Pharmacist-Provided Medication Management in Interdisciplinary Transitions in a Community Hospital (PMIT)

Outcomes of a Pharmacy-Driven Inpatient Chronic Obstructive Pulmonary Disease (COPD) Transitions of Care (TOC) Management Process

Background: Current data shows 30% of patients hospitalized for Chronic Obstructive Pulmonary Disease (COPD) exacerbation are readmitted within 30 days. Medication management during transitions of care (TOC) has shown impact on clinical outcomes, however there is insufficient data to suggest how pharmacy TOC services might benefit this patient population. Objective: Evaluate the effects of pharmacy-driven COPD TOC services on hospital re-presentation rates. Methods: A single-center retrospective chart review conducted of patients hospitalized for a COPD exacerbation. A comprehensive admission-to-discharge TOC service was provided by early immersion pharmacy students, advanced immersion pharmacy students, and an attending pharmacist in a layered learning model. The primary outcome was 30-day re-presentation rate. Secondary outcomes were 90-day re-presentation rate, volume of interventions made and description of the service. Results: From 1/1/2019 to 12/31/2019, there were 2422 patients admitted for COPD exacerbation management and 756 patients received at least one intervention from the COPD TOC service. 30% needed a change to inhaler therapy. The provider accepted 57.8% of the recommended changes, and 36% and 33% of eligible patients received an inhaler technique education and bedside delivery of the new inhaler, respectively. Outcomes in the 30-day re-presentation and 90-day censored re-presentation rates for the intervention and control group were 28.5% vs 25.5% (P = .12) and 46.7% vs 42.9%, respectively. Conclusion: This study did not find a significant change in 30-day re-presentation rate with a pharmacy-driven COPD TOC service. It did find that a significant number of patients admitted with COPD exacerbation may need an inhaler change, and demonstrates the utility of this kind of TOC service for identifying and correcting medication-related problems unique to this disease state. There were opportunities for improvement in percent of patients receiving the full intended intervention.

Effectiveness of a structured pharmacist-delivered intervention for patients post-acute coronary syndromes on all-cause hospitalizations and cardiac-related hospital readmissions: a prospective quasi-experimental study

BACKGROUND

Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity in Qatar and globally.

AIM

The primary objective of the study was to evaluate the effectiveness of a structured clinical pharmacist-delivered intervention on all-cause hospitalizations and cardiac-related readmissions in patients with ACS.

METHOD

A prospective quasi-experimental study was conducted at Heart Hospital in Qatar. Discharged ACS patients were allocated to one of three study arms: (1) an intervention group (received a structured clinical pharmacist-delivered medication reconciliation and counselling at discharge, and two follow-up sessions at 4 weeks and 8 weeks post-discharge), (2) a usual care group (received the general usual care at discharge by clinical pharmacists) or, (3) a control group (discharged during weekends or after clinical pharmacists' working hours). Follow-up sessions for the intervention group were designed to re-educate and counsel patients about their medications, remind them about the importance of medication adherence, and answer any questions they may have. At the hospital, patients were allocated into one of the three groups based on intrinsic and natural allocation procedures. Recruitment of patients took place between March 2016 and December 2017. Data were analyzed based on intention-to-treat principles.

RESULTS

Three hundred seventy-three patients were enrolled in the study (intervention = 111, usual care = 120, control = 142). Unadjusted results showed that the odds of 6-month all-cause hospitalizations were significantly higher among the usual care (OR 2.034; 95% CI: 1.103-3.748, p = 0.023) and the control arms (OR 2.704; 95% CI: 1.456-5.022, p = 0.002) when compared to the intervention arm. Similarly, patients in the usual care arm (OR 2.304; 95% CI: 1.122-4.730, p = 0.023) and the control arm (OR 3.678; 95% CI: 1.802-7.506, p ≤ 0.001) had greater likelihood of cardiac-related readmissions at 6 months. After adjustment, these reductions were only significant for cardiac-related readmissions between control and intervention groups (OR 2.428; 95% CI: 1.116-5.282, p = 0.025).

CONCLUSION

This study demonstrated the impact of a structured intervention by clinical pharmacists on cardiac-related readmissions at 6 months post-discharge in patients post-ACS. The impact of the intervention on all-cause hospitalization was not significant after adjustment for potential confounders. Large cost-effective studies are required to determine the sustained impact of structured clinical pharmacist-provided interventions in ACS setting.

