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Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review. J Am Pharm Assoc (2003) 2022; 62:1477-1498.e8. [PMID: 35718715 DOI: 10.1016/j.japh.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/15/2022]
Abstract
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.
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Becker C, Zumbrunn S, Beck K, Vincent A, Loretz N, Müller J, Amacher SA, Schaefert R, Hunziker S. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2119346. [PMID: 34448868 PMCID: PMC8397933 DOI: 10.1001/jamanetworkopen.2021.19346] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear. OBJECTIVE To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes. DATA SOURCES PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021. STUDY SELECTION Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge. RESULTS We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66). CONCLUSIONS AND RELEVANCE These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.
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Affiliation(s)
- Christoph Becker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Samuel Zumbrunn
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Beck
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Alessia Vincent
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Nina Loretz
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Jonas Müller
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Simon A Amacher
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Rainer Schaefert
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
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Marcum ZA, Jiang S, Bacci JL, Ruppar TM. Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis. J Am Geriatr Soc 2021; 69:3301-3311. [PMID: 34287846 DOI: 10.1111/jgs.17373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 06/26/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVE As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years). DESIGN/SETTING/PARTICIPANTS Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance. MEASUREMENTS Medication adherence using any method of measurement. RESULTS Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70). CONCLUSION This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.
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Affiliation(s)
- Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Shangqing Jiang
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Jennifer L Bacci
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Todd M Ruppar
- College of Nursing, Rush University, Chicago, Illinois, USA
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Michaelis M, Witte (née Farian) C, Schüle B, Frick K, Rieger MA. Can Motivational Interviewing Make a Difference in Supporting Employees to Deal with Elevated Blood Pressure? A Feasibility Study at the Workplace. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084179. [PMID: 33920894 PMCID: PMC8071336 DOI: 10.3390/ijerph18084179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/30/2021] [Accepted: 04/10/2021] [Indexed: 11/27/2022]
Abstract
Background: To overcome the problem of a high prevalence of undiscovered or untreated arterial hypertension in people of working age, the effects of behavioral change counseling in occupational health (OH) services should be investigated. The technique of motivational interviewing (MI) to support health-related lifestyle changes by physicians and/or occupational nurses (‘health coach’) has been shown to be successful in patients with chronic diseases. In 2010, we planned a randomized controlled trial (RCT) with employees who suffer from mild arterial hypertension. A preliminary feasibility study was performed in a large manufacturing company in Germany. Methods: All employees with elevated blood pressure measured by the OH-service were invited to undergo validation by 30 self-measurements. Persons with validated elevated values and without medical treatment received either usual hypertension counseling (control group, CG) or intensified MI-counseling (intervention group, IG) by the occupational health physician. Subsequently, the IG received MI-support from the ‘health coach’ in four telephone counseling sessions. Assessed feasibility factors included organizational processes, the acceptance of the validation procedure and the MI-counseling, and as primary outcome for an RCT the extent to which participants made health-related changes to their lifestyles. Results: Initially, 299 individuals were included in Study Part A (screening). At the end of Study Part B (intervention), out of 34 participants with validated and non-treated mild hypertension, only 7 (IG) and 6 (CG) participants completed the intervention including documentation. The high drop-out rate was due to the frequent lack of willingness to perform the 30 self-measurements at home with their own equipment. Acceptance was little higher when we changed the method to two repeated measurements in the OH service. MI-counseling, especially by the health coach, was evaluated positively. Conclusions: Despite the promising counseling approach, the feasibility study showed that an RCT with previous screening in the operational setting can only be implemented with high financial and personnel effort to reach an appropriate number of subjects. This substantial result could only be achieved through this comprehensive feasibility study, which investigated all aspects of the planned future RCT.
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Affiliation(s)
- Martina Michaelis
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital of Tübingen, 72074 Tübingen, Germany; (C.W.); (M.A.R.)
- Research Centre for Occupational and Social Medicine (FFAS), 79098 Freiburg, Germany
- Correspondence:
| | - Carmen Witte (née Farian)
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital of Tübingen, 72074 Tübingen, Germany; (C.W.); (M.A.R.)
| | - Barbara Schüle
- Occupational Health Service, Daimler AG, 70546 Stuttgart, Germany;
| | - Katrin Frick
- German Academy for Psychology, 10179 Berlin, Germany;
| | - Monika A. Rieger
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital of Tübingen, 72074 Tübingen, Germany; (C.W.); (M.A.R.)
