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Postdischarge interventions by pharmacists and impact on hospital readmission rates
Research
Postdischarge interventions by pharmacists and impact on hospital readmission rates Jessica M. Bellone, Jamie C. Barner, and Debra A. Lopez
Received October 28, 2010, and in revised form April 19, 2011. Accepted for publication April 22, 2011.
Abstract Objectives: To determine whether a difference exists in hospital readmission rates at 60 days postdischarge between patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of discharge and to describe the number and type of pharmacist interventions. Design: Retrospective electronic record review. Setting: Austin, TX, from January 2006 to January 2010. Patients: 131 adult patients aged 18 to 65 years who were on at least three prescription medications. Intervention: Pharmacist visit within 60 days post–hospital discharge. Main outcome measure: Hospital readmission rates at 60 days postdischarge. Results: The intervention and control groups did not differ regarding age or gender, but the control group had a higher percentage of whites, fewer medications, and fewer diseases. Chi-square analyses revealed that of 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days of discharge compared with 12 of 66 (18.2%) intervention group patients (P = 0.0020). Pharmacists provided approximately two interventions per patient. The most frequently provided pharmacist interventions were medication counseling (88.1%) and drug dosage adjustment (52.2%). Conclusion: Patients on multiple prescription medications and with chronic diseases may benefit from a pharmacist visit within 60 days of hospital discharge. However, future studies are needed to further determine the effectiveness of pharmacists’ interventions post–hospital discharge. Keywords: Continuity of care, interventions, hospital readmissions. J Am Pharm Assoc. 2012;52:358–362. doi: 10.1331/JAPhA.2012.10172
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Jessica M. Bellone, PharmD, BCACP, was PGY-2 Ambulatory Care Pharmacy Resident/ Clinical Instructor, College of Pharmacy/ Blackstock Family Practice, University of Texas at Austin, at the time this study was conducted; she is currently Assistant Clinical Professor, Harrison School of Pharmacy, Auburn University, Mobile, AL. Jamie C. Barner, PhD, BSPharm, is Professor, College of Pharmacy, University of Texas at Austin. Debra A. Lopez, PharmD, CDE, BCACP, is Clinical Pharmacist/Clinical Associate Professor, College of Pharmacy/Blackstock Family Practice, University of Texas at Austin. Correspondence: Jessica M. Bellone, PharmD, BCACP, Harrison School of Pharmacy, Auburn University, 650 Clinic Dr., Room 2100, Mobile, AL 36688. Fax: 251-445-9341. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Bob Brown, MS, BSPharm; Anjum Khurshid, PhD, MB BS; and Daniel Brown, MHA, for technical support and data collection. Previous present ation: Alcalde Pharmacy Residency and Leadership Conference, Galveston, TX, April 8–9, 2010.
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he Medicare Payment Advisory Commission reported that up to $12 billion per year are spent on potentially preventable rehospitalizations.1 According to Medicare claims data from 2003 to 2004, patient rehospitalization rates at 60 days were 31.1%, while only 19.6% of patients were rehospitalized at 30 days.1 Of the patients rehospitalized within 30 days, 50.1% did not have an outpatient visit bill.1 The authors concluded that the differences in rehospitalizations were likely a result of increased rates of hospitalization over time, as well as the lack of follow-up care.1 Several organizations have recognized that continuity of care is necessary in providing optimal patient care and reducing hospital readmissions.2–6 The Joint Commission recognizes that communication errors can increase when changes in patient care personnel occur.2 Lack of communication when a patient moves between health care settings has been associated with up to 50% of medication errors in hospitals and up to 20% of adverse drug events.3 A 2011 national patient safety goal for ambulatory health care (NPSG.08.01.01) describes reconciling any medications whenever new medications are ordered or current medications are adjusted upon a patient’s transition of care.2 Clear communication of an accurate medication list when transferring between organizations is an element of performance for ambulatory health care NPSG.03.06.01.4 The Institute for Healthcare Improvement’s How-to Guide for Improving Transitions from the hospital to post–acute care settings incorporates an effective coordination of care plan at discharge
At a Glance Synopsis: Patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of discharge from a hospital were compared to determine whether they differed regarding hospital readmission rates. Of 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days of discharge compared with 12 of 66 (18.2%) intervention group patients (P = 0.0020). The most frequently provided pharmacist interventions were medication counseling (88.1%) and drug dosage adjustment (52.2%). Analysis: Although patients on multiple prescription medications and with chronic diseases may benefit from a pharmacist visit within 60 days of hospital discharge, more research is needed to further determine the effectiveness of pharmacists’ interventions post–hospital discharge. Pharmacists should contribute to processes that ensure each patient’s pharmaceutical care is maintained across care settings. Increased pharmacist involvement in coordinating and collaborating in maintaining medication management among providers across a variety of settings (including hospital, clinic, and the community) could be an important step toward minimizing medication-related adverse events and subsequent hospital readmissions.
