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Tsilimingras D, Schnipper J, Zhang L, Levy P, Korzeniewski S, Paxton J. Adverse Events in Patients Transitioning From the Emergency Department to the Inpatient Setting. J Patient Saf 2024:01209203-990000000-00263. [PMID: 39324989 DOI: 10.1097/pts.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVES The objective of this study was to determine the incidence and types of adverse events (AEs), including preventable and ameliorable AEs, in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. METHODS This was a prospective cohort study of patients at risk for AEs in 2 urban academic hospitals from August 2020 to January 2022. Eighty-one eligible patients who were being admitted to any internal medicine or hospitalist service were recruited from the ED of these hospitals by a trained nurse. The nurse conducted a structured interview during admission and referred possible AEs for adjudication. Two blinded trained physicians using a previously established methodology adjudicated AEs. RESULTS Over 22% of 81 patients experienced AEs from the ED to the inpatient setting. The most common AEs were adverse drug events (42%), followed by management (38%), and diagnostic errors (21%). Of these AEs, 75% were considered preventable. Patients who stayed in the ED longer were more likely to experience an AE (adjusted odds ratio = 1.99, 95% confidence interval = 1.19-3.32, P = 0.01). CONCLUSIONS AEs were common for patients transitioning from the ED to the inpatient setting. Further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.
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Affiliation(s)
- Dennis Tsilimingras
- From the Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Jeffrey Schnipper
- Division of General Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Liying Zhang
- From the Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Steven Korzeniewski
- From the Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - James Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan
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Jasińska-Stroschein M, Waszyk-Nowaczyk M. Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists. J Clin Med 2023; 12:3037. [PMID: 37109373 PMCID: PMC10142526 DOI: 10.3390/jcm12083037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists. METHODS articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test. RESULTS a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.
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Affiliation(s)
| | - Magdalena Waszyk-Nowaczyk
- Pharmacy Practice Division, Chair and Department of Pharmaceutical Technology, Poznan University of Medical Sciences, 6 Grunwaldzka Street, 60-780 Poznan, Poland
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Zakeri MA, Tavan A, Nadimi AE, Bazmandegan G, Zakeri M, Sedri N. Relationship Between Health Literacy, Quality of Life, and Treatment Adherence in Patients with Acute Coronary Syndrome. Health Lit Res Pract 2023; 7:e71-e79. [PMID: 37053051 PMCID: PMC10104679 DOI: 10.3928/24748307-20230320-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Acute coronary syndrome is a significant global health concern that can affect patients' health outcomes and quality of life. In addition, adherence to treatment and health literacy can affect health outcomes. OBJECTIVE This study aimed to investigate the relationship between treatment adherence, health literacy, and quality of life among patients with acute coronary syndrome. METHODS This cross-sectional study was conducted on 407 patients in Iran from April 2019 to November 2019. Patients were selected by convenience sampling method. Data were collected using demographic questionnaire, World Health Organization Quality of Life Brief Version, Adherence to Treatment Questionnaire, and Health Literacy for Iranian Adults questionnaire. SPSS 25 was used for statistical analysis. RESULTS Based on descriptive statistics in this study, most of the participants had good treatment adherence level (56.5%); 28.7% of the participants had insufficient health literacy level. The mean score of quality of life was 51.41 ± 12.03, which was greater than the midpoint of the questionnaire. Furthermore, Pearson's correlation coefficient showed a negative association between health literacy, treatment adherence (r = -0.167, p < .01), and quality of life (r = -0.153, p < .01), and a positive association between treatment adherence and quality of life (r = 0.169, p < .01). CONCLUSION The results of the current study showed a negative relationship between health literacy, quality of life, and treatment adherence among patients with acute coronary syndrome. [HLRP: Health Literacy Research and Practice. 2023;7(2):e71-e79.].
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Affiliation(s)
| | | | | | | | | | - Nadia Sedri
- Address correspondence to Nadia Sedri, MSc, Nursing Research Center, Kerman University of Medical Sciences, Hapht Bagh St. 7616913555, Kerman, Iran;
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Althomali A, Altowairqi A, Alghamdi A, Alotaibi M, Althubaiti A, Alqurashi A, Harbi AA, Algarni MA, Haseeb A, Elnaem MH, Alsenani F, Elrggal ME. Impact of Clinical Pharmacist Intervention on Clinical Outcomes in the Critical Care Unit, Taif City, Saudi Arabia: A Retrospective Study. PHARMACY 2022; 10:pharmacy10050108. [PMID: 36136841 PMCID: PMC9498917 DOI: 10.3390/pharmacy10050108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Objectives: Clinical pharmacists are now playing a significant role in hospitals aiming to reduce medication errors, adverse drug reactions, and healthcare costs. Therefore, the main objective of this study was to assess the interventions provided by a clinical pharmacist in the intensive care unit at the King Faisal Hospital in Taif city. (2) Methods: For this single-center retrospective study, patients were included from December 2021 to May 2022. In the present study, all the interventions of clinical pharmacists made over six months were included. The Intensive care unit (ICU) ward was covered by three clinical pharmacists, and the interventions made were categorized into four groups: (1) interventions related to indications; (2) interventions regarding safety; (3) interventions regarding dosing, and (4) miscellaneous. Descriptive statistics was applied to evaluate the results in the form of frequencies and percentages. Analysis was performed using the statistical package SPSS 20.0. (3) Results: Overall, a total of 404 interventions were recommended for 165 patients during the six- month period of study. Among them, 370 interventions (91.5%) were accepted by physicians. Among all the interventions, the majority were suggested regarding ‘indication’ (45.7%), including the addition of drugs, drugs with no indications, and duplication. The acceptance rate of clinical pharmacist intervention was 98.5%. (4) Conclusions: This retrospective study shows that clinical pharmacists played a critical role in optimizing drug therapy which could subsequently help to prevent drug-related issues and lower drug costs. More research is needed to do a thorough cost-benefit analysis.
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Affiliation(s)
- Abdullah Althomali
- Ministry of Health, King Faisal Medical Complex, Taif 26514, Saudi Arabia
| | - Ahmed Altowairqi
- Ministry of Health, King Faisal Medical Complex, Taif 26514, Saudi Arabia
| | - Afnan Alghamdi
- Ministry of Health, King Faisal Medical Complex, Taif 26514, Saudi Arabia
| | - Musim Alotaibi
- Ministry of Health, King Faisal Medical Complex, Taif 26514, Saudi Arabia
| | | | | | - Adnan Al Harbi
- College of Pharmacy, Umm Al Qura University, Makkah 21955, Saudi Arabia
| | - Majed Ahmed Algarni
- Clinical Pharmacy Department, College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | - Abdul Haseeb
- College of Pharmacy, Umm Al Qura University, Makkah 21955, Saudi Arabia
| | - Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University, Kuantan 53100, Pahang, Malaysia
| | - Faisal Alsenani
- College of Pharmacy, Umm Al Qura University, Makkah 21955, Saudi Arabia
| | - Mahmoud E. Elrggal
- College of Pharmacy, Umm Al Qura University, Makkah 21955, Saudi Arabia
- Correspondence: or
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text. MAIN RESULTS We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants; low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence). AUTHORS' CONCLUSIONS A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.
