Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pharmacist Assisting at Routine Medical Discharge: Project PhARMD

Similar presentations


Presentation on theme: "Pharmacist Assisting at Routine Medical Discharge: Project PhARMD"— Presentation transcript:

1 Pharmacist Assisting at Routine Medical Discharge: Project PhARMD
Preeyaporn Sarangarm, PharmD Stanley Snowden, PharmD Lisa Koselke, PharmD Thomas Dilworth, PharmD Matthew London, PharmD Christian Sanchez, PharmD PGY1 Pharmacy Practice Residents University of New Mexico Hospital

2 Background Approximately 20% of patients experience an adverse event after discharge Up to 60% are medication related and preventable Results in costly healthcare utilization Pharmacist discharge counseling has shown mixed results in reducing health care utilization Hospital readmissions ED visits

3 Background The American College of Clinical Pharmacists reviewed the literature between 2001 and surrounding clinical pharmacy services (CPSs) For every dollar spent on CPSs $4.81 was saved No study has examined the cost-effectiveness of an inpatient pharmacist discharge service The authors reviewed 93 articles; fifteen of which included a cost-benefit analysis. From these fifteen articles the authors found a median benefit to cost ratio of 4.81. Perez A et al. Pharmacotherapy. 2008;28(11): 285e-323e.

4 Background Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) July 2007 Inpatient Prospective Payment System (IPPS) linked to compliance with HCAHPS Patient Protection and Affordable Care Act of 2010 HCAHPS will be one of the measures used to calculate Value-based incentive payments (October 2012) Value-based incentive purchasing Patient perception has a significant effect on hospital income Earnings of $4980 per bed linked to one point gain in satisfaction Patients with higher satisfaction ratings of hospital services are less likely to enter into malpractice suits

5 Background When chronic disease states are treated ineffectively, complications of the disease may lead to increased use of hospital, ED, and other medical resources Medication non-adherence is related to greater morbidity and mortality in chronic disease Estimated to increase healthcare costs by over $170 billion annually in this country Increased adherence has the potential to generate medical savings that more than offset the associated increases in drug costs Underutilization of prescription medicines is a problem in U.S. Many patients are not taking the medications prescribed to them by health care providers Benner J, et al. JAMA. 2002;288:455–61. O’Connor PJ. Arch Int Med. 2006;166:1802–4. Sokol MC, et al. Med Care. 2005;43:521–30. Schlenk EA, et al. Futura Publishing Co; 2001:57–70. Miller NH. Am J Med. 1997;102:43– 49.

6 Study Objective Primary Outcome: To evaluate the impact of pharmacist discharge counseling on a combined endpoint of 30-day post-discharge hospital readmissions and ED visits Secondary Outcomes: Determine predictors for readmission/ED visits Describe the number and type of interventions Conduct a cost-benefit analysis Improve patient satisfaction Increase primary medication adherence

7 Methods

8 Methods: Study Design Single center, prospective intervention study
Number of patients Historical hospital data: 30-day readmission rate: 12.3% 30-day ED visits: 13.0% Excludes patients who were subsequently admitted A priori power analysis: 292 patients in each study group 33% reduction in the combined endpoint Power=80%, α=0.05

9 Methods: Patient Selection
Inclusion criteria: Discharged from internal medicine service English or Spanish speaking Exclusion criteria: Less than 18 years of age Unable or unwilling to receive counseling Discharged to anywhere other than home Planned readmission Previous inclusion into the study

10 Methods: Flow of Patients
Study introduction to patient Control Group: Usual Discharge Care Only Survey given and collected Review patients for readmissions and ED visits Intervention Group: Usual Care plus Counseling by a Pharmacy Resident Follow-up Phone Call Prior to discharge 30 days post-discharge 36-72 hours post-discharge DESCRIBE REGULAR DISCHARGE PROCESS SAY STANDARDIZED FOLLOW UP PHONE CALL

11 Method: Discharge Services
Prescription review Medication reconciliation Completeness of prescriptions Duplicative, unnecessary or incomplete therapy Drug interactions Insurance coverage/ability to pick up medications Counseling Medication information and administration Side effects Disease state education

12 Methods: Survey Distribution
Upon completion of discharge counseling, patients were given the anonymous English or Spanish survey Patients were then left in their room to fill out the survey without the pharmacist present Surveys were placed within the provided envelope by the patient and collected prior to the patient leaving the hospital Patients unable or unwilling to complete the survey were not included in the analysis This only covers the intervention group but both got the survey. Need to start with both groups received the survey prior to DC and explain briefly how done in the control group.

