increased use of hospital, ED, and other medical resources
Medication non-adherence is related to greater morbidity and mortality in chronic disease Estimated to increase healthcare costs by over
$170 billion annually in this country Increased adherence has the potential to
generate medical savings that more than offset the associated increases in drug costs
5Benner J, et al. JAMA. 2002;288:455–61.O’Connor PJ. Arch Int Med. 2006;166:1802–4.Sokol MC, et al. Med Care. 2005;43:521–30.
Schlenk EA, et al. Futura Publishing Co; 2001:57–70.
Miller NH. Am J Med. 1997;102:43– 49.
Study Objective Primary Outcome: To evaluate the impact of
pharmacist discharge counseling on a combined endpoint of 30-day post-discharge hospital readmissions and ED visits
Secondary Outcomes: Determine predictors for readmission/ED visits Describe the number and type of interventions Conduct a cost-benefit analysis Improve patient satisfaction Increase primary medication adherence
6
Methods
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Methods: Study Design Single center, prospective intervention
study Number of patients
Historical hospital data: 30-day readmission rate: 12.3% 30-day ED visits: 13.0%
Excludes patients who were subsequently admitted
A priori power analysis: 292 patients in each study group 33% reduction in the combined endpoint Power=80%, α=0.05
8
Methods: Patient Selection Inclusion criteria:
Discharged from internal medicine service English or Spanish speaking
Exclusion criteria: Less than 18 years of age Unable or unwilling to receive counseling Discharged to anywhere other than home Planned readmission Previous inclusion into the study
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Methods: Flow of Patients
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Method: Discharge Services Prescription review
Medication reconciliation Completeness of prescriptions Duplicative, unnecessary or incomplete therapy Drug interactions Insurance coverage/ability to pick up
medications Counseling
Medication information and administration Side effects Disease state education
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Methods: Survey Distribution Upon completion of discharge counseling,
patients were given the anonymous English or Spanish survey
Patients were then left in their room to fill out the survey without the pharmacist present
Surveys were placed within the provided envelope by the patient and collected prior to the patient leaving the hospital
Patients unable or unwilling to complete the survey were not included in the analysis
12
Methods: Data Collection Upon discharge:
Patient demographics Admission information Number of prior readmissions Number of medications at discharge Pharmacist interventions and time spent
At 30 days post-discharge: Number of hospital readmissions or ED visits and
reason/diagnosis Medication fill history from the UNMH Outpatient Pharmacy for
UNM care patients Cost data:
Estimated patient charges for readmissions and ED visits Pharmacist salary plus benefits Converted charges to costs using UNMH cost to charge ratio
13
14
Methods: Intervention ClassificationDiscontinue drug Therapeutic duplication Medication without
indication Adverse drug reaction (ADR)
Add drug Untreated condition Prevent or treat ADR
Change drug Drug interaction Actual or potential ADR Reverse auto-substitution
Change dosing Incorrect or inappropriate Drug interaction Renal adjustment Hepatic adjustment
Allergies Allergy updated or clarified Allergy avoided
Incomplete prescription
Other
Bayley BK, et al. Ther Clin Risk Manag. 2007; 3:695-703.