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Affiliation(s)
- Daniela C Gonçalves-Bradley
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natasha A Lannin
- Brain Recovery and Rehabilitation Group, Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Lindy Clemson
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Sydney Medical School, Northern Clinical School, The University of Sydney, St Leonards, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Dalleur O, Beeler PE, Schnipper JL, Donzé J. 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events. J Patient Saf 2021; 17:e379-e386. [PMID: 28306610 DOI: 10.1097/pts.0000000000000346] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the patterns of potentially avoidable readmissions due to adverse drug events (ADEs) to identify the most appropriate risk reduction interventions. METHODS In this observational study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges from the medical department of an academic hospital. Readmissions due to ADEs were reviewed to identify the causative drugs and the severity and interventions to prevent them. RESULTS Seventy cases (13.1%) of readmission were partially or predominantly due to ADEs, of which, 58 (82.9%) were serious ADEs. Overall, 65 (92.9%) of the ADEs have been confirmed to be preventable. Inappropriate prescribing was identified as the cause of ADE in 34 cases (48.6%) mainly involving diuretics, analgesics, or antithrombotics: misprescribing n = 19 (27.1%), underprescribing n = 8 (11.4%), and overprescribing n = 7 (10.0%). The remaining half of preventable ADEs (n = 36; 51.4%) were related to suboptimal patient monitoring/education, such as adherence issues (n = 6; 8.6%) or lack of monitoring (n = 31; 44.3%). In 64 cases (91.4%), the readmission could have been potentially prevented by better monitoring for drug efficacy/disease control, or for predictable side effect. Thirty-three (97.1%) of the 34 ADEs due to inappropriate prescribing could have also been prevented by better monitoring. CONCLUSIONS Adverse drug events accounted for approximately 13% of 30-day preventable readmissions. A half were due to prescription errors involving mainly diuretics, analgesics, or antithrombotics, and the other half were due to suboptimal patient monitoring/education, most frequently with antineoplastics. Both these avoidable causes may represent opportunities to reduce the total drug-related adverse events.
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Choi JJ, Contractor JH, Shaw AL, Abdelghany Y, Frye J, Renzetti M, Smith E, Soiefer LR, Lu S, Kingery JR, Krishnan JK, Levine WJ, Safford MM, Shapiro MF. COVID-19-Related Circumstances for Hospital Readmissions: A Case Series From 2 New York City Hospitals. J Patient Saf 2021; 17:264-269. [PMID: 33852540 PMCID: PMC8131259 DOI: 10.1097/pts.0000000000000870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of the study was to determine the main factors contributing to hospital readmissions and their potential preventability after a coronavirus disease 2019 (COVID-19) hospitalization at 2 New York City hospitals. METHODS This was a retrospective study at 2 affiliated New York City hospitals located in the Upper East Side and Lower Manhattan neighborhoods. We performed case reviews using the Hospital Medicine Reengineering Network framework to determine potentially preventable readmissions among patients hospitalized for COVID-19 between March 3, 2020 (date of first case) and April 27, 2020, and readmitted to either of the 2 hospitals within 30 days of discharge. RESULTS Among 53 readmissions after hospitalization for COVID-19, 44 (83%) were deemed not preventable and 9 (17%) were potentially preventable. Nonpreventable readmissions were mostly due to disease progression or complications of COVID-19 (37/44, 84%). Main factors contributing to potentially preventable readmissions were issues with initial disposition (5/9, 56%), premature discharge (3/9, 33%), and inappropriate readmission (1/9, 11%) for someone who likely did not require rehospitalization. CONCLUSIONS Most readmissions after a COVID-19 hospitalization were not preventable and a consequence of the natural progression of the disease, specifically worsening dyspnea or hypoxemia. Some readmissions were potentially preventable, mostly because of issues with disposition that were directly related to challenges posed by the ongoing COVID-19 pandemic. Clinicians should be aware of challenges with disposition related to circumstances of the COVID-19 pandemic.
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Affiliation(s)
- Justin J. Choi
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Amy L. Shaw
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Jesse Frye
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Emily Smith
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Shuting Lu
- MD Program, Weill Cornell Medicine, New York, NY
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Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials. J Am Pharm Assoc (2003) 2021; 61:340-350.e5. [PMID: 33678564 DOI: 10.1016/j.japh.2021.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE(S) To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality. METHODS The initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model. RESULTS The participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant. CONCLUSION The evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.
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Lima MA, Duque AP, Rodrigues Junior LF, Lima VCS, Trotte LAC, Guimaraes TCF. Health literacy and quality of life in hospitalized heart failure patients: a cross-sectional study. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2020; 10:490-498. [PMID: 33224600 PMCID: PMC7675168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/10/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Heart Failure (HF) treatment may be improved by good knowledge of the disease (Health Literacy) that, despite the well-established role on improving self-care, preventing complications and avoiding worse outcomes, has little evidence on affecting QoL of HF patients. Therefore, the objective of the present study was to evaluate the impact of Health Literacy on QoL in hospitalized HF patients. METHODOLOGY A cross-sectional exploratory study was conducted with HF patients hospitalized at a public cardiological hospital. Health Literacy was assessed using the "Questionnaire about Heart Failure Patients' Knowledge of Disease" and QoL using the "Minnesota Living with Heart Failure Questionnaire" (MLHFQ). The association between Health Literacy and QoL was assessed by linear regression (P<0.05). RESULTS 50 patients were included in the study; the mean Health Literacy score was 34.2 ± 15.1 (the majority presenting acceptable or better knowledge). The mean MLHFQ score was 73.5 ± 19.8. The one-year hospital readmission rate (β=+3.8; P=0.009) and the patients' Health Literacy score (β=-0.4; P=0.024) or good knowledge category (β=-20.2; P=0.016) were independently associated with QoL. CONCLUSION While the readmission rate was inversely associated with QoL, the better the HF knowledge the better QoL in hospitalized HF patients.
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Affiliation(s)
- Marcone A Lima
- Education and Research Department, National Institute of CardiologyRio de Janeiro-RJ, Brazil
| | - Alice P Duque
- Education and Research Department, National Institute of CardiologyRio de Janeiro-RJ, Brazil
| | - Luiz F Rodrigues Junior
- Education and Research Department, National Institute of CardiologyRio de Janeiro-RJ, Brazil
- Department of Physiological Sciences, Federal University of The State of Rio de JaneiroRio de Janeiro-RJ, Brazil
| | - Viviani CS Lima
- Education and Research Department, National Institute of CardiologyRio de Janeiro-RJ, Brazil
| | - Liana AC Trotte
- Department of Nursing Methodology, Federal University of Rio de JaneiroRio de Janeiro-RJ, Brazil
| | - Tereza CF Guimaraes
- Education and Research Department, National Institute of CardiologyRio de Janeiro-RJ, Brazil
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Post-Discharge Adverse Events Among African American and Caucasian Patients of an Urban Community Hospital. J Racial Ethn Health Disparities 2020; 8:439-447. [PMID: 32557279 DOI: 10.1007/s40615-020-00800-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patient safety during the post-discharge period is a major public health concern. Racial differences on incidence and risk factors associated with post-discharge adverse events (AEs) are understudied. The aim of the study was to examine the differences on the incidence of post-discharge AEs and the associated risk factors between African American and Caucasian patients. METHODS This was a prospective cohort study of patients at risk for post-discharge AEs from December 2011 to October 2012. We included 589 patients who were African American or Caucasian and discharged home from an urban community hospital. The patients spoke English and could be contacted after discharge for evaluation. Two nurses performed 30-day post-discharge telephone interviews, and two physicians adjudicated health records to determine AEs using a previously established methodology. RESULTS African American patients had a slightly higher incidence of post-discharge AEs than Caucasian patients (30.6 vs. 29.9%), although the difference did not show statistical significance. The multivariable logistic regression model indicated that post-discharge AEs were associated with timely follow-up and the number of secondary discharge diagnoses. In subgroup analyses of the risk factors in each racial group separately, only timely follow-up ambulatory visits were associated with post-discharge AEs. CONCLUSION Post-discharge AEs were experienced by a large proportion of both African American and Caucasian patients, and there was no statistically significant difference in these proportions by race.
