Effect of Postdismissal Pharmacist Visits for Patients Using High-Risk Medications

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Abstract

Objective

To determine whether a pharmacist visit after hospital dismissal for patients taking at least 1 medication that places patients at high risk for emergent hospital admissions (termed high-risk medication) would decrease the risk of hospital readmission at 30 days compared with usual care.

Patients and Methods

This was a retrospective study at a tertiary care center conducted from July 26, 2013, through April 1, 2016. We reviewed outcomes among patients who did or did not have a post–hospital dismissal pharmacist visit immediately before a clinician visit. We included patients who were at least 18 years old and were taking at least 10 total medications at hospital dismissal, 1 or more of which were high-risk medications. A Cox proportional hazards model was used to compare the risk of 30-day readmission between the groups.

Results

The study cohort included 502 patients in each group (pharmacist + clinician group and clinician-only group). After adjusting for differences in background demographic characteristics, patients in the pharmacist + clinician group were significantly less likely to be readmitted to the hospital within 30 days postdismissal compared with the clinician-only group (hazard ratio, 0.49; 95% CI, 0.35-0.69; P<.001).

Conclusion

Patients seen by a pharmacist immediately before a clinician visit after hospital dismissal had a lower risk of readmission than patients who had a clinician-only visit. Patients taking high-risk medications for hospital admissions are ideal candidates for pharmacist involvement.

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Most cited references 7

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Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community.

Carl van Walraven, Irfan Dhalla, Chaim Bell … (2010)

Readmissions to hospital are common, costly and often preventable. An easy-to-use index to quantify the risk of readmission or death after discharge from hospital would help clinicians identify patients who might benefit from more intensive post-discharge care. We sought to derive and validate an index to predict the risk of death or unplanned readmission within 30 days after discharge from hospital to the community. In a prospective cohort study, 48 patient-level and admission-level variables were collected for 4812 medical and surgical patients who were discharged to the community from 11 hospitals in Ontario. We used a split-sample design to derive and validate an index to predict the risk of death or nonelective readmission within 30 days after discharge. This index was externally validated using administrative data in a random selection of 1,000,000 Ontarians discharged from hospital between 2004 and 2008. Of the 4812 participating patients, 385 (8.0%) died or were readmitted on an unplanned basis within 30 days after discharge. Variables independently associated with this outcome (from which we derived the mnemonic "LACE") included length of stay ("L"); acuity of the admission ("A"); comorbidity of the patient (measured with the Charlson comorbidity index score) ("C"); and emergency department use (measured as the number of visits in the six months before admission) ("E"). Scores using the LACE index ranged from 0 (2.0% expected risk of death or urgent readmission within 30 days) to 19 (43.7% expected risk). The LACE index was discriminative (C statistic 0.684) and very accurate (Hosmer-Lemeshow goodness-of-fit statistic 14.1, p=0.59) at predicting outcome risk. The LACE index can be used to quantify risk of death or unplanned readmission within 30 days after discharge from hospital. This index can be used with both primary and administrative data. Further research is required to determine whether such quantification changes patient care or outcomes.

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Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study.

Karen Pellegrin, Les Krenk, Sheena Jolson Oakes … (2017)

To evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication-related hospitalization in older adults.

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Sources and Types of Discrepancies Between Electronic Medical Records and Actual Outpatient Medication Use

Kathleen B. Orrico (2008)

BACKGROUND: Accuracy and transportability of the recorded outpatient medication list are important in the continuum of patient care. Classifying discrepancies between the electronic medical record (EMR) and actual drug use by the root cause of discrepancy (either system generated or patient generated) would guide quality improvement initiatives. OBJECTIVES: To quantify and categorize the number and type of medication discrepancies that exist between the medication lists recorded in EMRs and the comprehensive medication histories obtained through telephone interviews conducted by a team of nurses providing advice to health plan members at the Palo Alto Medical Foundation in Palo Alto, California. METHODS: The study was conducted as a retrospective comparison of EMR medication lists with information obtained by patient interview. Interview data were obtained by a review of telephone calls made to a nurse advice line by health plan members seeking information about sinusitis, urinary tract infection, acute conjunctivitis, pharyngitis, emergency contraception, or mastitis. As part of the advice protocol, a medication reconciliation process was conducted between July 1 and December 31, 2006. Changes to the medication list made during the telephone visit were extracted, categorized, and evaluated by the study's principal investigator. Data extraction included the number and type of identified medication discrepancies, patient age, gender, and condition that prompted the telephone contact. A modified version of the Medication Discrepancy Tool (MDT) was used to categorize medication discrepancies as either system generated (e.g., failure of the provider to update a medication list) or patient generated (e.g., failure of the patient to report use of an over-the-counter product). RESULTS: A total of 233 discrepancies were identified from 85 medication reconciliation phone visits, averaging 2.7 per medication list. The most common type of discrepancy was a medication recorded in the EMR but no longer being used by the patient (n=164, 70.4%), followed by omission from the EMR of a medication being taken by the patient (n=36, 15.5%). 79.8% (n=186) of the discrepancies were attributed to system-generated factors, whereas 20.2% (n=47) were patient generated. Approximately half (n=118, 50.6%) of the discrepancies fell into 4 broad American Hospital Formulary System therapeutic classifications: anti-infective agents (14.2%), anti-inflammatory agents (14.2%), analgesics (12.4%), and vitamins (9.9%). The most common patient-generated discrepancy was omission of a multivitamin (n=13, 27.7%), and the most common system generated prescription drug discrepancy was expired entry for the intranasal corticosteroid mometasone furoate (n=12, 6.5%). CONCLUSIONS: Discrepancies in the outpatient setting were common and predominantly system generated. The most common discrepancy was the presence in the EMR of a medication no longer being taken by the patient. Adding foreseeable end dates to prescription drug orders at computerized order entry might be considered in an effort to improve the accuracy of the outpatient medication list. Reliable systems to involve patients in routinely reconciling EMRs with actual medication use may also warrant examination. The MDT methodology served as a useful qualitative guide for evaluating discrepancies and developing targeted means for resolution.

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Author and article information

Contributors

Joseph R. Herges

Journal

Journal ID (nlm-ta): Mayo Clin Proc Innov Qual Outcomes

Journal ID (iso-abbrev): Mayo Clin Proc Innov Qual Outcomes

Title: Mayo Clinic Proceedings. Innovations, Quality & Outcomes

Publisher: Elsevier

ISSN (Electronic): 2542-4548

Publication date PMC-release: 01 February 2018

Publication date Collection: March 2018

Publication date (Electronic): 01 February 2018

Volume: 2

Issue: 1

Pages: 4-9

Affiliations

[a ]Pharmacy Services, Mayo Clinic, Rochester, MN

[b ]Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN

[c ]Department of Family Medicine, Mayo Clinic, Rochester, MN

Author notes

[∗ ] Correspondence: Address to Joseph R. Herges, PharmD, BCPS, Pharmacy Services, Mayo Clinic, 200 First St SW, Rochester, MN 55905. herges.joseph@ 123456mayo.edu

Article

Publisher ID: S2542-4548(17)30134-0

DOI: 10.1016/j.mayocpiqo.2017.12.004

PMC ID: 6124340

PubMed ID: 30225426

SO-VID: fac5c534-0794-4518-bd1f-8bfde322a376

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Effect of Postdismissal Pharmacist Visits for Patients Using High-Risk Medications

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Abstract

Objective

Patients and Methods

Results

Conclusion

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Most cited references 7

Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community.

Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study.

Sources and Types of Discrepancies Between Electronic Medical Records and Actual Outpatient Medication Use

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