Methods: Data Analysis Data was analyzed in SPSS (version 18)
Univariate analysis: Chi-square for categorical variables T-test for continuous variables
Multivariate analysis: Multiple logistic regression MANOVA
Nonparametric analysis: Mann-Whitney U test
15
Primary Outcome
Results: 30-day Readmission and ED visits
16
Study Recruitment and Flow
17
Demographics (n=279)
18*All values reported as n (%) unless specified otherwise
CharacteristicControl(n=139)
Intervention
(n=140)P-
value
Age, mean (SD), years 50.4 (16.5)
49.0 (15.8) 0.48
Male 81 (58.3) 75 (53.6) 0.43
Primary Language: English 129 (92.8)
121 (86.4) 0.08
EthnicityWhite, non-HispanicWhite, HispanicAfrican AmericanNative AmericanOther
43 (30.9)58 (41.7)
7 (5.0)25 (18.0)
6 (4.3)
46 (32.9)55 (39.3)12 (8.6)
16 (11.4)11 (7.8)
0.30
Marital StatusSingleMarriedSeparated/Divorced/Widower
79 (56.8)40 (28.8)20 (14.4)
90 (64.3)34 (24.3)16 (11.4)
0.23
Demographics (n=279)
19
CharacteristicControl(n=139)
Intervention
(n=140)P-
value
Current Primary Care Provider 80 (57.8) 84 (60.0) 0.68
InsurancePrivate InsurancePublic InsuranceCounty Provided Healthcare (UNM Care)
No Insurance
19 (13.7)76 (54.7)27 (19.4)17 (12.2)
17 (12.1)45 (32.1)42 (30.0)36 (25.7)
<0.001
Length of stay, mean (SD), days 6.1 (5.2) 7.3 (8.1) 0.14
Previous admission (within 1 year), mean (SD)
0.7 (1.5) 0.8 (1.6) 0.62
Charleson co-morbidity index score, mean (SD)
3.3 (2.9) 2.9 (2.8) 0.22
Distance from the hospital, mean (SD), miles
57.4 (94.0)
79.9 (229.0) 0.29*All values reported as n (%) unless specified otherwise
Intervention Group (n=140)
Declined(n=23)
16%
30-day Readmissions and ED Visits (Univariate Analysis)
Control(n=139)
N (%)
Intervention
(n=140)N (%)
P-value
Combined 30-day readmissions and ED visits30-day hospital readmission 30-day ED visits
24 (17.3)
16 (11.5)11 (7.9)
30 (21.4)
20 (14.3)17 (12.1)
0.34
0.490.24
Related readmission or ED visit
19/24 (79.2)
23/30 (76.7)
0.83
21
30-day Readmissions and ED Visits (Multivariate Analysis) Multivariate logistic regression
Adjusted for confounders that could potentially influence the outcome Factors in univariate analysis with p<0.1: sex
and insurance No difference in readmissions and ED visits
OR 1.25 (95%CI 0.67-2.34), p=0.48
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Conclusion: 30-day Readmissions and ED visits Pharmacist discharge counseling
services did not significantly improve 30-day hospital readmissions and ED visits
23
Secondary Outcome
Results: Predictors for Readmission and ED Visits
24
Risk Factors for Combined 30-day ED Visits and Readmissions
Risk factors
No readmission/ED visit
(n=225)
Readmission/ED visit
(n=54)P
value
Age, mean (SD), years 49.7 (15.8) 49.5 (17.5) 0.93
Primary care provider 132 (58.7) 32 (59.3) 0.94
Primary Language: English
202 (89.8) 48 (88.9) 0.85
Male 132 (58.7) 24 (44.4) 0.06
Insurance status Public Insurance UNM Care Private Insurance No Insurance
98 (43.6)54 (24)
30 (13.3)43 (19.1)
23 (42.6)15 (27.8)6 (11.1)
10 (18.5)
0.93
Marital statusMarriedSingleSeparated/DivorcedWidower
65 (28.9)135 (60)17 (7.6)8 (3.6)
9 (16.7)34 (63)7 (13)4 (7.4)
0.14
25*All values reported as n (%) unless specified otherwise
Risk Factors for Combined 30-day ED Visits and Readmissions
Risk factors
No readmission or ED visit(n=225)
Readmission or ED visit
(n=54)
P valu
e
EthnicityWhiteHispanicBlackNative AmericanOther
73 (32.4)84 (37.3)15 (6.7)
37 (16.4)16 (7.1)
16 (29.6)29 (53.7)
4 (7.4)4 (7.4)1 (1.9)
0.19
Distance from the hospital, mean (SD), miles
71.4 (186.14) 57.1 (120.98) 0.59
Length of hospital stay, mean (SD) 6.4 (6.35) 7.7 (8.48) 0.20
Previous hospital admissions, mean (SD)
0.6 (1.18) 1.3 (2.40) 0.002
Charlson comorbidity index, mean (SD)
2.9 (2.73) 3.5 (3.21) 0.19
Meds pre reconciliation, mean (SD) 5.3 (5.36) 6.8 (5.30) 0.17
Meds post reconciliation, mean (SD) 5.5 (5.21) 7.3 (5.06) 0.10
26*All values reported as n (%) unless specified otherwise