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Fernandes BD, Almeida PHRF, Foppa AA, Sousa CT, Ayres LR, Chemello C. Pharmacist-led medication reconciliation at patient discharge: A scoping review. Res Social Adm Pharm 2020; 16:605-613. [DOI: 10.1016/j.sapharm.2019.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 11/28/2022]
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Bagheri-Nesami M, Nikkhah A, Asgari S, Aghapoor S. The Effect of Telephone Follow-up on Lifestyle of Patients in Cardiac Care Units. JOURNAL OF RESEARCH DEVELOPMENT IN NURSING AND MIDWIFERY 2020. [DOI: 10.29252/jgbfnm.17.1.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Tobiano G, Chaboyer W, Teasdale T, Raleigh R, Manias E. Patient engagement in admission and discharge medication communication: A systematic mixed studies review. Int J Nurs Stud 2019; 95:87-102. [DOI: 10.1016/j.ijnurstu.2019.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/07/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022]
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Tsilimingras D, Zhang L, Chukmaitov A. Postdischarge Adverse Events Among Patients Who Received Home Health Care Services. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2019. [DOI: 10.1177/1084822319856004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adverse events that occur in urban and rural adults during the posthospitalization period have become a major public health concern. However, postdischarge adverse events for patients receiving home health care have been understudied. The objective of this study was to identify the prevalence and risk factors associated with postdischarge adverse events for patients who received home health care services. We analyzed data from a prospective cohort study that was conducted among patients who were hospitalized in the Tallahassee Memorial Hospital from December 2011 to October 2012. Telephone interviews were conducted by trained nurses who contacted patients within 4 weeks after discharge. Physicians reviewed cases with possible adverse events that were triaged by the nurses. The adverse events that were identified were categorized as preventable, ameliorable, and nonpreventable/nonameliorable. Nearly 39% of 85 patients who received home health care experienced postdischarge adverse events that were predominantly preventable or ameliorable. The associated risk factors were living alone (odds ratio [OR] = 7.860, p = .020), insured by Medicare or Medicaid (OR = 6.402, p = .048), type 2 diabetes mellitus (OR = 6.323, p = .004), pneumonia (OR = 5.504, p = .004), and other infections (OR = 4.618, p = .031). This study was able to identify that nearly one in every two patients who received home health care after hospital discharge experienced an adverse event. Patient safety research needs to focus in the home by developing specific interventions to avert adverse events and improve patient safety during the delivery of home health care services.
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Magnani JW, Mujahid MS, Aronow HD, Cené CW, Dickson VV, Havranek E, Morgenstern LB, Paasche-Orlow MK, Pollak A, Willey JZ. Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association. Circulation 2018; 138:e48-e74. [PMID: 29866648 PMCID: PMC6380187 DOI: 10.1161/cir.0000000000000579] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.
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Tsilimingras D, Ghosh S, Duke A, Zhang L, Carretta H, Schnipper J. The association of post-discharge adverse events with timely follow-up visits after hospital discharge. PLoS One 2017; 12:e0182669. [PMID: 28796810 PMCID: PMC5552135 DOI: 10.1371/journal.pone.0182669] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/16/2017] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE There has been little research to examine the association of post-discharge adverse events (AEs) with timely follow-up visits after hospital discharge. We aimed to examine whether having a timely follow-up outpatient visit would reduce the risk for post-discharge AEs. METHODS This was a methods study of patients at risk for post-discharge AEs from December 2011 through October 2012. Five hundred and forty-five patients who were under the care of hospitalist physicians and were discharged home from a community hospital, spoke English, and could be contacted after discharge were evaluated. The aim of the study was to examine the association of post-discharge AEs with timely follow-up visits after hospital discharge based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology. RESULTS We observed a higher incidence of AEs with patients that had their first follow-up visit within 7 days after hospital discharge (33.5% vs. 23.0%, p = 0.007). This effect was attenuated somewhat but remained significant when adjusted for several patient factors (adjusted OR 1.33, 95% confidence interval 1.16-2.71). CONCLUSION This observational study paradoxically showed an increase in post-discharge AEs with early follow-up, likely a result of confounding by indication and/or information bias that could not be completely adjusted for. This study illustrates the potential hazards with conducting observational studies to determine the efficacy of various transitional care interventions, such as early follow-up, where risk for confounding by indication is high.
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Affiliation(s)
- Dennis Tsilimingras
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Samiran Ghosh
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Ashley Duke
- Tallahassee Memorial Hospital, Tallahassee, Florida, United States of America
| | - Liying Zhang
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Henry Carretta
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, United States of America
| | - Jeffrey Schnipper
- Division of General Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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Predictors for unintentional medication reconciliation discrepancies in preadmission medication: a systematic review. Eur J Clin Pharmacol 2017; 73:1355-1377. [DOI: 10.1007/s00228-017-2308-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
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18
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Donzé JD, Lipsitz S, Schnipper JL. Risk Factors and Patterns of Potentially Avoidable Readmission in Patients With Cancer. J Oncol Pract 2017; 13:e68-e76. [DOI: 10.1200/jop.2016.011445] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Patients with cancer are particularly at risk for readmission within 30-days after discharge. To identify the patients who might benefit from more-intensive discharge interventions, we identified the risk factors associated with 30-day potentially avoidable readmissions. Methods and Materials: We included all consecutive discharges from the oncology division of an academic tertiary medical center in Boston, Massachusetts, between July 1, 2009, and June 30, 2010. Potentially avoidable 30-day readmissions to the index hospital and two other hospitals within its network were identified. We performed a multivariable logistic regression in which the final model included variables found in bivariable testing to be significantly associated with the outcome. Results: Among the 2,916 patients discharged during the study period, 1,086 (37.3%) were readmitted within 30 days. Of these, 341 (31.4% of all readmissions, 11.7% of all discharges) were identified as potentially avoidable. In the multivariable analysis, the following patient factors were associated with a significantly higher risk of a potentially avoidable readmission: total number of medications at discharge, liver disease, last sodium level, and last hemoglobin level before discharge. In addition, potentially avoidable readmissions occurred significantly earlier than unavoidable readmissions (median, 10 v 13 days; P < .001). Conclusion: Almost 40% of patients with cancer had a 30-day readmission, and almost one third of these were deemed potentially avoidable, and several risk factors for this were identified. Interventions at discharge may be prioritized to patients with these risk factors.
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Affiliation(s)
- Jacques D. Donzé
- Bern University Hospital, Bern, Switzerland; Brigham and Women’s Hospital; and Harvard Medical School, Boston, MA
| | - Stuart Lipsitz
- Bern University Hospital, Bern, Switzerland; Brigham and Women’s Hospital; and Harvard Medical School, Boston, MA
| | - Jeffrey L. Schnipper
- Bern University Hospital, Bern, Switzerland; Brigham and Women’s Hospital; and Harvard Medical School, Boston, MA
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Crockett BM, Jasiak KD, Walroth TA, Degenkolb KE, Stevens AC, Jung CM. Pharmacist Involvement in a Community Paramedicine Team. J Pharm Pract 2016; 30:223-228. [PMID: 27000138 DOI: 10.1177/0897190016631893] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital readmissions have recently gained scrutiny by health systems as a result of their high costs of care and potential for financial penalty in hospital reimbursement. Mobile-integrated health and community paramedicine (MIH-CP) programs have expanded to serve patients at high risk of hospital readmission. Pharmacists have also improved clinical outcomes for patients during in-home visits. However, pharmacists working with a MIH-CP program have not been previously described. This project utilized a novel multidisciplinary Community Paramedicine Team (CPT) consisting of a pharmacist, paramedic, and social worker to target patients with heart failure at high risk of readmission to assist with coordination of care and education. OBJECTIVES This article describes the development of the CPT, delineation of CPT member responsibilities, and outcomes from pilot visits. METHODS The CPT visited eligible patients in their homes to provide services. Patients with heart failure who were readmitted within 30 days were eligible for a home visit. RESULTS A total of 6 patients were seen during the pilot, and 2 additional patients were seen after the pilot. CONCLUSION Imbedding a pharmacist into a CPT provides a unique expansion of pharmacy services and a novel approach to address hospital readmissions.