13 Methods: Data Collection
Upon discharge: Patient demographics Admission information Number of prior readmissions Number of medications at discharge Pharmacist interventions and time spent At 30 days post-discharge: Number of hospital readmissions or ED visits and reason/diagnosis Medication fill history from the UNMH Outpatient Pharmacy for UNM care patients Cost data: Estimated patient charges for readmissions and ED visits Pharmacist salary plus benefits Converted charges to costs using UNMH cost to charge ratio Admission information = PMH, discharge diagnosis, length of stay

14 Methods: Intervention Classification
Discontinue drug Therapeutic duplication Medication without indication Adverse drug reaction (ADR) Add drug Untreated condition Prevent or treat ADR Change drug Drug interaction Actual or potential ADR Reverse auto-substitution Change dosing Incorrect or inappropriate Drug interaction Renal adjustment Hepatic adjustment Allergies Allergy updated or clarified Allergy avoided Incomplete prescription Other Bayley BK, et al. Ther Clin Risk Manag. 2007; 3: 14

15 Methods: Data Analysis
Data was analyzed in SPSS (version 18) Univariate analysis: Chi-square for categorical variables T-test for continuous variables Multivariate analysis: Multiple logistic regression MANOVA Nonparametric analysis: Mann-Whitney U test

16 Results: 30-day Readmission and ED visits
Primary Outcome

17 Study Recruitment and Flow

18 Demographics (n=279) Characteristic Control (n=139) Intervention
P-value Age, mean (SD), years 50.4 (16.5) 49.0 (15.8) 0.48 Male 81 (58.3) 75 (53.6) 0.43 Primary Language: English 129 (92.8) 121 (86.4) 0.08 Ethnicity White, non-Hispanic White, Hispanic African American Native American Other 43 (30.9) 58 (41.7) 7 (5.0) 25 (18.0) 6 (4.3) 46 (32.9) 55 (39.3) 12 (8.6) 16 (11.4) 11 (7.8) 0.30 Marital Status Single Married Separated/Divorced/Widower 79 (56.8) 40 (28.8) 20 (14.4)    90 (64.3) 34 (24.3) 0.23 *All values reported as n (%) unless specified otherwise

19 Demographics (n=279) Characteristic Control (n=139) Intervention
P-value Current Primary Care Provider 80 (57.8) 84 (60.0) 0.68 Insurance Private Insurance Public Insurance County Provided Healthcare (UNM Care) No Insurance 19 (13.7) 76 (54.7) 27 (19.4) 17 (12.2) 17 (12.1) 45 (32.1) 42 (30.0) 36 (25.7) <0.001 Length of stay, mean (SD), days 6.1 (5.2) 7.3 (8.1) 0.14 Previous admission (within 1 year), mean (SD) 0.7 (1.5) 0.8 (1.6) 0.62 Charleson co-morbidity index score, mean (SD) 3.3 (2.9) 2.9 (2.8) 0.22 Distance from the hospital, mean (SD), miles 57.4 (94.0) 79.9 (229.0) 0.29 *All values reported as n (%) unless specified otherwise

20 Intervention Group (n=140)
Declined (n=23) 16%

21 30-day Readmissions and ED Visits (Univariate Analysis)
Control (n=139) N (%) Intervention (n=140) P-value Combined 30-day readmissions and ED visits 30-day hospital readmission 30-day ED visits 24 (17.3) 16 (11.5) 11 (7.9) 30 (21.4) 20 (14.3) 17 (12.1) 0.34 0.49 0.24 Related readmission or ED visit 19/24 (79.2) 23/30 (76.7) 0.83

22 30-day Readmissions and ED Visits (Multivariate Analysis)
Multivariate logistic regression Adjusted for confounders that could potentially influence the outcome Factors in univariate analysis with p<0.1: sex and insurance No difference in readmissions and ED visits OR 1.25 (95%CI ), p=0.48

23 Conclusion: 30-day Readmissions and ED visits
Pharmacist discharge counseling services did not significantly improve 30-day hospital readmissions and ED visits Would move this conclusion up to the previous slide where you show the stats and OR.

