Presentation on theme: "Pharmacist Assisting at Routine Medical Discharge: Project PhARMD"— Presentation transcript:
1Pharmacist Assisting at Routine Medical Discharge: Project PhARMD Preeyaporn Sarangarm, PharmDStanley Snowden, PharmDLisa Koselke, PharmDThomas Dilworth, PharmDMatthew London, PharmDChristian Sanchez, PharmDPGY1 Pharmacy Practice ResidentsUniversity of New Mexico Hospital
2BackgroundApproximately 20% of patients experience an adverse event after dischargeUp to 60% are medication related and preventableResults in costly healthcare utilizationPharmacist discharge counseling has shown mixed results in reducing health care utilizationHospital readmissionsED visits
3BackgroundThe 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 savedNo study has examined the cost-effectiveness of an inpatient pharmacist discharge serviceThe 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.
4BackgroundHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)July 2007 Inpatient Prospective Payment System (IPPS) linked to compliance with HCAHPSPatient Protection and Affordable Care Act of 2010HCAHPS will be one of the measures used to calculateValue-based incentive payments (October 2012)Value-based incentive purchasingPatient perception has a significant effect on hospital incomeEarnings of $4980 per bed linked to one point gain in satisfactionPatients with higher satisfaction ratings of hospital services are less likely to enter into malpractice suits
5BackgroundWhen chronic disease states are treated ineffectively, complications of the disease may lead to increased use of hospital, ED, and other medical resourcesMedication non-adherence is related to greater morbidity and mortality in chronic diseaseEstimated to increase healthcare costs by over $170 billion annually in this countryIncreased adherence has the potential to generate medical savings that more than offset the associated increases in drug costsUnderutilization of prescription medicines is a problem in U.S.Many patients are not taking the medications prescribed to them by health care providersBenner 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.
6Study ObjectivePrimary Outcome: To evaluate the impact of pharmacist discharge counseling on a combined endpoint of 30-day post-discharge hospital readmissions and ED visitsSecondary Outcomes:Determine predictors for readmission/ED visitsDescribe the number and type of interventionsConduct a cost-benefit analysisImprove patient satisfactionIncrease primary medication adherence
8Methods: Study Design Single center, prospective intervention study Number of patientsHistorical hospital data:30-day readmission rate: 12.3%30-day ED visits: 13.0%Excludes patients who were subsequently admittedA priori power analysis:292 patients in each study group33% reduction in the combined endpointPower=80%, α=0.05
9Methods: Patient Selection Inclusion criteria:Discharged from internal medicine serviceEnglish or Spanish speakingExclusion criteria:Less than 18 years of ageUnable or unwilling to receive counselingDischarged to anywhere other than homePlanned readmissionPrevious inclusion into the study
10Methods: Flow of Patients Study introduction to patientControl Group:Usual Discharge Care OnlySurvey given and collectedReview patients for readmissions and ED visitsIntervention Group:Usual Care plus Counseling by a Pharmacy ResidentFollow-upPhone CallPrior to discharge30 days post-discharge36-72 hours post-dischargeDESCRIBE REGULAR DISCHARGE PROCESSSAY STANDARDIZED FOLLOW UP PHONE CALL
11Method: Discharge Services Prescription reviewMedication reconciliationCompleteness of prescriptionsDuplicative, unnecessary or incomplete therapyDrug interactionsInsurance coverage/ability to pick up medicationsCounselingMedication information and administrationSide effectsDisease state education
12Methods: Survey Distribution Upon completion of discharge counseling, patients were given the anonymous English or Spanish surveyPatients were then left in their room to fill out the survey without the pharmacist presentSurveys were placed within the provided envelope by the patient and collected prior to the patient leaving the hospitalPatients unable or unwilling to complete the survey were not included in the analysisThis 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.