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Affiliation(s)
- Baely M Crockett
- 1 Department of Pharmacy at Eskenazi Health, Indianapolis, IN, USA
| | - Karalea D Jasiak
- 1 Department of Pharmacy at Eskenazi Health, Indianapolis, IN, USA
| | - Todd A Walroth
- 1 Department of Pharmacy at Eskenazi Health, Indianapolis, IN, USA
| | | | - Andrew C Stevens
- 2 Indiana University Department of Emergency Medicine, Indianapolis, IN, USA.,3 Indianapolis Emergency Medical Services, Indianapolis, IN, USA
| | - Carolyn M Jung
- 1 Department of Pharmacy at Eskenazi Health, Indianapolis, IN, USA.,4 Butler University College of Pharmacy & Health Sciences, Department of Pharmacy Practice, Indianapolis, IN, USA
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Bell SP, Schnipper JL, Goggins K, Bian A, Shintani A, Roumie CL, Dalal AK, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Labonville SA, Johnson D, Neal EB, Kripalani S. Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial. J Gen Intern Med 2016; 31:470-7. [PMID: 26883526 PMCID: PMC4835388 DOI: 10.1007/s11606-016-3596-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. OBJECTIVE The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge. DESIGN Randomized, controlled trial with concealed allocation and blinded outcome assessors SETTING Two tertiary care academic medical centers PARTICIPANTS Adults hospitalized with a diagnosis of ACS and/or ADHF. INTERVENTION Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge MAIN MEASURES The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported. KEY RESULTS A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition. CONCLUSION A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.
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Affiliation(s)
- Susan P Bell
- Vanderbilt Center for Translational and Clinical Cardiovascular Research (VTRACC), Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Suite 300-A 2525 West End Avenue, Nashville, TN, 37232-8300, USA.
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN, USA.
| | - Jeffrey L Schnipper
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center, Nashville, TN, USA
| | - Anuj K Dalal
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Terry A Jacobson
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kimberly J Rask
- Department of Epidemiology, Rollins School of Public Health, and Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, and Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Stephanie A Labonville
- Department of Pharmacy Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Johnson
- Vanderbilt University, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin B Neal
- Vanderbilt University, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, Fletcher G, Ruhnke GW, Flanders SA, Kim C, Williams MV, Thomas L, Giang V, Herzig SJ, Patel K, Boscardin WJ, Robinson EJ, Schnipper JL. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med 2016; 176:484-93. [PMID: 26954564 PMCID: PMC6900926 DOI: 10.1001/jamainternmed.2015.7863] [Citation(s) in RCA: 258] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE Likelihood that a readmission could have been prevented. RESULTS The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%). CONCLUSIONS AND RELEVANCE Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.
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Affiliation(s)
- Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Sunil Kripalani
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Neil Sehgal
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Grant Fletcher
- Division of General Internal Medicine, Harborview Medical Center, Seattle, Washington
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Christopher Kim
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky College of Medicine, Louisville
| | - Larissa Thomas
- Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California
| | - Vernon Giang
- Department of Medicine, California Pacific Medical Center, San Francisco
| | - Shoshana J Herzig
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - W John Boscardin
- Department of Medicine, University of California, San Francisco15Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Edmondo J Robinson
- Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, Delaware
| | - Jeffrey L Schnipper
- Hospital Medicine Service, Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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García-Molina Sáez C, Urbieta Sanz E, Madrigal de Torres M, Vicente Vera T, Pérez Cárceles MD. Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study. J Clin Pharm Ther 2016; 41:203-8. [PMID: 26916590 DOI: 10.1111/jcpt.12365] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 01/25/2016] [Indexed: 01/01/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE It is well known that medication reconciliation at discharge is a key strategy to ensure proper drug prescription and the effectiveness and safety of any treatment. Different types of interventions to reduce reconciliation errors at discharge have been tested, many of which are based on the use of electronic tools as they are useful to optimize the medication reconciliation process. However, not all countries are progressing at the same speed in this task and not all tools are equally effective. So it is important to collate updated country-specific data in order to identify possible strategies for improvement in each particular region. Our aim therefore was to analyse the effectiveness of a computerized pharmaceutical intervention to reduce reconciliation errors at discharge in Spain. METHODS A quasi-experimental interrupted time-series study was carried out in the cardio-pneumology unit of a general hospital from February to April 2013. The study consisted of three phases: pre-intervention, intervention and post-intervention, each involving 23 days of observations. At the intervention period, a pharmacist was included in the medical team and entered the patient's pre-admission medication in a computerized tool integrated into the electronic clinical history of the patient. The effectiveness was evaluated by the differences between the mean percentages of reconciliation errors in each period using a Mann-Whitney U test accompanied by Bonferroni correction, eliminating autocorrelation of the data by first using an ARIMA analysis. In addition, the types of error identified and their potential seriousness were analysed. RESULTS AND DISCUSSION A total of 321 patients (119, 105 and 97 in each phase, respectively) were included in the study. For the 3966 medicaments recorded, 1087 reconciliation errors were identified in 77·9% of the patients. The mean percentage of reconciliation errors per patient in the first period of the study was 42·18%, falling to 19·82% during the intervention period (P = 0·000). When the intervention was withdrawn, the mean percentage of reconciliation errors increased again to 27·72% (P = 0·008). The difference between the percentages of pre- and post-intervention periods was statistically significant (P = 0·000). Most reconciliation errors were due to omission (46·7%) or incomplete prescription (43·8%), and 35·3% of which could have caused harm to the patient. WHAT IS NEW AND CONCLUSION A computerized pharmaceutical intervention is shown to reduce reconciliation errors in the context of a high incidence of such errors.
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Affiliation(s)
| | - E Urbieta Sanz
- Department of Hospital Pharmacy, Queen Sofia Hospital, Murcia, Spain
| | | | - T Vicente Vera
- Department of Cardiology, Queen Sofia Hospital, Murcia, Spain
| | - M D Pérez Cárceles
- Department of Legal Medicine, Regional Campus of International Excellence 'Campus Mare Nostrum', School of Medicine, University of Murcia, Murcia, Spain
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Zhai XB, Gu ZC, Liu XY. Effectiveness of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: a propensity score-matched analysis. Ther Clin Risk Manag 2016; 12:241-50. [PMID: 26937196 PMCID: PMC4762444 DOI: 10.2147/tcrm.s98300] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pharmacist-led medication review services have been assessed in the meta-analyses in hospital. Of the 135 relevant articles located, 21 studies met the inclusion criteria; however, there was no statistically significant difference found between pharmacists’ interventions and usual care for mortality (odds ratio 1.50, 95% confidence interval 0.65, 3.46, P=0.34). These analyses may not have found a statistically significant effect because they did not adequately control the wide variation in the delivery of care and patient selection parameters. Additionally, the investigators did not conduct research on the cases of death specifically and did not identify all possible drug-related problems (DRPs) that could cause or contribute to mortality and then convince physicians to correct. So there will be a condition to use a more precise approach to evaluate the effect of clinical pharmacist interventions on the mortality rates of hospitalized cardiac patients. Objective To evaluate the impact of the clinical pharmacist as a direct patient-care team member on the mortality of all patients admitted to the cardiology unit. Methods A comparative study was conducted in a cardiology unit of a university-affiliated hospital. The clinical pharmacists did not perform any intervention associated with improper use of medications during Phase I (preintervention) and consulted with the physicians to address the DRPs during Phase II (postintervention). The two phases were compared to evaluate the outcome, and propensity score (PS) matching was applied to enhance the comparability. The primary endpoint of the study was the composite of all-cause mortality during Phase I and Phase II. Results Pharmacists were consulted by the physicians to correct any drug-related issues that they suspected may cause or contribute to a fatal outcome in the cardiology ward. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92.0%) of them were accepted by the cardiology team, and violation of incompatibilities had the highest percentage of acceptance by the cardiology team. All-cause mortality was 1.5% during Phase I (preintervention) and was reduced to 0.9% during Phase II (postintervention), and the difference was statistically significant (P=0.0005). After PS matching, all-cause mortality changed from 1.7% during Phase I down to 1.0% during Phase II, and the difference was also statistically significant (P=0.0074). Conclusion DRPs that were suspected to cause or contribute to a possibly fatal outcome were determined by clinical pharmacist service in patients hospitalized in a cardiology ward. Correction of these DRPs by physicians after pharmacist’s advice caused a significant decrease in mortality as analyzed by PS matching. The significant reduction in the mortality rate in this patient population observed in this study is “hypothesis generating” for future randomized studies.