24 Results: Predictors for Readmission and ED Visits
Secondary Outcome

25 Risk Factors for Combined 30-day ED Visits and Readmissions
No readmission/ED visit (n=225) Readmission/ED visit (n=54) P value Age, mean (SD), years 49.7 (15.8) 49.5 (17.5) 0.93 Primary care provider 132 (58.7) 32 (59.3) 0.94 Primary Language: English 202 (89.8) 48 (88.9) 0.85 Male 24 (44.4) 0.06 Insurance status Public Insurance UNM Care Private Insurance No Insurance 98 (43.6) 54 (24) 30 (13.3) 43 (19.1) 23 (42.6) 15 (27.8) 6 (11.1) 10 (18.5) Marital status Married Single Separated/Divorced Widower 65 (28.9) 135 (60) 17 (7.6) 8 (3.6) 9 (16.7) 34 (63) 7 (13) 4 (7.4) 0.14 *All values reported as n (%) unless specified otherwise

26 Risk Factors for Combined 30-day ED Visits and Readmissions
No readmission or ED visit (n=225) Readmission or ED visit (n=54) P value Ethnicity White Hispanic Black Native American Other 73 (32.4) 84 (37.3) 15 (6.7) 37 (16.4) 16 (7.1) 16 (29.6) 29 (53.7) 4 (7.4) 1 (1.9) 0.19 Distance from the hospital, mean (SD), miles 71.4 (186.14) 57.1 (120.98) 0.59 Length of hospital stay, mean (SD) 6.4 (6.35) 7.7 (8.48) 0.20 Previous hospital admissions, mean (SD) 0.6 (1.18) 1.3 (2.40) 0.002 Charlson comorbidity index, mean (SD) 2.9 (2.73) 3.5 (3.21) Meds pre reconciliation, mean (SD) 5.3 (5.36) 6.8 (5.30) 0.17 Meds post reconciliation, mean (SD) 5.5 (5.21) 7.3 (5.06) 0.10 *All values reported as n (%) unless specified otherwise

27 Multivariate Regression
Logistic regression for ED visits and readmissions within 30 days post-discharge Risk factors OR 95% CI P value Previous hospital admissions* No Yes -- 1.26 0.008 *Statistically significant (P≤0.05), this regression included risk factors with a P<0.1 (gender, previous hospitalization)

28 Multivariate Regression
Readmissions within 30-days Risk factors OR 95% CI P value Length of stay* 1.06 0.015 ED visits within 30-days Previous hospital admissions* 1.23 0.035 Divorced* 5.67 0.014 *Statistically significant (P≤0.05), this regression included risk factors with a P<0.1

29 Conclusion: Predictors
Hospitalizations in the previous year was a significant predictor for readmissions and ED visits Divorce and previous hospital admissions were predictive of ED visits while length of hospital stay was predictive of readmissions

30 Results: Interventions by Pharmacists
Secondary Outcome

31 Intervention Group (n=140)

32 Number of Interventions by Type
# % total Type of Intervention 66 33.3% Add drug: untreated condition 29 14.6% Change dosing: incorrect or inappropriate 23 11.6% Discontinue drug: medication without indication 19 9.6% Other intervention 15 7.6% Discontinue drug: therapeutic duplication 12 6.0% Incomplete prescription Cost-savings or third party intervention 10 5.1% Add drug: prevent or treat adverse drug reaction Two slides. In order.

33 Number of Interventions by Type (cont.)
# % total Type of Intervention 6 3.0% Change dosing: dosage form or route 4 2.0% Change dosing: renal adjustment 1 0.5% Change drug: drug interaction Change drug: reverse auto-substitution Allergy clarified or updated 0.0% Change dosing: hepatic adjustment Change dosing: drug interaction Allergy avoided

34 Top Interventions By class: By medication: Anti-infectives 17.79%
Cardiovascular 15.95% Gastrointestinal 12.98% Endocrine 11.66% By medication: Oxycodone: 7 interventions Docusate: 7 interventions Ciprofloxacin, clindamycin, insulin glargine, lisinopril, sulfamethoxazole-trimethoprim: 4 interventions

35 Intervention Acceptance Rate
198 Total number of interventions attempted - 13 Interventions not accepted 185 Total number of accepted interventions 93.4% Intervention acceptance rate

36 Unaccepted Interventions
# unaccepted/total % unaccepted Add drug: Untreated condition 4/66 6.1% Discontinue drug: Medication w/o indication 4/23 17.4% Cost-savings/third-party 2/12 16.7% Change dosing: incorrect 1/29 3.4% Reverse auto-sub 1/1 0% Change dosing: renal 1/4 25%

37 Predictors for Need for Intervention
Multivariate logistic regression to identify predictors for ≥ 1 pharmacist intervention Age, sex, ethnicity, language, length of stay, previous admission in past year, having a primary care provider at admission, number of medications, and Charlson score were NOT predictors for intervention Elaborated on this.

