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Pharmacist Assisting at Routine Medical Discharge: Project PhARMD Preeyaporn Sarangarm, PharmD Stanley Snowden, PharmD Lisa Koselke, PharmD Thomas Dilworth,

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Presentation on theme: "Pharmacist Assisting at Routine Medical Discharge: Project PhARMD Preeyaporn Sarangarm, PharmD Stanley Snowden, PharmD Lisa Koselke, PharmD Thomas Dilworth,"— 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 1 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 2

3 Background  The American College of Clinical Pharmacists reviewed the literature between 2001 and 2005 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 3 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 4

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 5 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 6

7 Methods 7

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 8

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 9

10 Methods: Flow of Patients hours post- discharge 30 days post- discharge Prior to discharge 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 Survey given and collected Follow-up Phone Call Review patients for readmissions and ED visits 10

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 11

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 12

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 13

14 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:

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 15

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

17 Study Recruitment and Flow 17

18 Demographics (n=279) 18 *All values reported as n (%) unless specified otherwise Characteristic Control (n=139) Intervention (n=140)P-value Age, mean (SD), years50.4 (16.5)49.0 (15.8)0.48 Male81 (58.3)75 (53.6)0.43 Primary Language: English129 (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) 16 (11.4) 0.23

19 Demographics (n=279) 19 Characteristic Control (n=139) Intervention (n=140)P-value Current Primary Care Provider80 (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), days6.1 (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), miles57.4 (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) N (%)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) Related readmission or ED visit19/24 (79.2)23/30 (76.7)

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=

23 Conclusion: 30-day Readmissions and ED visits  Pharmacist discharge counseling services did not significantly improve 30-day hospital readmissions and ED visits 23

24 Secondary Outcome Results: Predictors for Readmission and ED Visits 24

25 Risk Factors for Combined 30-day ED Visits and Readmissions Risk factors No readmission/ED visit (n=225) Readmission/ED visit (n=54)P value Age, mean (SD), years49.7 (15.8)49.5 (17.5)0.93 Primary care provider132 (58.7)32 (59.3)0.94 Primary Language: English202 (89.8)48 (88.9)0.85 Male 132 (58.7)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) 0.93 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) *All values reported as n (%) unless specified otherwise

26 Risk Factors for Combined 30-day ED Visits and Readmissions Risk factors 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), miles71.4 (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)0.19 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) *All values reported as n (%) unless specified otherwise

27 Multivariate Regression Logistic regression for ED visits and readmissions within 30 days post- discharge Risk factorsOR95% CIP value Previous hospital admissions*  No  Yes *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 factorsOR95% CIP value Length of stay* ED visits within 30-days Risk factorsOR95% CIP value Previous hospital admissions* Divorced* *Statistically significant (P≤0.05), this regression included risk factors with a P<0.1 28

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 29

30 Secondary Outcome Results: Interventions by Pharmacists 30

31 Intervention Group (n=140)

32 Number of Interventions by Type #% totalType of Intervention %Add drug: untreated condition %Change dosing: incorrect or inappropriate %Discontinue drug: medication without indication 199.6%Other intervention 157.6%Discontinue drug: therapeutic duplication 126.0%Incomplete prescription 126.0%Cost-savings or third party intervention 105.1%Add drug: prevent or treat adverse drug reaction 126.0%Cost-savings or third party intervention 32

33 Number of Interventions by Type (cont.) #% totalType of Intervention 63.0%Change dosing: dosage form or route 42.0%Change dosing: renal adjustment 10.5%Change drug: drug interaction 10.5%Change drug: reverse auto-substitution 10.5%Allergy clarified or updated 00.0%Change dosing: hepatic adjustment 00.0%Change dosing: drug interaction 00.0%Allergy avoided 33

34 Top Interventions  By class:  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 34

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

36 Unaccepted Interventions Intervention# unaccepted/total% unaccepted Add drug: Untreated condition 4/666.1% Discontinue drug: Medication w/o indication 4/2317.4% Cost-savings/third-party 2/1216.7% Change dosing: incorrect 1/293.4% Reverse auto-sub 1/10% Change dosing: renal 1/425% 36

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 37

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 38

39 Secondary Outcome Results: Cost-benefit Analysis 39

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 40

41 Mean Costs per Patient Mean (SD) in dollarsDifference 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)(95% CI) P value Combined readmissions and ED visits $10, ($10,565.96) $13, ($3,800.43) $2, (-$10, to $6,274.72)

42 Intervention Outlier Analysis Outlier Intervention 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) (8.1) 42

43 Mean Costs per Patient Excluding Outlier Mean (SD) in dollarsDifference 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)(95% CI) P value Combined readmissions and ED visits $10, ($10,565.96) $10, ($10,051.77) $ (-$5, to $6,266.24)

44 Intervention Costs  Total pharmacist time cost  Pharmacist cost plus benefits = $68.14 / hour  Total hours = hrs  Total cost = $7,  Cost per patient $7, / 140 patients = $54.93 / patient 44

45 Net Benefit Analysis Net benefit per patient Benefit to Cost Ratio All patients-$ All patients who incurred cost -$2, All patients who incurred cost excluding outlier $

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 46

47 Secondary Outcome Results: Patient Satisfaction 47

48 Survey Items 1.Explanation of what your medications are for 2.Explanation of how to take your medications 3.Information the healthcare provider gave you about your problem or condition 4.Information the healthcare provider gave you about possible medication side effects 5.Overall rating of the information you received during discharge 6.Knowledge of the healthcare provider who taught you 7.Friendliness/courtesy of healthcare provider who taught you 8.Answers provided by the healthcare provider to your questions 9.Overall rating of the healthcare provider giving discharge teaching Likert response scale 1=Very Bad, 2=Bad, 3=Fair, 4=Good, 5=Very Good 48

49 Overall Response Rates 49

50 50 Overall Mean Response by Group TypeN Mean of Summed Responses (max score 45)tP value Control < Intervention

51 51 Mean Rank by Group TypeNMean RankSum of RanksP value Control Intervention <0.0001

52 Response Means by Group 52

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 53

54 Secondary Outcome Results: Primary Medication Adherence 54

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 55

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

57 UNM Care Demographics (n=66) Characteristic Control (n=27) Intervention (n=39)P-value Age, mean (SD), years47.6 (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)

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 6 (22.2) 9 (33.3) 5 (18.5) 7 (25.9) 10 (25.6) 12 (30.8) 5 (12.8)

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)

60 Primary Adherence by Therapeutic Class 60 Number of Rx’s

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

62 62 Mean Rank by Group TypeNMean RankSum of RanksP value Control Intervention

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 63

64 Discussion 64

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 65

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 66

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 67

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 68


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