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Affiliation(s)
- Xiao-Bo Zhai
- Department of Pharmacy, Shanghai East Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiao-Yan Liu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.
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Affiliation(s)
| | - Natasha A Lannin
- Alfred HealthOccupational TherapyThe Alfred55 Commercial RoadPrahranVictoriaAustralia3004
| | - Lindy M Clemson
- University of SydneyFaculty of Health SciencesJ005, East St. LidcombeLidcombeNSWAustralia1825
| | - Ian D Cameron
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchSt LeonardsNSWAustralia2065
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthOxfordUK
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25
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Wiener ES, Mullins CD, Pincus KJ. A framework for pharmacist-assisted medication adherence in hard-to-reach patients. Res Social Adm Pharm 2015; 11:595-601. [DOI: 10.1016/j.sapharm.2014.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 11/30/2014] [Indexed: 11/17/2022]
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Post-Discharge Adverse Events Among Urban and Rural Patients of an Urban Community Hospital: A Prospective Cohort Study. J Gen Intern Med 2015; 30:1164-71. [PMID: 25822112 PMCID: PMC4510218 DOI: 10.1007/s11606-015-3260-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/05/2015] [Accepted: 02/18/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND There has been little research to examine post-discharge adverse events (AEs) in rural patients discharged from community hospitals. OBJECTIVE We aimed to determine the rate of post-discharge AEs, classify the types of post-discharge AEs, and identify risk factors for post-discharge AEs in urban and rural patients. DESIGN This was a prospective cohort study of patients at risk for post-discharge adverse events from December 2011 through October 2012. PATIENTS Six hundred and eighty-four patients who were under the care of hospitalist physicians and were being discharged home, spoke English, and could be contacted after discharge, were admitted to the medical service. Patients were stratified as urban/rural using zip code of residence. Rural patients were oversampled to ensure equal enrollment of urban and rural patients. MAIN MEASURES The main outcome of the study was post-discharge AEs based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology. RESULTS Over 28% of 684 patients experienced post-discharge AEs, most of which were either preventable or ameliorable. There was no difference in the incidence of post-discharge AEs in urban versus rural patients (ARR 1.04 95% CI 0.82-1.32 ), but post-discharge AEs were associated with hypertension, type 2 diabetes mellitus, and number of secondary discharge diagnoses only in urban patients. CONCLUSIONS Post-discharge AEs were common in both urban and rural patients and many were preventable or ameliorable. Potentially different risk factors for AEs in urban versus rural patients suggests the need for further research into the underlying causes. Different interventions may be required in urban versus rural patients to improve patient safety during transitions in care.
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Conn VS, Ruppar TM, Chan KC, Dunbar-Jacob J, Pepper GA, De Geest S. Packaging interventions to increase medication adherence: systematic review and meta-analysis. Curr Med Res Opin 2015; 31:145-60. [PMID: 25333709 PMCID: PMC4562676 DOI: 10.1185/03007995.2014.978939] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. RESEARCH DESIGN AND METHODS Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. RESULTS Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. CONCLUSIONS Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.
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Flynn AJ, Klasnja P, Friedman CP. MedMinify: An Advice-giving System for Simplifying the Schedules of Daily Home Medication Regimens Used to Treat Chronic Conditions. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2014; 2014:1728-1737. [PMID: 25954445 PMCID: PMC4420013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
For those with high blood pressure, diabetes, or high cholesterol, adherence to a home medication regimen is important for health. Reductions in the number of daily medication-taking events or daily pill burden improve adherence. A novel advice-giving computer application was developed using the SMART platform to generate advice on how to potentially simplify home medication regimens. MedMinify generated advice for 41.3% of 1,500 home medication regimens for adults age 60 years and older with chronic medical conditions. If the advice given by MedMinify were implemented, 320 regimen changes would have reduced daily medication-taking events while an additional 295 changes would have decreased the daily pill burden. The application identified four serious drug-drug interactions and so advised against taking two pairs of medications simultaneously. MedMinify can give advice to change home medication regimens that could result in simpler home medication-taking schedules.
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Affiliation(s)
- Allen J Flynn
- School of Information, University of Michigan, Ann Arbor, MI
| | - Predrag Klasnja
- School of Information, University of Michigan, Ann Arbor, MI
| | - Charles P Friedman
- School of Information, University of Michigan, Ann Arbor, MI ; School of Public Health, University of Michigan, Ann Arbor, MI
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Anderson K, Willmore C, Doran E, Oki N, Vonnahme J, Gates BJ. Cognitive and Literacy Screening as Predictors of Ability to Fill a Pillbox Using Two Pillbox Assessment Scoring Methods. ACTA ACUST UNITED AC 2014; 29:304-16. [DOI: 10.4140/tcp.n.2014.304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Donzé J, Lipsitz S, Schnipper JL. Risk factors for potentially avoidable readmissions due to end-of-life care issues. J Hosp Med 2014; 9:310-4. [PMID: 24532224 DOI: 10.1002/jhm.2173] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/23/2014] [Accepted: 01/28/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Repeated hospitalizations are frequent toward the end of life, where each admission should be an opportunity to initiate advance-care planning to high-risk patients. OBJECTIVE To identify the risk factors for having a 30-day potentially avoidable readmission due to end-of-life care issues among all medical patients. DESIGN Nested case-control study. SETTING/PATIENTS All 10,275 consecutive discharges from any medical service of an academic tertiary medical center in Boston, Massachusetts between July 1, 2009 and June 30, 2010. MEASUREMENTS A random sample of all the potentially avoidable 30-day readmissions was independently reviewed by 9 trained physicians to identify the ones due to end-of-life issues. RESULTS Among 534, 30-day potentially avoidable readmission cases reviewed, 80 (15%) were due to an end-of-life care issue. In multivariable analysis, the following risk factors were significantly associated with a 30-day potentially avoidable readmission due to end-of-life care issues: number of admissions in the previous 12 months (odds ratio [OR]: 1.10 per admission, 95% confidence interval [CI]: 1.02-1.20), neoplasm (OR: 5.60, 95% CI: 2.85-10.98), opiate medications at discharge (OR: 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index (OR: 1.16 per 5-point increase, 95% CI: 1.10-1.22). The discrimination of the model (C statistic) was 0.85. CONCLUSIONS In a medical population, we identified 4 main risk factors that were significantly associated with 30-day potentially avoidable readmission due to end-of-life care issues, producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end-of-life care and possibly reduce unnecessary rehospitalizations.
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Affiliation(s)
- Jacques Donzé
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Auerbach AD, Patel MS, Metlay JP, Schnipper JL, Williams MV, Robinson EJ, Kripalani S, Lindenauer PK. The Hospital Medicine Reengineering Network (HOMERuN): a learning organization focused on improving hospital care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:415-20. [PMID: 24448050 PMCID: PMC4876026 DOI: 10.1097/acm.0000000000000139] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Converting the health care delivery system into a learning organization is a key strategy for improving health outcomes. Although the collaborative learning organization approach has been successful in neonatal intensive care units and disease-specific collaboratives, there are few examples in general medicine and none in adult medicine that have leveraged the role of hospitalists nationally across multiple institutions to implement improvements. The authors describe the rationale for and early work of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011 that seeks to measure, benchmark, and improve the efficiency, quality, and outcomes of care in the hospital and afterwards. Robust and timely evaluation, with learning and refinement of approaches across institutions, should accelerate improvement efforts. The authors review HOMERuN's collaborative model, which focuses on a community-based participatory approach modified to include hospital-based staff as well as the larger community. HOMERuN's initial project is described, focusing on care transition measurement using perspectives from the patient, caregiver, and providers. Next steps and sustainability of the organization are discussed, including benchmarking, collaboration, and effective dissemination of best practices to stakeholders.