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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: 2] [Impact Index Per Article: 0.7] [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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Ozavci G, Bucknall T, Woodward-Kron R, Hughes C, Jorm C, Joseph K, Manias E. A systematic review of older patients' experiences and perceptions of communication about managing medication across transitions of care. Res Social Adm Pharm 2020; 17:273-291. [PMID: 32299684 DOI: 10.1016/j.sapharm.2020.03.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Communication about managing medications may be difficult when older people move across transitions of care. Communication breakdowns may result in medication discrepancies or incidents. OBJECTIVE The aim of this systematic review was to explore older patients' experiences and perceptions of communication about managing medications across transitions of care. DESIGN A systematic review. METHODS A comprehensive review was conducted of qualitative, quantitative and mixed method studies using CINAHL Complete, MEDLINE, Embase and PsycINFO, Web of Science, INFORMIT and Scopus. These databases were searched from inception to 14.12.2018. Key article cross-checking and hand searching of reference lists of included papers were also undertaken. INCLUSION CRITERIA studies of the medication management perspectives of people aged 65 or older who transferred between care settings. These settings comprised patients' homes, residential aged care and acute and subacute care. Only English language studies were included. Comments, case reports, systematic reviews, letters, editorials were excluded. Thematic analysis was undertaken by synthesising qualitative data, whereas quantitative data were summarised descriptively. Methodological quality was assessed with the Mixed Methods Appraisal Tool. RESULTS The final review comprised 33 studies: 12 qualitative, 17 quantitative and 4 mixed methods studies. Twenty studies addressed the link between communication and medication discrepancies; ten studies identified facilitators of self-care through older patient engagement; 18 studies included older patients' experiences with health professionals about their medication regimen; and, 13 studies included strategies for communication about medications with older patients. Poor communication between primary and secondary care settings was reported as a reason for medication discrepancy before discharge. Older patients expected ongoing and tailored communication with providers and timely, accurate and written information about their medications before discharge or available for the post-discharge period. CONCLUSIONS Communication about medications was often found to be ineffective. Most emphasis was placed on older patients' perspectives at discharge and in the post-discharge period. There was little exploration of older patients' views of communication about medication management on admission, during hospitalisation, or transfer between settings.
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Affiliation(s)
- Guncag Ozavci
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Tracey Bucknall
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia; Deakin-Alfred Health Nursing Research Centre, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia.
| | - Robyn Woodward-Kron
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Grattan Street Parkville, 3052, Victoria, Australia.
| | - Carmel Hughes
- Queen's University Belfast, School of Pharmacy, 97 Lisburn Road Belfast BT9 7BL, UK, Northern Ireland, UK.
| | - Christine Jorm
- NSW Regional Health Partners, Wisteria House, James Fletcher Hospital, 72 Watt St, Newcastle, 2300, NSW, Australia.
| | - Kathryn Joseph
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Elizabeth Manias
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
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Bonetti AF, Reis WC, Mendes AM, Rotta I, Tonin FS, Fernandez-Llimos F, Pontarolo R. Impact of Pharmacist-led Discharge Counseling on Hospital Readmission and Emergency Department Visits: A Systematic Review and Meta-analysis. J Hosp Med 2020; 15:52-59. [PMID: 30897055 DOI: 10.12788/jhm.3182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transitions of care can contribute to medication errors and other adverse drug events. PURPOSE The aim of this study was to evaluate the impact of pharmacist-led discharge counseling on hospital readmission and emergency department visits through a systematic review and meta-analysis. EDATA SOURCES Lectronic searches were performed in PubMed, Scopus, and DOAJ (Directory of Open Access Journals), along with a manual search (July 2017). PROSPERO registration no. CRD42017068444. STUDY SELECTION Two independent reviewers performed all the steps of the systematic review process (screening of titles and abstracts, full-text appraisal, data extraction, and quality assessment), with contributions from a third researcher. We included randomized controlled trials (RCTs) reporting data on pharmacist-led discharge counseling. DATA EXTRACTION Primary extracted outcomes were emergency department visits and hospital readmission rates. DATA SYNTHESIS Meta-analyses of intervention versus usual care for hospital readmission and emergency department visit rates were performed using the inverse variance method. Results are reported as risk ratios (RRs) with 95% confidence intervals (CIs). Prediction intervals (PIs) were also calculated. Sensitivity and subgroup analyses were performed. A total of 21 RCTs were included in the qualitative synthesis and 18 in the meta-analyses (n = 7,244 patients). The original meta-analysis revealed a significant difference in the impact between pharmacist-led discharge counseling and usual care on overall hospital readmission (RR = 0.864 [95% CI 0.763-0.997], P = .020) and emergency department (RR = 0.697 [95% CI 0.535-0.907], P = .007) visits. However, the small number of included studies, the high heterogeneity among trials (I2 between 40% and 60%), and the wide PIs (hospital readmission: PI 0.542-1.186; emergency department visits: PI 0.027-1.367) prevented drawing further conclusions. CONCLUSIONS Insufficient evidence exists regarding the effect of pharmacist-led discharge counseling on hospital readmission and emergency department visits. Further well-designed clinical trials with defined core outcome sets are needed.
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Affiliation(s)
- Aline F Bonetti
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Walleri C Reis
- Department of Pharmacy, Federal University of Paraiba, João Pessoa, Brazil
| | - Antonio M Mendes
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Inajara Rotta
- Pharmacy Service, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Department of Social Pharmacy, College of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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Zimmerman DE, Covvey JR, Nemecek BD, Guarascio AJ, Wilson L, Freedy HR, Yassin MH. Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 27:279-285. [PMID: 30536468 DOI: 10.1111/ijpp.12497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 11/02/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP). METHODS An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts. KEY FINDINGS A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/β-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/β-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS). CONCLUSIONS The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.
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Affiliation(s)
- David E Zimmerman
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Jordan R Covvey
- Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Branden D Nemecek
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Anthony J Guarascio
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Allegheny General Hospital, Pittsburgh, PA, USA
| | - Laura Wilson
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Henry R Freedy
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Mohamed H Yassin
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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