Medication Reconciliation: The Inpatient Hospitalist Perspective Quality is Personal 4/22/2017 Medication Reconciliation: The Inpatient Hospitalist Perspective Peter Kaboli, MD, MS Iowa City VAMC CRIISP (Center for Research in the Implementation of Innovative Strategies in Practice) University of Iowa, Iowa City, IA AHRQ-Washington, D.C. September 27, 2007 ECS 117

JCAHO Definition of Med Reconciliation Quality is Personal 4/22/2017 JCAHO Definition of Med Reconciliation The process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. Due to the lack of reliability of the medical record as an accurate source of medication history, many groups advocate computerized medication profiles and physician order entry. ECS 117

Is Med Reconciliation New? Absolutely not. JCAHO & IOM put it into the spotlight. Transitions of care have always been a problem. EMRs help, but don’t fix problem (VA). Fragmented care is the norm, even as far back as 1872.

Beethoven's Doctor Accidentally Poisoned Him, Pathologist Claims Wednesday, August 29, 2007             VIENNA, AUSTRIA —  DID SOMEONE KILL BEETHOVEN? A VIENNESE PATHOLOGIST CLAIMS THE COMPOSER'S PHYSICIAN DID — INADVERTENTLY OVERDOSING HIM WITH LEAD IN A CASE OF A CURE THAT WENT WRONG. OTHER RESEARCHERS ARE NOT CONVINCED, BUT THERE IS NO CONTROVERSY ABOUT ONE FACT: THE MASTER HAD BEEN A VERY SICK MAN YEARS BEFORE HIS DEATH IN 1827.

Are Computerized Med Lists Accurate? Quality is Personal 4/22/2017 Are Computerized Med Lists Accurate? 493 older veterans on >5 medications Pharmacist “brown bag” interview Mean of 12.4 regularly scheduled meds range 5-49 8.0 Rx, 2.9 OTC, 1.5 vitamins/herbals Kaboli, et al. Assessing the Accuracy of Computerized Medication Histories, AJMC. 2004;10;872-877 ECS 117

Agreement Definitions % of Patients with Perfect Agreement between the interview and computer Omissions: meds not on computer profile, but being taken by the patient Commissions: meds on the computer profile, but not being taken by the patient

Findings Only 5.3% of patients had perfect agreement Omissions: 1.3 medications per patient 25% of all medications omitted Commissions: 12.6% of all medications not being taken 23% of Allergies and 64% of ADEs missing Impossible to have 100% accuracy all the time

34% of omissions were prescription drugs Top 5 Omissions By Drug Class By Drug Name Vitamins 26% Aspirin 10.4% Anticoag/platelet 12% Multivitamin 8.2% GI 12% Acetaminophen 6.7% Herbals 9.2% Calcium 5.4% Cardiovascular 8.2% Vitamin E 4.2% 34% of omissions were prescription drugs

66% of commissions were prescription drugs Top 5 Commissions By Drug Class By Drug Name Cardiovascular 16% Aspirin 5.0% Derm/Topicals 13% Docusate 3.5% GI 12% Diuretics 3.5% Respiratory 9.3% Albuterol 3.1% NSAID/COX-II 7.4% Tylenol 2.8% 66% of commissions were prescription drugs

Other findings from our VA outpatient clinical pharmacist/physician intervention: Health literacy was associated with medication knowledge, but NOT with taking meds correctly or ADEs at 6 and 12 months. Outpatient pharmacist/physician evaluation can improve medication appropriateness, but hard to show improved clinical outcomes (ADEs). Patients are just as likely to NOT be taking a recommended medication as they are to be taken extra medications (polypharmacy).

Implementing Med Reconciliation Kaboli, et al Implementing Med Reconciliation Kaboli, et al. Clinical Pharmacists and Inpatient Medical Care: A Systematic Review. Arch Int Med, 166, May 8, 2006 Clinical Pharmacists 11 RCTs of Admission and/or Discharge Med Reconciliation ↓ Preventable ADEs ↓ Time to input allergy information ↓ Readmission ↑ Medication knowledge ↑ Medication appropriateness ↑ Compliance Why wouldn’t a clinical pharmacist help? Unfortunately not cheap or available 24-7

Clinical Pharmacist Intervention Schnipper, et al Clinical Pharmacist Intervention Schnipper, et al. Role of Pharmacist Counseling in Preventing ADEs After Hospitalization. Arch Int Med, 166, Mar 13, 2006. Discharge counseling with 3-5 day follow-up phone call (N=178). 30 day Preventable ADE rate 11% vs. 1%, but not all ADES Half of patients had discrepancies from pre-admit to discharge Did not improve medication adherence or ED/hospital re-admission

Inpatient Clinical Pharmacists: Roles Careful review of med lists, including contacting local pharmacy if necessary Rounding with team, especially in ICU Make recommendations to inpatient team at admit and/or discharge Ensure patients get medications 3-5 day follow-up phone calls Are they “better” than physicians or nurses?

What works for you? Clinical pharmacists Hospitalists Residents Nurses Pharmacy students Pharmacy techs

Summary Keys for Success Pharmacist and Physician champions Electronic or paper format Team accountability Involvement of patient/family Health literacy and social support Discharge counseling Communication to primary care or SNF and outpatient pharmacy Follow-up phone call