Multivariate RegressionLogistic regression for ED visits and readmissions within 30 days post-discharge
Risk factors OR 95% CI P value
Previous hospital admissions*NoYes
--1.26
--1.06-1.49
0.008
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*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1 (gender, previous hospitalization)
Multivariate Regression Readmissions within 30-daysRisk factors OR 95% CI P value
Length of stay* 1.06 1.01-1.12 0.015
ED visits within 30-daysRisk factors OR 95% CI P value
Previous hospital admissions*
1.23 1.01-1.48 0.035
Divorced* 5.67 1.42-22.66 0.014*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1
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Conclusion: Predictors Hospitalizations in the previous year was
a significant predictor for readmissions and ED visits
Divorce and previous hospital admissions were predictive of ED visits while length of hospital stay was predictive of readmissions
29
Secondary Outcome
Results: Interventions by Pharmacists
30
Intervention Group (n=140)
Number of Interventions by Type
#%
totalType of Intervention
66 33.3% Add drug: untreated condition
29 14.6% Change dosing: incorrect or inappropriate
23 11.6%Discontinue drug: medication without indication
19 9.6% Other intervention
15 7.6% Discontinue drug: therapeutic duplication
12 6.0% Incomplete prescription
12 6.0% Cost-savings or third party intervention
10 5.1%Add drug: prevent or treat adverse drug reaction
12 6.0% Cost-savings or third party intervention32
Number of Interventions by Type (cont.)
#%
totalType of Intervention
6 3.0% Change dosing: dosage form or route
4 2.0% Change dosing: renal adjustment
1 0.5% Change drug: drug interaction
1 0.5% Change drug: reverse auto-substitution
1 0.5% Allergy clarified or updated
0 0.0% Change dosing: hepatic adjustment
0 0.0% Change dosing: drug interaction
0 0.0% Allergy avoided
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Top Interventions By class:
Anti-infectives 17.79% Cardiovascular 15.95% Gastrointestinal 12.98% Endocrine 11.66%
By medication: Oxycodone: 7 interventions Docusate: 7 interventions Ciprofloxacin, clindamycin, insulin glargine,
lisinopril, sulfamethoxazole-trimethoprim: 4 interventions
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Intervention Acceptance Rate198 Total number of interventions attempted
- 13 Interventions not accepted
185 Total number of accepted interventions
93.4% Intervention acceptance rate
35
Unaccepted InterventionsIntervention #
unaccepted/total
% unaccepted
Add drug: Untreated condition
4/66 6.1%
Discontinue drug:Medication w/o indication
4/23 17.4%
Cost-savings/third-party 2/12 16.7%Change dosing: incorrect 1/29 3.4%Reverse auto-sub 1/1 0%Change dosing: renal 1/4 25%
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Predictors for Need for Intervention Multivariate logistic regression to identify
predictors for ≥ 1 pharmacist intervention
Age, sex, ethnicity, language, length of stay, previous admission in past year, having a primary care provider at admission, number of medications, and Charlson score were NOT predictors for intervention
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Conclusion: Interventions by Pharmacists Nearly 60% of patients discharge
prescriptions warranted some change by a pharmacist
Majority of interventions (93%) accepted and implemented by physician
No predictors for which patients needed most interventions Pharmacy discharge services beneficial to
all patients
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Secondary Outcome
Results: Cost-benefit Analysis
39
Cost-Benefit Analysis Net benefit = (CC- CI)
Benefit to cost ratio = (CC- CI)/C A ratio greater than 1.0 will demonstrate an
overall benefit of the intervention
CI = readmission and ED costs, intervention
CC = readmission and ED costs, control C = cost of pharmacist intervention
40
Mean Costs per PatientMean (SD) in
dollarsDifference in dollars
All patients Control (n=139)