13Methods: Data Collection Upon discharge:Patient demographicsAdmission informationNumber of prior readmissionsNumber of medications at dischargePharmacist interventions and time spentAt 30 days post-discharge:Number of hospital readmissions or ED visits and reason/diagnosisMedication fill history from the UNMH Outpatient Pharmacy for UNM care patientsCost data:Estimated patient charges for readmissions and ED visitsPharmacist salary plus benefitsConverted charges to costs using UNMH cost to charge ratioAdmission information = PMH, discharge diagnosis, length of stay
14Methods: Intervention Classification Discontinue drugTherapeutic duplicationMedication without indicationAdverse drug reaction (ADR)Add drugUntreated conditionPrevent or treat ADRChange drugDrug interactionActual or potential ADRReverse auto-substitutionChange dosingIncorrect or inappropriateDrug interactionRenal adjustmentHepatic adjustmentAllergiesAllergy updated or clarifiedAllergy avoidedIncomplete prescriptionOtherBayley BK, et al. Ther Clin Risk Manag. 2007; 3:14
15Methods: Data Analysis Data was analyzed in SPSS (version 18)Univariate analysis:Chi-square for categorical variablesT-test for continuous variablesMultivariate analysis:Multiple logistic regressionMANOVANonparametric analysis:Mann-Whitney U test
16Results: 30-day Readmission and ED visits Primary Outcome
2130-day Readmissions and ED Visits (Univariate Analysis) Control(n=139)N (%)Intervention(n=140)P-valueCombined 30-day readmissions and ED visits30-day hospital readmission30-day ED visits24 (17.3)16 (11.5)11 (7.9)30 (21.4)20 (14.3)17 (12.1)0.340.490.24Related readmission or ED visit19/24 (79.2)23/30 (76.7)0.83
2230-day Readmissions and ED Visits (Multivariate Analysis) Multivariate logistic regressionAdjusted for confounders that could potentially influence the outcomeFactors in univariate analysis with p<0.1: sex and insuranceNo difference in readmissions and ED visitsOR 1.25 (95%CI ), p=0.48
23Conclusion: 30-day Readmissions and ED visits Pharmacist discharge counseling services did not significantly improve 30-day hospital readmissions and ED visitsWould move this conclusion up to the previous slide where you show the stats and OR.
24Results: Predictors for Readmission and ED Visits Secondary Outcome
25Risk Factors for Combined 30-day ED Visits and Readmissions No readmission/ED visit(n=225)Readmission/ED visit(n=54)P valueAge, mean (SD), years49.7 (15.8)49.5 (17.5)0.93Primary care provider132 (58.7)32 (59.3)0.94Primary Language: English202 (89.8)48 (88.9)0.85Male24 (44.4)0.06Insurance statusPublic InsuranceUNM CarePrivate InsuranceNo Insurance98 (43.6)54 (24)30 (13.3)43 (19.1)23 (42.6)15 (27.8)6 (11.1)10 (18.5)Marital statusMarriedSingleSeparated/DivorcedWidower65 (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
26Risk Factors for Combined 30-day ED Visits and Readmissions No readmission or ED visit(n=225)Readmission or ED visit(n=54)P valueEthnicityWhiteHispanicBlackNative AmericanOther73 (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)0.19Distance from the hospital, mean (SD), miles71.4 (186.14)57.1 (120.98)0.59Length of hospital stay, mean (SD)6.4 (6.35)7.7 (8.48)0.20Previous hospital admissions, mean (SD)0.6 (1.18)1.3 (2.40)0.002Charlson 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)0.17Meds post reconciliation, mean (SD)5.5 (5.21)7.3 (5.06)0.10*All values reported as n (%) unless specified otherwise
27Multivariate Regression Logistic regression for ED visits and readmissions within 30 days post-dischargeRisk factorsOR95% CIP valuePrevious hospital admissions*NoYes--1.260.008*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1 (gender, previous hospitalization)
28Multivariate Regression Readmissions within 30-daysRisk factorsOR95% CIP valueLength of stay*1.060.015ED visits within 30-daysPrevious hospital admissions*1.230.035Divorced*5.670.014*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1
29Conclusion: Predictors Hospitalizations in the previous year was a significant predictor for readmissions and ED visitsDivorce and previous hospital admissions were predictive of ED visits while length of hospital stay was predictive of readmissions
30Results: Interventions by Pharmacists Secondary Outcome
32Number of Interventions by Type #% totalType of Intervention6633.3%Add drug: untreated condition2914.6%Change dosing: incorrect or inappropriate2311.6%Discontinue drug: medication without indication199.6%Other intervention157.6%Discontinue drug: therapeutic duplication126.0%Incomplete prescriptionCost-savings or third party intervention105.1%Add drug: prevent or treat adverse drug reactionTwo slides. In order.
