Maury MED REC presentation 6.20.2014

“Care Transition Services: A pharmacy-driven program for medication reconciliation

through the continuum of care”

6/20/2014Florentina Eller

2015 PharmD CandidateMedication Reconciliation APPE Rotation

Study Background

• Medication errors• 22% during admissions• 66% during transition to or from the intensive care unit • 12% during discharge

~ 40% of medication errors can cause• Moderate to severe discomfort• Clinical deterioration

~ 50% of discharged patients suffered• ≥ 1 clinically important medication error• Within 30 day postdischarge

Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014

May 15;71(10):802-10. doi: 10.2146/ajhp130589

Causes of Postdischarge Medication Errors

• Nonadherence• Potential adverse drug events• Physician and system errors• Outpatient pharmacy discrepancies• Patient safety issues• Discharge medication confusion– Health literacy


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Why Pharmacist-Led Medication Reconciliation?

• Uniquely qualified• Formal training in obtaining medication histories• Extensive medication expertise

• Proven to obtain more accurate and comprehensive medication histories

• Most have training in both hospital and retail pharmacy settings

• Better understanding of diverse medication distribution systems


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Purpose of Study

• “To analyze an ongoing inpatient-focused, pharmacy-driven program—the Care Transitions Service (CTS)—and its impact on identifying and resolving medication-related problems (MRPs)

• To evaluate the implementation of a pilot extension of this service into the outpatient setting and its impact on MRP identification and resolution through the continuum of care”


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design

• Single-center descriptive study • University of New Mexico Hospital (UNMH) and an outpatient

UNMH family clinic

• Analyses of the inpatient service were conducted over a five-month period (November 2012–March 2013)

• Analyses of the outpatient service were conducted over a two-month period (January–February 2013)


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design: EligibilityInclusion criteria • Received medication reconciliation services from CTS during the

predefined study periods• At least 18 years of age and speak English or Spanish

Exclussion criteria• Lack of extensive medication history (at least three long-term medications)

or• Patient is scheduled for readmission• Has a previous admission within the last 14 days and already received CTS

services• Is unwilling to undergo a medication interview• Has been discharged to a skilled nursing facility, long-term care facility, or

prison Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014

May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design: Care Transition Service (CTS)

• An ongoing pharmacy-driven program • Provides

• 3 phases of inpatient services• 4th pilot phase of outpatient clinical services

• The outpatient extension offered to patients • Who received inpatient CTS services• Were scheduled for postdischarge outpatient family

clinic appointment• Were independently able to answer questions about

their medications


May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTS


May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTSPhase 1• Admission medication reconciliation (Med Rec)• In addition to other Med Rec performed by a nonpharmacist provider Phase 2• Discharge medication review • Hospital-to-community pharmacist handoff (obtaining consent from the

patient’s PCP to call the patient’s pharmacy and authorize discontinuation of any prescriptions no longer needed after hospital discharge)

Phase 3• Follow-up phone call within 72 hours of discharge• Assesses adherence and tolerance of discharge medications• Remind patients to take all medication bottles to their follow-up

appointmentPhase 4 (the pilot extension )• Outpatient Med Rec conducted by a pharmacist at the first postdischarge

appointment

CTS• Phases 1–3 conducted by CTS team:

• lead inpatient pharmacist• four PGY1 residents• and six APPE pharmacy students

• Phase 4 conducted by• a lead pharmacist • a PGY2 ambulatory care resident

• APPE students and PGY1 residents were provided extensive training to ensure consistency of CTS processes

• All members of the CTS team were responsible for identification and documentation of MRPs

• All documentation was summarized in a written clinical note and posted in an electronic medical record (EMR)

• APPE students were supervised by the PGY1 residents as MRPs were identified and documented

• Weekly quality checks were completed by the lead pharmacistConklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014

May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTS: Data CollectionMRPs• Identified and documented by a CTS member during the admission reconciliation

process• Classified only once• Outpatient MRPs were also documented

– medication continuance despite discontinuation orders at discharge – patient self-discontinuation of medications despite continuation orders at discharge– NVS (Newest Vital Sign) was assessed and recorded

Interventions• Performed independently of provider review • Based on protocols agreed on by the pharmacy department and inpatient family

medicine serviceCommunication with providers• Phone calls• Pages• Alerts in the EM


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Interventions and Recommendations


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Outcomes

Primary endpoint • To evaluate the numbers and types of MRPs identified by

pharmacists at hospital admission

Secondary endpoints• Inpatient services evaluation

– Medication classes most commonly associated with MRPs and patient-specific predictors of MRPs