Intervention
(n=140) (95% CI)
P valu
e
Combined readmissions and ED visits
$1,897.65 ($5,998.90
)
$2,859.39 ($10,194.9
7)
$961.74 (-$2,935.04 to $1,011.56)
0.34
Only patients who incurred cost
Control (n=24)
Intervention (n=30) (95% CI)
P valu
e
Combined readmissions and ED visits
$10,990.50 ($10,565.9
6)
$13,343.80 ($3,800.43)
$2,353.26 (-$10,981.23to $6,274.72)
0.59
41
Intervention Outlier Analysis
OutlierInterventionMean (SD)
Combined cost for readmissions and ED visits in patients who incurred cost
$98,042$13,343.80 ($3,800.43)
Initial Length of Stay (days)
56 7.3 (8.1)
42
Mean Costs per Patient Excluding Outlier
Mean (SD) in dollars
Difference in dollars
All patientsControl (n=139)
Intervention
(n=139) (95% CI)
P valu
e
Combined readmissions and ED visits
$1,897.65 ($5,998.90
)
$2,174.62 ($6,210.31)
$276.97 (-$1,718.71 to $1,164.77)
0.71
Only patients who incurred cost
Control (n=24)
Intervention (n=29) (95% CI)
P valu
e
Combined readmissions and ED visits
$10,990.54 ($10,565.9
6)
$10,423.17 ($10,051.7
7)
$567.37 (-$5,131.50 to $6,266.24)
0.84
43
Intervention Costs Total pharmacist time cost
Pharmacist cost plus benefits = $68.14 / hour
Total hours = 111.55 hrs Total cost = $7,601.02 Cost per patient
$7,601.02 / 140 patients = $54.93 / patient
44
Net Benefit AnalysisNet benefit per
patientBenefit to Cost
Ratio
All patients -$961.74 -17.5
All patients who incurred cost
-$2,353.26 -42.8
All patients who incurred cost
excluding outlier$567.37 10.3
45
Conclusion: Cost-benefit Analysis A pharmacist-run discharge service
consisting of medication reconciliation, patient counseling, and a follow up phone call did not reduce readmission and ED visit costs at UNMH A sub-analysis of only patients who incurred
cost with the exclusion of an outlier showed a positive benefit to cost ratio resulting from the intervention
46
Secondary Outcome
Results: Patient Satisfaction
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Survey Items1. Explanation of what your medications are for2. Explanation of how to take your medications3. Information the healthcare provider gave you about your
problem or condition4. Information the healthcare provider gave you about possible
medication side effects5. Overall rating of the information you received during discharge6. Knowledge of the healthcare provider who taught you7. Friendliness/courtesy of healthcare provider who taught you8. Answers provided by the healthcare provider to your questions9. Overall rating of the healthcare provider giving discharge
teaching
Likert response scale1=Very Bad, 2=Bad, 3=Fair, 4=Good, 5=Very Good
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Overall Response Rates
49
50
Overall Mean Response by Group
Type N
Mean of Summed Responses
(max score 45) tP
value
Control 76 40.37 -3.99
7
<0.0001Interventio
n97 43.14
51
Mean Rank by Group
Type NMean Rank
Sum of Ranks
P value
ControlIntervention
7697
72.3098.52
54959556
<0.0001
Response Means by Group
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Conclusion: Patient Satisfaction Overall pharmacist-run discharge counseling
services had higher satisfaction scores when compared to the usual discharge services provided at UNMH
The largest differences between groups were seen in Items 1, 2, 4 and 5 Item 1 Explanation of what your medications are
for Item 2 Explanation of how to take your medications Item 4 Information the healthcare provider gave
you about possible medication side effects Item 5 Overall rating of the information you
received during discharge53
Secondary Outcome
Results: Primary Medication Adherence
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Primary Medication Adherence Considered adherent if
Picked up medication within 30 days of discharge
If did not pick up within 30 days, still considered adherent if Supply of medication at home prior to hospitalization PRN medication
Rate of primary adherence Expressed as the number of prescriptions filled