33Number of Interventions by Type (cont.) #% totalType of Intervention63.0%Change dosing: dosage form or route42.0%Change dosing: renal adjustment10.5%Change drug: drug interactionChange drug: reverse auto-substitutionAllergy clarified or updated0.0%Change dosing: hepatic adjustmentChange dosing: drug interactionAllergy avoided
37Predictors for Need for Intervention Multivariate logistic regression to identify predictors for ≥ 1 pharmacist interventionAge, 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 interventionElaborated on this.
38Conclusion: Interventions by Pharmacists Nearly 60% of patients discharge prescriptions warranted some change by a pharmacistMajority of interventions (93%) accepted and implemented by physicianNo predictors for which patients needed most interventionsPharmacy discharge services beneficial to all patients
40Cost-Benefit Analysis Net benefit = (CC- CI)Benefit to cost ratio = (CC- CI)/CA ratio greater than 1.0 will demonstrate an overall benefit of the interventionCI = readmission and ED costs, interventionCC = readmission and ED costs, controlC = cost of pharmacist interventionCost-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.
41Mean Costs per Patient Mean (SD) in dollars Difference in dollars All patientsControl (n=139)Intervention (n=140)(95% CI)P valueCombined readmissions and ED visits$1, ($5,998.90)$2, ($10,194.97)$ (-$2, to $1,011.56)0.34Only patients who incurred costControl (n=24)Intervention (n=30)$10, ($10,565.96)$13, ($3,800.43)$2,353.26(-$10,981.23to $6,274.72)0.59T-test bc these are mean costs per patient per groupNo significant difference in patient costs between groups
42Intervention 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)567.3 (8.1)
43Mean Costs per Patient Excluding Outlier Mean (SD) in dollarsDifference in dollarsAll patientsControl (n=139)Intervention (n=139)(95% CI)P valueCombined readmissions and ED visits$1, ($5,998.90)$2, ($6,210.31)$ (-$1, to $1,164.77)0.71Only patients who incurred costControl (n=24)Intervention (n=29)$10, ($10,565.96)$10, ($10,051.77)$ (-$5, to $6,266.24)0.84T-test bc these are mean costs per patient per group
44Intervention Costs Total pharmacist time cost Pharmacist cost plus benefits = $68.14 / hourTotal hours = hrsTotal cost = $7,601.02Cost per patient$7, / 140 patients = $54.93 / patient47.8 minutes spent per patient (this included med rec, interventions with MDs and patient counseling)
45Net benefit per patient Net Benefit AnalysisNet benefit per patientBenefit to Cost RatioAll patients-$961.74-17.5All patients who incurred cost-$2,353.26-42.8All patients who incurred cost excluding outlier$567.3710.3
46Conclusion: 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 UNMHA 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
48Survey Items Explanation of what your medications are for Explanation of how to take your medicationsInformation the healthcare provider gave you about your problem or conditionInformation the healthcare provider gave you about possible medication side effectsOverall rating of the information you received during dischargeKnowledge of the healthcare provider who taught youFriendliness/courtesy of healthcare provider who taught youAnswers provided by the healthcare provider to your questionsOverall rating of the healthcare provider giving discharge teachingLikert response scale1=Very Bad, 2=Bad, 3=Fair, 4=Good, 5=Very Good
50Overall Mean Response by Group TypeNMean of Summed Responses(max score 45)tP valueControl7640.37-3.997<0.0001Intervention9743.14
51Mean Rank by Group Type N Mean Rank Sum of Ranks P value Control Transition why both analysisTypeNMean RankSum of RanksP valueControlIntervention769772.3098.5254959556<0.0001
52Response Means by Group F ratio and P value lambda