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Affiliation(s)
- Andrew D Auerbach
- Dr. Auerbach is professor of medicine, University of California, San Francisco Division of Hospital Medicine, San Francisco, California. Dr. Patel is resident physician, Perelman School of Medicine, University of Pennsylvania, Section of Hospital Medicine, Philadelphia, Pennsylvania. Dr. Metlay is professor of medicine, Perelman School of Medicine, University of Pennsylvania, Section of Hospital Medicine, Philadelphia, Pennsylvania. Dr. Schnipper is associate professor of medicine, Division of General Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts. Dr. Williams is professor of medicine, Northwestern University Feinberg School of Medicine, Division of Hospital Medicine, Chicago, Illinois. Dr. Robinson is physician in chief and associate chief medical officer, Christiana Care Health System, Wilmington, Delaware. Dr. Kripalani is associate professor, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee. Dr. Lindenauer is associate professor of medicine, Tufts University School of Medicine, Boston, Massachusetts, and director, Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
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Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ 2013; 347:f7171. [PMID: 24342737 PMCID: PMC3898702 DOI: 10.1136/bmj.f7171] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the primary diagnoses and patterns of 30 day readmissions and potentially avoidable readmissions in medical patients with each of the most common comorbidities. DESIGN Retrospective cohort study. SETTING Academic tertiary medical centre in Boston, 2009-10. PARTICIPANTS 10,731 consecutive adult discharges from a medical department. MAIN OUTCOME MEASURES Primary readmission diagnoses of readmissions within 30 days of discharge and potentially avoidable 30 day readmissions to the index hospital or two other hospitals in its network. RESULTS Among 10,731 discharges, 2398 (22.3%) were followed by a 30 day readmission, of which 858 (8.0%) were identified as potentially avoidable. Overall, infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder were the most frequent primary diagnoses of potentially avoidable readmissions. Almost all of the top five diagnoses of potentially avoidable readmissions for each comorbidity were possible direct or indirect complications of that comorbidity. In patients with a comorbidity of heart failure, diabetes, ischemic heart disease, atrial fibrillation, or chronic kidney disease, the most common diagnosis of potentially avoidable readmission was acute heart failure. Patients with neoplasm, heart failure, and chronic kidney disease had a higher risk of potentially avoidable readmissions than did those without those comorbidities. CONCLUSIONS The five most common primary diagnoses of potentially avoidable readmissions were usually possible complications of an underlying comorbidity. Post-discharge care should focus attention not just on the primary index admission diagnosis but also on the comorbidities patients have.
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Affiliation(s)
- Jacques Donzé
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA
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Burke RE, Donzé J, Schnipper JL. Contribution of psychiatric illness and substance abuse to 30-day readmission risk. J Hosp Med 2013; 8:450-5. [PMID: 23589474 DOI: 10.1002/jhm.2044] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/27/2013] [Accepted: 03/07/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about the contribution of psychiatric illness to medical 30-day readmission risk. OBJECTIVE To determine the independent contribution of psychiatric illness and substance abuse to all-cause and potentially avoidable 30-day readmissions in medical patients. DESIGN Retrospective cohort study. SETTING Patients discharged from the medicine services at a large teaching hospital from July 1, 2009 to June 30, 2010. MEASUREMENTS The main outcome of interest was 30-day all-cause and potentially avoidable readmissions; the latter determined by a validated algorithm (SQLape) in both bivariate and multivariate analysis. Readmissions were captured at 3 hospitals where the majority of these patients are readmitted. RESULTS Of 6987 discharged patients, 1260 were readmitted within 30 days (18.0%); 388 readmissions were potentially avoidable (5.6%). In multivariate analysis, 2 or more prescribed outpatient psychiatric medications (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.01-1.20) or any prescription of anxiolytics (OR: 1.16, 95% CI: 1.00-1.35) were associated with increased all-cause readmissions, whereas discharge diagnoses of anxiety (OR: 0.82, 95% CI: 0.68-0.99) or substance abuse (OR: 0.80, 96% CI: 0.65-0.99) were associated with fewer all-cause readmissions. These findings were not replicated as predictors of potentially avoidable readmissions; rather, patients with discharge diagnoses of depression (OR: 1.49, 95% CI: 1.09-2.04) and schizophrenia (OR: 2.63, 95% CI: 1.13-6.13) were at highest risk. CONCLUSIONS Our data suggest that patients treated during a hospitalization for depression and for schizophrenia are at higher risk for potentially avoidable 30-day readmissions, whereas those prescribed more psychiatric medications as outpatients are at increased risk for all-cause readmissions. These populations may represent fruitful targets for interventions to reduce readmission risk.
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Affiliation(s)
- Robert E Burke
- Hospital Medicine Section, Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, CO 80220, USA.
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Shah NS, Huffman MD, Ning H, Lloyd-Jones DM. Trends in vascular risk factor treatment and control in US stroke survivors: the National Health and Nutrition Examination Surveys (1999-2010). Circ Cardiovasc Qual Outcomes 2013; 6:270-7. [PMID: 23652733 PMCID: PMC10084945 DOI: 10.1161/circoutcomes.113.000112] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 03/14/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Treatment and control of vascular risk factors reduce the likelihood of recurrent stroke. Present nationally representative data are sparse regarding secondary prevention treatment and control rates. METHODS AND RESULTS We evaluated sex- and race-stratified blood pressure, cholesterol, and hemoglobin A1c levels and treatment and control rates in 1154 self-reported stroke survivors from the National Health and Nutrition Examination Surveys 1999 to 2010. We used weighted linear regression to estimate time trends. Participants were 54% to 61% women, 70% to 76% white, and had a mean age of 63 to 66 years. For blood pressure, treatment rates remained unchanged in men, but in women, treatment rates increased from 41% in 1999 to 2000 to 65% in 2009 to 2010 (P=0.03), and control rates increased from 23% to 79% (P=0.03). Treatment rates remained unchanged in non-Hispanic whites, non-Hispanic blacks, and Mexican Americans, although control rates increased in non-Hispanic whites from 50% in 1999 to 2002 to 69% in 2007 to 2010 (P=0.04). For cholesterol, treatment rates increased from 30% to 40% in men (P=0.02) and from 28% to 36% (P<0.01) in women, but control rates increased only in men, from 62% to 87% (P<0.01). Cholesterol treatment rates increased only in non-Hispanic blacks, from 18% to 37% (P=0.02). By sex and race, there was no change in dysglycemia treatment and control. CONCLUSIONS Despite improvements in blood pressure treatment and control and cholesterol treatment for women and cholesterol treatment and control for men, stroke secondary prevention through treatment and control of vascular risk factors remains suboptimal. Urgent action is needed to improve secondary prevention to reduce stroke morbidity and mortality in this high-risk group.
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Affiliation(s)
- Nilay S Shah
- Northwestern University Feinberg School of Medicine, Department of Preventive Medicine, Chicago, IL 60611, USA
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Mueller SK, Donzé J, Schnipper JL. Intern workload and discontinuity of care on 30-day readmission. Am J Med 2013; 126:81-8. [PMID: 23260505 DOI: 10.1016/j.amjmed.2012.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 09/27/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Stephanie K Mueller
- BWH Hospitalist Service and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Kirwin J, Canales AE, Bentley ML, Bungay K, Chan T, Dobson E, Holder RM, Johnson D, Lilliston A, Mohammad RA, Spinler SA. Process indicators of quality clinical pharmacy services during transitions of care. Pharmacotherapy 2012; 32:e338-47. [PMID: 23108762 DOI: 10.1002/phar.1214] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The American College of Clinical Pharmacy charged the Public and Professional Relations Committee to develop a short white paper describing quality measures of clinical pharmacists' patient care services in transitional care settings. Transitional care describes patient movement from one health care setting or service to another. Care transitions are associated with an increased risk of adverse events for patients. Pharmacists play an important role in ensuring that medication errors and adverse events are minimized during these transitions, largely through the reconciliation of medications and assurance of continuity of care. Quality measures are often divided into three domains: structure, process, and outcome. Given the typical nature of the pharmacist's role, process indicators are best suited to evaluate quality clinical pharmacist services. However, process indicators relevant to pharmacists' activities are not yet fully described in the literature. The committee searched available literature describing quality measures that are directly influenced by the pharmacist during care transitions. This white paper describes these process indicators as quality measures of clinical pharmacists' services, identifies the transitional settings and activities to which they are most applicable, and provides the published sources from which indicators were derived. For process indicators that could not be found in published sources, we propose relevant measures that can be adapted for use in a given setting. As pharmacists become more involved in diverse and emerging patient care areas such as transitional care, it will be critical that they use these types of measures to document the quality of new services and reinforce the need for pharmacist participation during transitions of care.