• Outpatient services evaluation – Types and frequencies of new or persistent MRPs – From hospital discharge to the first follow-up appointment– Association of health literacy and MRPs


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Statistical Analysis

• Descriptive analyses – To characterize the types and rates of medication reconciliation

discrepancies between the inpatient and outpatient settings and the health literacy of CTS patients

• Univariate Poisson regression models – To determine variables that would be retained for testing in the

final model– With a priori level of significance of 0.2

• To prevent the elimination of variables too soon

• Multivariate Poisson regression model – With a priori level of significance of 0.05 – To determine patient-specific predictors of MRPs


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Patient Characteristics

Inpatient CTS sample (5 months evaluation)• 191 total patients received admission Med Rec (CTS

phase 1)• Mean age was 61 years, 48% were male• ~ 50% of patients were of Hispanic/Latino ethnicity, • ~50% received discharge medication review and

hospital-to-community pharmacist handoff (CTS phase 2)

• 24 % received a follow-up phone call (CTS phase 3)Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014

May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Patient Characteristics

Outpatient CTS sample ( 2 months pilot testing)• 30 were eligible for phase 4 of the CTS • 7 of the 30 patients failed to attend their scheduled postdischarge

appointment• 3 patients were ineligible for the service because they were unable

to independently answer questions • 1 patient deferred the service• Missed opportunity, due to external factors occurred in 3 patients• Only 16 patients received outpatient CTS services and were

included in the analysis• Those patients had a mean age of 57.8 years, 56% were male, and

50% were Hispanic/LatinoConklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014

May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Inpatients


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Outpatients


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Identified Medication Related Problems (MRPs)

Inpatient CTS sample• 1140 MRPs were identified during admission Med Rec• 6 MRPs per patient• 49% of MRPs due to:

– Patient variables: safety, appropriateness, effectiveness– Nonadherence

• Common medication classes associated with MRPs :– Cardiovascular agents (22%)– Gastrointestinal–genitourinary– Central nervous system (CNS)– Analgesic and endocrine–metabolic agents


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Identified MRPs

Outpatient CTS sample• 28 MRPs were identified with an average of 1.56 per patient• In 37.5% of patients a maximum of 3 MRPs were identified• In 18.8% no MRPs were identified• ~75% of the MRPs identified were related to patient variables

and nonadherence• In over 80% of patients, fewer MRPs were identified at the

follow-up appointment than had been identified during their admission to the hospital

• 86% of all postdischarge MRPs were newly identified MRPs, while 14% had persisted through the continuum of care


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Interventions


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Recommendations


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Predictor of Inpatient MRPs


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Predictor of Inpatient MRPs ( Cont.)


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Health Literacy and MRPs

• 69% of patients who completed the NVS health literacy assessment during the phase 4 outpatient service evaluation were found to have a high likelihood of limited health literacy (defined as NVS score of 0 or 1)

• 31% of patients were found to have adequate health literacy (an NVS score or 4 or 5)

• MRPs were identified in patients with limited health literacy as well as those with adequate health literacy ( small sample sizes limits the ability to make an association between high NVS scores and MRPs)


May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Limitations• Inability to classify MRPs based on potential to cause harm

due to short study duration

• The short duration of the study limits the ability to assess the clinical impact of identified MRPs on readmission rates or patient outcomes.

• The results might not apply to the majority of US hospitals because the CTS services are offered only to patients eligible for the UNMH inpatient family medicine services

• The results might not be reproducible due to inconsistencies in data collection associated with multiple staff pharmacists that offer CTS

• Recall biased from patients and caregivers during the Med Rec interview

Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health

Syst Pharm. 2014 May 15;71(10):802-10. doi: 10.2146/ajhp130589

Discussion and Conclusion• There is a need for a Med Rec pharmacist at admitting to take

a thorough history

• If staff shortages: target patients with cognitive, physical, financial constraints to improve adherence and reduce MRPs during hospital and 30 days post admitting

• Consider patients with transportation difficulties and cultural belief-barriers

• High risk patients for MRPs are those taking more than 3 medications, those receiving medications that require monitoring , have no insurance or have private insurance


May 15;71(10):802-10. doi: 10.2146/ajhp130589

ReferencesConklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014 May 15;71(10):802-10. doi: 10.2146/ajhp130589

Documents

Maury MED REC presentation 6.20.2014