53Conclusion: Patient Satisfaction Overall pharmacist-run discharge counseling services had higher satisfaction scores when compared to the usual discharge services provided at UNMHThe largest differences between groups were seen in Items 1, 2, 4 and 5Item 1 Explanation of what your medications are forItem 2 Explanation of how to take your medicationsItem 4 Information the healthcare provider gave you about possible medication side effectsItem 5 Overall rating of the information you received during discharge
55Primary Medication Adherence Considered adherent ifPicked up medication within 30 days of dischargeIf did not pick up within 30 days, still considered adherent ifSupply of medication at home prior to hospitalizationPRN medicationRate of primary adherenceExpressed as the number of prescriptions filled divided by the total number of prescriptions written
56UNM Care Patients for Project PhARMD 698 patients screened In Project PhARMD279 patients enrolled(UNM Care)71 patientsInclusion criteria66 patients met5 patients excluded(no Rx written)
58UNM Care Demographics (n=66) CharacteristicControl (n=27)Intervention (n=39)P-valueMarital Status (%)SingleMarriedDivorcedWidower16 (59.3)6 (22.2)4 (14.8)1 (3.7)26 (66.7)6 (15.4)1 (2.6)0.62Length of Stay, days (SD)6.04 (4.01)9.49 (11.48)0.09Charlson Co-morbidity Index (%)No RiskMildModerateSevere9 (33.3)5 (18.5)7 (25.9)10 (25.6)12 (30.8)5 (12.8)0.51
59Ordered Discharge Prescriptions CharacteristicControl (n=27)Intervention (n=39)P-valueNumber of medications, mean (SD)3.58 (1.84)4.13 (2.4)0.95Number of scheduled medications, mean (SD)3.04 (1.71)3.49 (2.37)0.41Number of PRN medications,mean (SD)0.54 (0.76)0.64 (0.87)0.63
60Primary Adherence by Therapeutic Class Number of Rx’s
62Mean Rank by Group Type N Mean Rank Sum of Ranks P value Control Mann-whitney U: Mean rank between groups trending toward significanceTypeNMean RankSum of RanksP valueControlIntervention273927.9636.3672714180.05
63Conclusion: Primary Medication Adherence Pharmacist discharge counseling services yielded a higher primary medication adherence rate in intervention groupRates of primary adherence between groups trending toward statistical significanceIntervention group primary adherence rate similar to that seen in literature for primary care
65Limitations Study underpowered to detect a difference A priori power analysis not reflective of study populationLow historical readmission rateExcluded patients that would have potentially benefittedDischarged to outside facilities or left hospital prior to counselingDischarge procedure not standardized between pharmacistsPatients may have been readmitted to other hospitalsUse of estimated costs rather than actual costsPharmacist interventions were not associated with a cost-savings valueOnly evaluated primary medication adherence for UNM Care patientsPatients could have filled at other pharmaciesPotential for selection bias with survey responseHealth literacy was not assessedNo factor analysis conducted to validate survey itemsThe 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.
66DiscussionStudy highlighted areas for possible improvement in the discharge processPharmacist intervention earlier in hospital stay may improve outcomesPatient 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 counselingCreate more patient interaction opportunities for pharmacistsPatients satisfaction with the service is highOverall satisfaction rates were high with discharge services in both groupsPatients had higher satisfaction with discharge services when pharmacist provided counseling in addition to the usual care
67Future Research Additional studies need to be done to assess Pharmacist impact on readmissions and ED visits in a broader populationPredictors for readmissions and ED visits in a broader patient populationMore 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
68Acknowledgements Gretchen Ray, PharmD, PhC, BCPS Richard D’Angio, PharmD, BCPSResidency Committee, University of New Mexico Hospital and College of PharmacyPeggy Beeley, MDDepartment of Internal Medicine, University of New Mexico Hospital