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Affiliation(s)
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- American College of Clinical Pharmacy, Lenexa, Kansas 66215, USA.
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Haynes KT, Oberne A, Cawthon C, Kripalani S. Pharmacists' recommendations to improve care transitions. Ann Pharmacother 2012; 46:1152-9. [PMID: 22872752 DOI: 10.1345/aph.1q641] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Increasingly, hospitals are implementing multifaceted programs to improve medication reconciliation and transitions of care, often involving pharmacists. OBJECTIVE To assess pharmacists' views on their roles in hospital-based medication reconciliation and discharge counseling and provide their recommendations for improving care transitions. METHODS Eleven study pharmacists at 2 hospitals participated in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study and completed semistructured one-on-one interviews, which were coded systematically in NVivo. Pharmacists provided their perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (eg, pill box, illustrated daily medication schedule), and telephone follow-up. RESULTS Pharmacists indicated that they considered medication reconciliation, although time consuming, to be their most important role in improving care transitions, particularly through detection of errors that required correction in the admission medication history. They also identified patients who required additional counseling because of poor understanding of their medications. Providing adherence aids was felt to be highly valuable for patients with low health literacy, although less useful for patients with adequate health literacy. Pharmacists noted that having trained administrative staff conduct initial postdischarge follow-up calls to screen for issues and triage which patients needed pharmacist follow-up was helpful and an efficient use of resources. Pharmacists' recommendations for improving care transitions included clear communication among team members, protected time for discharge counseling, patient and family engagement in discharge counseling, and provision of patient education materials. CONCLUSIONS Pharmacists are well positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care. Additional studies are needed to confirm these findings in other settings and to determine the efficacy and cost-effectiveness of different models of pharmacist involvement.
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Affiliation(s)
- Katherine Taylor Haynes
- Department of Leadership, Policy and Organizations, Peabody College of Education and Human Development, Vanderbilt University, Nashville, TN, USA
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Salanitro AH, Osborn CY, Schnipper JL, Roumie CL, Labonville S, Johnson DC, Neal E, Cawthon C, Businger A, Dalal AK, Kripalani S. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intern Med 2012; 27:924-32. [PMID: 22350761 PMCID: PMC3403136 DOI: 10.1007/s11606-012-2003-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 01/13/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). CONCLUSIONS Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.
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Affiliation(s)
- Amanda H Salanitro
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, TN, USA.
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Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, Shintani A, Sponsler KC, Harris LJ, Theobald C, Huang RL, Scheurer D, Hunt S, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Bates DW, Williams MV, Schnipper JL. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med 2012; 157:1-10. [PMID: 22751755 PMCID: PMC3575734 DOI: 10.7326/0003-4819-157-1-201207030-00003] [Citation(s) in RCA: 210] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). OBJECTIVE To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. DESIGN Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021) SETTING Two tertiary care academic hospitals. PATIENTS Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. INTERVENTION Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. MEASUREMENTS The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. RESULTS Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). LIMITATION The characteristics of the study hospitals and participants may limit generalizability. CONCLUSION Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Sunil Kripalani
- Department of Medicine, Vanderbilt University, 1215 21st Avenue South, Suite 6000 Medical Center East, Nashville, TN 37232, USA.
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Cohen MJ, Shaykevich S, Cawthon C, Kripalani S, Paasche-Orlow MK, Schnipper JL. Predictors of medication adherence postdischarge: the impact of patient age, insurance status, and prior adherence. J Hosp Med 2012; 7:470-5. [PMID: 22473754 PMCID: PMC3575732 DOI: 10.1002/jhm.1940] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/04/2012] [Accepted: 03/12/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence. METHODS The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence. RESULTS The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI -7.6% to -1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence. CONCLUSIONS In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions.
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Affiliation(s)
- Marya J Cohen
- Division of General Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Noureldin M, Plake KS, Morrow DG, Tu W, Wu J, Murray MD. Effect of health literacy on drug adherence in patients with heart failure. Pharmacotherapy 2012; 32:819-26. [PMID: 22744746 DOI: 10.1002/j.1875-9114.2012.01109.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVE To assess the effect of health literacy on drug adherence in the context of a pharmacist-based intervention for patients with heart failure. DESIGN Post hoc analysis of a randomized controlled trial. SETTING Inner-city ambulatory care practice affiliated with an academic medical center. PATIENTS The original trial enrolled 314 patients with heart failure who were aged 50 years or older and were taking at least one cardiovascular drug for heart failure; 122 patients received the pharmacist intervention (patient education, therapeutic monitoring, and communication with primary care providers), and 192 patients received usual care (regular follow-up with primary care providers). We analyzed the results of 281 patients who had available health literacy and adherence data. MEASUREMENTS AND MAIN RESULTS Drug adherence was assessed over 9 months using electronic prescription container monitors on cardiovascular drugs. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults (scores range from 0-36, with an adequate literacy score defined as ≥ 23). Taking adherence, defined as the percentage of prescribed drug doses taken by the patient compared with the number of doses prescribed by the physician, was assessed for each group. Patients were a mean ± SD of 63 ± 9 years old, 51% had less than 12 years of education, 29% had inadequate health literacy, and they received a mean ± SD of 11 ± 4 drugs. In the usual care group, taking adherence was greater among patients with adequate (69.4%) than those with inadequate (54.2%) health literacy (p=0.001). In the intervention group, the difference in taking adherence among patients with adequate (77.3%) and inadequate (65.3%) health literacy was not statistically significant (p=0.06). Among patients with inadequate health literacy, the intervention increased adherence (65%, 95% confidence interval [CI] 54-77%) by an order of magnitude similar to that of the baseline adherence of patients with adequate health literacy (69%, 95% CI 65-74%). Multivariable analysis supported the association between health literacy and adherence. CONCLUSION In patients with heart failure, those with adequate health literacy have better adherence to cardiovascular drugs than those with inadequate health literacy. The pharmacist intervention improved adherence in patients with adequate and inadequate health literacy. Health literacy may be an important consideration in drug adherence interventions.
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Affiliation(s)
- Marwa Noureldin
- Department of Pharmacy Practice, Center on Aging and the Life Course, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
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Schnipper JL, Gandhi TK, Wald JS, Grant RW, Poon EG, Volk LA, Businger A, Williams DH, Siteman E, Buckel L, Middleton B. Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. J Am Med Inform Assoc 2012; 19:728-34. [PMID: 22556186 DOI: 10.1136/amiajnl-2011-000723] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety. DESIGN From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating 'eJournals' that enabled rapid updating of medication lists during subsequent clinical visits. MEASUREMENTS A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies. RESULTS Among 121,046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04). CONCLUSIONS When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record. TRIAL REGISTRATION NUMBER This study was registered at ClinicalTrials.gov (NCT00251875).
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts 02120-1613, USA.
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Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Cresswell K, Eden M, Elliott RA, Howard R, Kendrick D, Morris CJ, Prescott RJ, Swanwick G, Franklin M, Putman K, Boyd M, Sheikh A. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012; 379:1310-9. [PMID: 22357106 PMCID: PMC3328846 DOI: 10.1016/s0140-6736(11)61817-5] [Citation(s) in RCA: 278] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. METHODS In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. FINDINGS 72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38-0·89); a β blocker if they had asthma (0·73, 0·58-0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34-0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months. INTERPRETATION The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. FUNDING Patient Safety Research Portfolio, Department of Health, England.