38 Conclusion: Interventions by Pharmacists
Nearly 60% of patients discharge prescriptions warranted some change by a pharmacist Majority of interventions (93%) accepted and implemented by physician No predictors for which patients needed most interventions Pharmacy discharge services beneficial to all patients

39 Results: Cost-benefit Analysis
Secondary Outcome

40 Cost-Benefit Analysis
Net benefit = (CC- CI) Benefit to cost ratio = (CC- CI)/C A ratio greater than 1.0 will demonstrate an overall benefit of the intervention CI = readmission and ED costs, intervention CC = readmission and ED costs, control C = cost of pharmacist intervention Cost-effective analysis, cost-minimization analysis and cost-utility analysis were not used bc they do not compare costs and benefits in monetary units. Essentially, you BENEFIT more than you COST.

41 Mean Costs per Patient Mean (SD) in dollars Difference in dollars
All patients Control (n=139) Intervention (n=140) (95% CI) P value Combined readmissions and ED visits $1, ($5,998.90) $2, ($10,194.97) $ (-$2, to $1,011.56) 0.34 Only patients who incurred cost Control (n=24) Intervention (n=30) $10, ($10,565.96) $13, ($3,800.43) $2,353.26 (-$10,981.23 to $6,274.72) 0.59 T-test bc these are mean costs per patient per group No significant difference in patient costs between groups

42 Intervention Outlier Analysis
Mean (SD) Combined cost for readmissions and ED visits in patients who incurred cost $98,042 $13, ($3,800.43) Initial Length of Stay (days) 56 7.3 (8.1)

43 Mean Costs per Patient Excluding Outlier
Mean (SD) in dollars Difference in dollars All patients Control (n=139) Intervention (n=139) (95% CI) P value Combined readmissions and ED visits $1, ($5,998.90) $2, ($6,210.31) $ (-$1, to $1,164.77) 0.71 Only patients who incurred cost Control (n=24) Intervention (n=29) $10, ($10,565.96) $10, ($10,051.77) $ (-$5, to $6,266.24) 0.84 T-test bc these are mean costs per patient per group

44 Intervention Costs Total pharmacist time cost
Pharmacist cost plus benefits = $68.14 / hour Total hours = hrs Total cost = $7,601.02 Cost per patient $7, / 140 patients = $54.93 / patient 47.8 minutes spent per patient (this included med rec, interventions with MDs and patient counseling)

45 Net benefit per patient
Net Benefit Analysis Net benefit per patient Benefit to Cost Ratio All patients -$961.74 -17.5 All patients who incurred cost -$2,353.26 -42.8 All patients who incurred cost excluding outlier $567.37 10.3

46 Conclusion: Cost-benefit Analysis
A pharmacist-run discharge service consisting of medication reconciliation, patient counseling, and a follow up phone call did not reduce readmission and ED visit costs at UNMH A sub-analysis of only patients who incurred cost with the exclusion of an outlier showed a positive benefit to cost ratio resulting from the intervention

47 Results: Patient Satisfaction
Secondary Outcome

48 Survey Items Explanation of what your medications are for
Explanation of how to take your medications Information the healthcare provider gave you about your problem or condition Information the healthcare provider gave you about possible medication side effects Overall rating of the information you received during discharge Knowledge of the healthcare provider who taught you Friendliness/courtesy of healthcare provider who taught you Answers provided by the healthcare provider to your questions Overall rating of the healthcare provider giving discharge teaching Likert response scale 1=Very Bad, 2=Bad, 3=Fair, 4=Good, 5=Very Good

49 Overall Response Rates

50 Overall Mean Response by Group
Type N Mean of Summed Responses (max score 45) t P value Control 76 40.37 -3.997 <0.0001 Intervention 97 43.14

51 Mean Rank by Group Type N Mean Rank Sum of Ranks P value Control
Transition why both analysis Type N Mean Rank Sum of Ranks P value Control Intervention 76 97 72.30 98.52 5495 9556 <0.0001

52 Response Means by Group
F ratio and P value lambda

53 Conclusion: Patient Satisfaction
Overall pharmacist-run discharge counseling services had higher satisfaction scores when compared to the usual discharge services provided at UNMH The largest differences between groups were seen in Items 1, 2, 4 and 5 Item 1 Explanation of what your medications are for Item 2 Explanation of how to take your medications Item 4 Information the healthcare provider gave you about possible medication side effects Item 5 Overall rating of the information you received during discharge

54 Results: Primary Medication Adherence
Secondary Outcome

55 Primary Medication Adherence
Considered adherent if Picked up medication within 30 days of discharge If did not pick up within 30 days, still considered adherent if Supply of medication at home prior to hospitalization PRN medication Rate of primary adherence Expressed as the number of prescriptions filled divided by the total number of prescriptions written