divided by the total number of prescriptions written
55
UNM Care Patients
56
UNM Care Demographics (n=66)
CharacteristicControl (n=27)
Intervention (n=39)
P-value
Age, mean (SD), years 47.6 (16.8) 47.9 (13) 0.25
Male (%) 18 (66.7) 23 (59) 0.52
Primary Language: English (%)
26 (96.3) 33 (84.6) 0.13
Ethnicity (%)White, Non-Hispanic White, HispanicAfrican AmericanNative AmericanAsianOther
10 (37)13 (48.1)
2 (7.4)2 (7.4)0 (0)0 (0)
11 (28.2)18 (46.2)4 (10.3)2 (5.1)1 (2.6)3 (7.7)
0.63
Current Primary Care Provider (%)
15 (55.6) 27 (69.2) 0.2657
UNM Care Demographics (n=66)
CharacteristicControl (n=27)
Intervention (n=39)
P-value
Marital Status (%)Single MarriedDivorcedWidower
16 (59.3)6 (22.2)4 (14.8)1 (3.7)
26 (66.7)6 (15.4)6 (15.4)1 (2.6)
0.62
Length of Stay, days (SD) 6.04 (4.01) 9.49 (11.48) 0.09
Charlson Co-morbidity Index (%)No RiskMildModerateSevere
6 (22.2)9 (33.3)5 (18.5)7 (25.9)
10 (25.6)12 (30.8)12 (30.8)5 (12.8)
0.51
58
Ordered Discharge Prescriptions
CharacteristicControl (n=27)
Intervention (n=39)
P-value
Number of medications, mean (SD)
3.58 (1.84) 4.13 (2.4) 0.95
Number of scheduled medications, mean (SD)
3.04 (1.71) 3.49 (2.37) 0.41
Number of PRN medications,
mean (SD)
0.54 (0.76) 0.64 (0.87) 0.63
59
Primary Adherence by Therapeutic Class
60
Nu
mb
er
of
Rx’s
Primary Medication Adherence Rate
Control (n=27)
Intervention
(n=39)
Primary medication adherence rate (mean, %)
58.5 75.7
61
62
Mean Rank by Group
Type N Mean Rank Sum of Ranks
P value
ControlIntervention
2739
27.9636.36
7271418
0.05
Conclusion: Primary Medication Adherence Pharmacist discharge counseling
services yielded a higher primary medication adherence rate in intervention group Rates of primary adherence between
groups trending toward statistical significance
Intervention group primary adherence rate similar to that seen in literature for primary care
63
Discussion
64
Limitations Study underpowered to detect a difference
A priori power analysis not reflective of study population Low historical readmission rate
Excluded patients that would have potentially benefitted Discharged to outside facilities or left hospital prior to counseling
Discharge procedure not standardized between pharmacists Patients may have been readmitted to other hospitals Use of estimated costs rather than actual costs Pharmacist interventions were not associated with a cost-savings
value Only evaluated primary medication adherence for UNM Care
patients Patients could have filled at other pharmacies
Potential for selection bias with survey response Health literacy was not assessed No factor analysis conducted to validate survey items
65
Discussion Study highlighted areas for possible improvement in the
discharge process Pharmacist intervention earlier in hospital stay may improve
outcomes Patient counseling may have increased patient knowledge of
disease state(s) Identifying risk factors for hospital readmissions and ED
visits may: Identify patients that would benefit most from discharge
counseling Create more patient interaction opportunities for pharmacists
Patients satisfaction with the service is high Overall satisfaction rates were high with discharge services in
both groups Patients had higher satisfaction with discharge services when
pharmacist provided counseling in addition to the usual care
66
Future Research Additional studies need to be done to
assess Pharmacist impact on readmissions and ED
visits in a broader population Predictors for readmissions and ED visits in a
broader patient population More rigorous studies are needed to examine
the effects of pharmacist interventions on readmission and ED visit costs given previous studies demonstrating the cost-effectiveness of CPSs
67
Acknowledgements Gretchen Ray, PharmD, PhC, BCPS Richard D’Angio, PharmD, BCPS Residency Committee, University of New
Mexico Hospital and College of Pharmacy Peggy Beeley, MD Department of Internal Medicine,
University of New Mexico Hospital
68