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Affiliation(s)
- Anthony J Avery
- Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK.
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Cawthon C, Walia S, Osborn CY, Niesner KJ, Schnipper JL, Kripalani S. Improving care transitions: the patient perspective. JOURNAL OF HEALTH COMMUNICATION 2012; 17 Suppl 3:312-324. [PMID: 23030579 PMCID: PMC3603351 DOI: 10.1080/10810730.2012.712619] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
After hospital discharge, patients commonly suffer potentially avoidable adverse events and hospital readmissions. As hospitals implement interventions to improve discharge transitions, it is important to understand patients' perspectives on which intervention components are most beneficial. This study examined a sample of 125 patients randomized to the intervention arm of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease study who completed a telephone survey about the helpfulness of different components of the intervention, which included medication reconciliation, inpatient counseling, simple adherence aids, and telephone follow-up. The majority of patients indicated that it was "very helpful" to speak with a pharmacist about their medications before discharge (72.8%), particularly about how to take the medications and how to prevent and manage side effects. Receiving an illustrated medication list (69.6%) and a follow-up phone call after discharge (68.0%) were also considered very helpful. Patients with limited health literacy indicated the greatest benefit. Patients also reported feeling more comfortable speaking with their outpatient providers about their medications after receiving the intervention. In conclusion, patients--particularly those with limited health literacy--found a hospital pharmacist-based intervention to be very helpful and empowering.
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Affiliation(s)
- Courtney Cawthon
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University
| | - Sheena Walia
- College of Medicine, University of Arkansas for Medical Sciences
| | - Chandra Y. Osborn
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University
- Department of Biomedical Informatics, Vanderbilt University
| | - Kurt J. Niesner
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University
- Geriatric Research Education Clinical Center (GRECC), HSR&D Targeted Research Enhancement Program for Patient Healthcare Behavior, VA Tennessee Valley Health System
| | - Jeffrey L. Schnipper
- BWH Hospitalist Service and Division of General Medicine, Brigham and Women’s Hospital
- Harvard Medical School
| | - Sunil Kripalani
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University
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Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper J. JL, Kripalani S. Health literacy and medication understanding among hospitalized adults. J Hosp Med 2011; 6:488-93. [PMID: 22042745 PMCID: PMC3575735 DOI: 10.1002/jhm.925] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/18/2011] [Accepted: 03/17/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients' ability to accurately report their preadmission medications is a vital aspect of medication reconciliation, and may affect subsequent medication adherence and safety. Little is known about predictors of preadmission medication understanding. METHODS We conducted a cross-sectional evaluation of patients at 2 hospitals using a novel Medication Understanding Questionnaire (MUQ). MUQ scores range from 0 to 3 and test knowledge of the medication purpose, dose, and frequency. We used multivariable ordinal regression to determine predictors of higher MUQ scores. RESULTS Among the 790 eligible patients, the median age was 61 (interquartile range [IQR] 52, 71), 21% had marginal or inadequate health literacy, and the median number of medications was 8 (IQR 5, 11). Median MUQ score was 2.5 (IQR 2.2, 2.8). Patients with marginal or inadequate health literacy had a lower odds of understanding their medications (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.34 to 0.84; P = 0.0001; and OR = 0.49; 95% CI, 0.31 to 0.78; P = 0.0001; respectively), compared to patients with adequate health literacy. Higher number of prescription medications was associated with lower MUQ scores (OR = 0.52; 95% CI, 0.36 to 0.75; for those using 6 medications vs 1; P = 0.0019), as was impaired cognitive function (OR = 0.57; 95% CI, 0.38 to 0.86; P = 0.001). CONCLUSIONS Lower health literacy, lower cognitive function, and higher number of medications each were independently associated with less understanding of the preadmission medication regimen. Clinicians should be aware of these factors when considering the accuracy of patient-reported medication regimens, and counseling patients about safe and effective medication use.
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Affiliation(s)
| | - Christianne L. Roumie
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University, Nashville, TN
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC), HSR&D Targeted Research Enhancement Program for Patient Healthcare Behavior, and Clinical Research Center of Excellence (CRCoE), Nashville, TN
| | - Svetlana K. Eden
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Courtney Cawthon
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University, Nashville, TN
| | - Jeffrey L. Schnipper J.
- Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, MA
- Brigham and Women's Hospital Academic Hospitalist Service, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sunil Kripalani
- Vanderbilt Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University, Nashville, TN
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN
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Kripalani S, Osborn CY, Vaccarino V, Jacobson TA. Development and evaluation of a medication counseling workshop for physicians: can we improve on 'take two pills and call me in the morning'? MEDICAL EDUCATION ONLINE 2011; 16:MEO-16-7133. [PMID: 21915162 PMCID: PMC3171175 DOI: 10.3402/meo.v16i0.7133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 07/13/2011] [Accepted: 07/20/2011] [Indexed: 05/24/2023]
Abstract
BACKGROUND Physicians often do not provide adequate medication counseling. PURPOSE To develop and evaluate an educational program to improve physicians' assessment of adherence and their medication counseling skills, with attention to health literacy. METHODS We compared internal medicine residents' confidence and counseling behaviors, measured by self-report at baseline and one month after participation in a two-hour interactive workshop. RESULTS Fifty-four residents participated; 35 (65%) completed the follow-up survey. One month after training, residents reported improved confidence in assessing and counseling patients (p<0.001), including those with low health literacy (p<0.001). Residents also reported more frequent use of desirable behaviors, such as assessing patients' medication understanding and adherence barriers (p<0.05 for each), addressing costs when prescribing (p<0.01), suggesting adherence aids (p<0.01), and confirming patient understanding with teach-back (p<0.05). CONCLUSION A medication counseling workshop significantly improved residents' self-reported confidence and behaviors regarding medication counseling one month later.
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Affiliation(s)
- Sunil Kripalani
- Department of Medicine, Vanderbilt University, Nashville, TN, USA.
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Carlisle A, Jacobson KL, Di Francesco L, Parker RM. Practical strategies to improve communication with patients. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2011; 36:576-89. [PMID: 22346326 PMCID: PMC3278143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Accepted: 05/13/2011] [Indexed: 05/31/2023]
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Giugliano RP, Braunwald E. The year in non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 2011; 56:2126-38. [PMID: 21144974 DOI: 10.1016/j.jacc.2010.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 08/30/2010] [Accepted: 09/02/2010] [Indexed: 12/30/2022]
Affiliation(s)
- Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine; the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, CT
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Chaudhry SI, Herrin J, Phillips C, Butler J, Mukerjhee S, Murillo J, Onwuanyi A, Seto TB, Spertus J, Krumholz HM. Racial disparities in health literacy and access to care among patients with heart failure. J Card Fail 2010; 17:122-7. [PMID: 21300301 DOI: 10.1016/j.cardfail.2010.09.016] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/15/2010] [Accepted: 09/30/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous work has shown that there is a higher frequency of hospitalizations among black heart failure patients relative to white heart failure patients. We sought to determine whether racial differences exist in health literacy and access to outpatient medical care, and to identify factors associated with these differences. METHODS We evaluated data from 1464 heart failure patients (644 black and 820 white). Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Revised (ie, REALM-R), and access to care was assessed through participants' self-report. RESULTS Black race was strongly associated with worse health literacy and all measures of poor access to care in unadjusted analyses. After adjusting for demographics, noncardiac comorbidity, social support, insurance status, and socioeconomic status (income and education), the strongest associations were seen between race and: health literacy (OR 2.13, 95% CI 1.46 to 3.10), absence of a medical home (OR 1.76, 1.19-2.61), and cost as a deterrent to seeking health care (OR 1.55, 1.07 to 2.23). CONCLUSIONS Our findings highlight that important racial differences in health literacy and access to care exist among patients with heart failure. These differences persist even after adjustment for a broad range of potential mediators, including educational attainment, income, and insurance status.
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Affiliation(s)
- Sarwat I Chaudhry
- Department of Internal Medicine, Section of General Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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