56 UNM Care Patients for Project PhARMD 698 patients screened
In Project PhARMD 279 patients enrolled (UNM Care) 71 patients Inclusion criteria 66 patients met 5 patients excluded (no Rx written)

57 UNM Care Demographics (n=66)
Characteristic Control (n=27) Intervention (n=39) P-value Age, mean (SD), years 47.6 (16.8) 47.9 (13) 0.25 Male (%) 18 (66.7) 23 (59) 0.52 Primary Language: English (%) 26 (96.3) 33 (84.6) 0.13 Ethnicity (%) White, Non-Hispanic White, Hispanic African American Native American Asian Other 10 (37) 13 (48.1) 2 (7.4) 0 (0) 11 (28.2) 18 (46.2) 4 (10.3) 2 (5.1) 1 (2.6) 3 (7.7) 0.63 Current Primary Care Provider (%) 15 (55.6) 27 (69.2) 0.26 Many similarities

58 UNM Care Demographics (n=66)
Characteristic Control (n=27) Intervention (n=39) P-value Marital Status (%) Single Married Divorced Widower 16 (59.3) 6 (22.2) 4 (14.8) 1 (3.7) 26 (66.7) 6 (15.4) 1 (2.6) 0.62 Length of Stay, days (SD) 6.04 (4.01) 9.49 (11.48) 0.09 Charlson Co-morbidity Index (%) No Risk Mild Moderate Severe 9 (33.3) 5 (18.5) 7 (25.9) 10 (25.6) 12 (30.8) 5 (12.8) 0.51

59 Ordered Discharge Prescriptions
Characteristic Control (n=27) Intervention (n=39) P-value Number of medications, mean (SD) 3.58 (1.84) 4.13 (2.4) 0.95 Number of scheduled medications, mean (SD) 3.04 (1.71) 3.49 (2.37) 0.41 Number of PRN medications, mean (SD) 0.54 (0.76) 0.64 (0.87) 0.63

60 Primary Adherence by Therapeutic Class
Number of Rx’s

61 Primary Medication Adherence Rate
Control (n=27) Intervention (n=39) Primary medication adherence rate (mean, %) 58.5 75.7

62 Mean Rank by Group Type N Mean Rank Sum of Ranks P value Control
Mann-whitney U: Mean rank between groups trending toward significance Type N Mean Rank Sum of Ranks P value Control Intervention 27 39 27.96 36.36 727 1418 0.05

63 Conclusion: Primary Medication Adherence
Pharmacist discharge counseling services yielded a higher primary medication adherence rate in intervention group Rates of primary adherence between groups trending toward statistical significance Intervention group primary adherence rate similar to that seen in literature for primary care

64 Discussion

65 Limitations Study underpowered to detect a difference
A priori power analysis not reflective of study population Low historical readmission rate Excluded patients that would have potentially benefitted Discharged to outside facilities or left hospital prior to counseling Discharge procedure not standardized between pharmacists Patients may have been readmitted to other hospitals Use of estimated costs rather than actual costs Pharmacist interventions were not associated with a cost-savings value Only evaluated primary medication adherence for UNM Care patients Patients could have filled at other pharmacies Potential for selection bias with survey response Health literacy was not assessed No factor analysis conducted to validate survey items The a priori analysis was actually fine but we did not account of the large percentage of patients that would be excluded, especially discharged to home. Not exactly sure what the selection bias was. May need to explain a bit further. Another limitation was the we did not associate a value with the pharmacist interventions in this study.

66 Discussion Study highlighted areas for possible improvement in the discharge process Pharmacist intervention earlier in hospital stay may improve outcomes Patient counseling may have increased patient knowledge of disease state(s) Identifying risk factors for hospital readmissions and ED visits may: Identify patients that would benefit most from discharge counseling Create more patient interaction opportunities for pharmacists Patients satisfaction with the service is high Overall satisfaction rates were high with discharge services in both groups Patients had higher satisfaction with discharge services when pharmacist provided counseling in addition to the usual care

67 Future Research Additional studies need to be done to assess
Pharmacist impact on readmissions and ED visits in a broader population Predictors for readmissions and ED visits in a broader patient population More rigorous studies are needed to examine the effects of pharmacist interventions on readmission and ED visit costs given previous studies demonstrating the cost-effectiveness of CPSs

68 Acknowledgements Gretchen Ray, PharmD, PhC, BCPS
Richard D’Angio, PharmD, BCPS Residency Committee, University of New Mexico Hospital and College of Pharmacy Peggy Beeley, MD Department of Internal Medicine, University of New Mexico Hospital


Download ppt "Pharmacist Assisting at Routine Medical Discharge: Project PhARMD"

Similar presentations


Ads by Google