TRIAL REGISTRATION

Clinical Trials: NCT02648243 Registration date: January 7, 2016.

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

BACKGROUND

The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.

OBJECTIVES

To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.

METHODS

This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.

RESULTS

A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.

CONCLUSION

Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.

Impact of Pharmacist Counseling at Discharge for Older People

Objective To examine the evidence surrounding how the implementation of pharmacist discharge counseling affects the number of readmissions. Data Sources A search was conducted using EBSCOhost and the National Library of Medicine databases for articles published through December 2020 with the keywords "discharge counseling," "discharge teaching," "discharge education," "patient education," "patient teaching," "medication reconciliation," "pharmacist," and "readmission rates." The authors independently screened citations and applied inclusion and exclusion criteria. Study Selection A total of 32 articles were reviewed and analyzed. Inclusion criteria included articles published in the English language with human subjects, and adults (18 years of age and older) involving pharmacist-led discharge counseling and assessment of readmission rates were included. Data Extraction Study characteristics, intervention type, and outcomes with statistical significance where reported were included in the literature analysis. Data Synthesis Studies examined reported varying health care improvements postdischarge with the implementation of pharmacist services in the discharge process. Not all results were significant for reduction in readmission rates, but a downward trend was observed. Conclusion Implementation of pharmacist discharge counseling may decrease the number of hospital readmissions, particularly in older people.

Aiming Beyond: A Pharmacist Impact on 90-Day Readmissions and Clinical Outcomes Within a Family Medicine Service

Previous studies have shown pharmacists positively impact 30-day readmission rates. However, there is limited data regarding the effect of clinical pharmacist (CP) follow-up on 90-day readmission or evaluation of disease-specific goals after hospitalization. Investigators analyzed the impact of postdischarge extended CP follow-up within a family medicine service (FMS). The primary end point was all-cause 90-day readmission rates. Secondary end points included all-cause 30- and 60-day readmission rates and the achievement of disease-specific goals postdischarge. Retrospective chart review was performed for patients admitted from August 2016 to November 2017 who were seen by a physician within the FMS 14 days postdischarge. Fourteen percent of patients within the CP intervention group were readmitted within 90 days in comparison to 22% in the standard of care group ( P = .244). Readmission rates at 30 and 60 days were as follows: intervention group 2%, 10%, and standard of care group 16%, 22% ( P = .015, P = .089, respectively). In addition, multiple patients with uncontrolled diabetes who completed CP visits upon hospital discharge met glycemic goals at the end of the study time period. Despite inclusion of the CP in postdischarge care, 90-day readmission rate remained unchanged.

Virtual academic detailing (e-Detailing): A vital tool during the COVID-19 pandemic

As the coronavirus disease (COVID-19) pandemic continues its course in 2020, telehealth technology provides opportunities to connect patients and providers. Health policies have been amended to allow easy access to virtual health care, highlighting the field's dynamic ability to adapt to a public health crisis. Academic detailing, a peer-to-peer collaborative outreach designed to improve clinical decision-making, has traditionally relied on in-person encounters for effectiveness. A growth in the adoption of telehealth technology translates to increases in academic detailing reach for providers unable to meet with academic detailers in person. The U.S. Department of Veterans Affairs (VA) has used academic detailing to promote and reinforce evidence-based practices and has encouraged more virtual academic detailing (e-Detailing). Moreover, VA academic detailers are primarily clinical pharmacy specialists who provide clinical services and education and have made meaningful contributions to improving health care at VA. Amid the COVID-19 pandemic and physical isolation orders, VA academic detailers have continued to meet with providers to disseminate critical health care information in a timely fashion by using video-based telehealth. When working through the adoption of virtual technology for the delivery of medical care, providers may need time and nontraditional delivery of "evidence" before eliciting signals for change. Academic detailers are well suited for this role and can develop plans to help address provider discomfort surrounding the use of telehealth technology. By using e-Detailing as a method for both familiarizing and normalizing health professionals with video-based telehealth technology, pharmacists are uniquely poised to deliver consultation and direct-care services. Moreover, academic detailing pharmacists are ambassadors of change, serving an important role navigating the evolution of health care in response to emergent public health crises and helping define the norms of care delivery to follow.

Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

BACKGROUND

Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery.

OBJECTIVE

To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017.

METHOD

We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used.

RESULTS

A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift.

CONCLUSION

The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

Evolution of Interdisciplinary Transition of Care Services in a Primary Care Organization

Transitions of care create complex management challenges for providers and leave patients vulnerable to medication errors and hospital readmissions. This article examines the evolution of an interdisciplinary team of pharmacists and nurse care managers and their impact on safe and effective transitions from the acute care settings back into primary care. This article explores successes and challenges of this primary-care-based clinic in managing patients safely through often-complex situations, and explores future directions for improving care processes and outcomes.

Care transition strategies in Latin American countries: an integrative review

OBJECTIVE

To identify and analyze available literature on care transition strategies in Latin American countries.

METHODS

Integrative literature review that included studies indexed in PubMed, LILACS, Web of Science Core Collection, CINAHL, SCOPUS databases, and the Scientific Electronic Library Online (SciELO), published in Portuguese, Spanish or English, between 2010 and 2017.

RESULTS

Eleven articles were selected and the strategies were grouped into components of care transition: discharge planning, advanced care planning, patient education and promotion of self-management, medication safety, complete communication of information, and outpatient follow-up. These strategies were carried out by multidisciplinary team members, in which nurses play a leading role in promoting safe care transitions.

CONCLUSIONS

Care transition activities are generally initiated very close to patient discharge, this differs from recommendations of care transition programs and models, which suggest implementing care transition strategies from the time of admission until discharge.

Multifaceted Pharmacist-led Interventions in the Hospital Setting: A Systematic Review

Clinical pharmacy services often comprise complex interventions. In this MiniReview, we conducted a systematic review aiming to evaluate the impact of multifaceted pharmacist-led interventions in a hospital setting. We searched MEDLINE, Embase, Cochrane Library and CINAHL for peer-reviewed articles published from 2006 to 1 March 2018. Controlled trials concerning hospitalized patients in any setting receiving patient-related multifaceted pharmacist-led interventions were considered. All types of outcome were accepted. Inclusion and data extraction were performed. Study characteristics were collected, and risk of bias assessment was conducted utilizing the Cochrane Risk of Bias tools. All stages were conducted by at least two independent reviewers. The review was registered in PROSPERO (CRD42017075808). A total of 11,896 publications were identified, and 28 publications were included. Of these, 17 were conducted in Europe. Six of the included publications were multi-centre studies, and 16 were randomized trials. Usual care was the comparator. Significant results on quality of medication use were reported as positive in eleven studies (n = 18; 61%) and negative in one (n = 18, 6%). Hospital visits were reduced significantly in seven studies (n = 16; 44%). Four studies (n = 12; 33%) reported a positive significant effect on either length of stay or time to revisit, and one study reported a negative effect (n = 12; 6%). All studies investigating mortality (n = 6), patient-reported outcome (n = 7) and cost-effectiveness (n = 1) showed no significant results. This MiniReview indicates that multifaceted pharmacist-led interventions in a hospital setting may improve the quality of medication use and reduce hospital visits and length of stay, while no effect was seen on mortality, patient-reported outcome and cost-effectiveness.

Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review

INTRODUCTION

Medication errors are commonly affected by breakdowns in communication. Interdisciplinary collaboration is an important means of facilitating communication between health professionals in clinical practice. To date, there has been little systematic examination of past research in this area.

AREAS COVERED

The aims of this integrative review are to examine how interdisciplinary collaboration influences medication errors in hospitals, the araes of interdisciplinary collaboration that have been researched in previous work, and recommendations for future research and practice. An integrative review was undertaken of research papers (N = 30) published from inception to August 2017 using MEDLINE, the Cochrane Library, CINAHL, PsycINFO, and Embase.

EXPERT OPINION

Five different areas of interdisciplinary collaboration were identified in research involving medication errors. These areas were: communication through tools including guidelines, protocols, and communication logs; participation of pharmacists in interdisciplinary teams; collaborative medication review on admission and at discharge; collaborative workshops and conferences; and complexity of role differentiation and environment. Despite encouraging results demonstrated in past research, medication errors continued to occur. Increased focus is needed on developing tailored, individualized strategies that can be applied in particular contexts to create further reductions in medication errors. Greater understandings are also needed about the changing roles of various disciplines.