Journal of the American Pharmacists Association
across settings in an effort to reduce rehospitalizations.5 Interventions include assessment of postdischarge needs, enhanced teaching and learning, enhanced communication at discharge, and timely follow-up.5 According to the American Society of Health-System Pharmacists (ASHP) Minimum Standards for Pharmaceutical Services in Ambulatory Care, pharmacists should consistently be involved in processes that maintain pharmaceutical care for individual patients across different practice settings.6 The ASHP practice policy for continuity of care is “to recognize that continuity of patient care is a vital requirement for appropriate use of medications.”7 ASHP’s 2015 initiative includes pharmacists routinely counseling patients with complex high-risk medication regimens in 95% of health systems providing clinic care as a goal. 8 Adopting these goals may be one step toward reducing hospital readmissions among patients with multiple and highrisk medications. Few studies exist that assess the impact of pharmacist interventions on hospital readmission rates. These studies primarily focus on pharmacist interventions via telephone followup. Dudas et al.9 investigated whether telephone follow-up to patients within 48 hours after hospitalization improved patient satisfaction and decreased hospital readmissions. During telephone calls, pharmacists addressed patient questions regarding hospital stay, follow-up appointments, and medications. The pharmacist was responsible for addressing problems and notifying the inpatient medical team if warranted.9 Of the 71 patient satisfaction surveys received in the telephone followup group, 86% were very satisfied with medication instruction compared with 61% in the control group (P = 0.007).9 In addition, patients who received a follow-up telephone call from a pharmacist were significantly less likely to have an emergency department visit within 30 days compared with the control group (10% vs. 24%, P = 0.005).9 Although not statistically significant, patients in the telephone group also had a lower frequency of hospital readmissions within 30 days compared with the control group (15% vs. 25%, P = 0.07).9 Another study reviewed pharmacists’ impact on medication discrepancies at discharge and subsequent emergency department visits within 72 hours, 14 days, and 30 days of discharge and hospital readmission rates within 14 days and 30 days.10 Duties of pharmacists included participating in interdisciplinary discharge rounds, interviewing patients, assessing medication lists, performing medication reconciliation, ensuring that a follow-up plan was in place, providing medication counseling, verifying patient understanding, communicating updated medication lists, and providing a follow-up telephone call within 72 hours and 30 days after hospital discharge.10 Medication discrepancies were less likely to occur in the intervention group compared with the control group (33.5% vs. 59.6%, P < 0.001). However, no significant difference in hospital readmission rates at 14 days (P = 0.65) and 30 days (P = 0.17) was observed between the two groups.10 In addition, no significant differences occurred between the two groups regarding emergency department visits within 72 hours (P = 0.60), 14 days (P = 0.51), and 30 days (P = 0.23).10 Although these studies have www. japh a. or g
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shown the impact of pharmacist interventions at discharge and postdischarge telephone follow-up, more information is needed to understand the impact of face-to-face pharmacist visits postdischarge and to characterize the types of interventions provided.
Patients admitted for dialysis treatment, chemotherapy or radiation treatment, or an invasive procedure were excluded. Patients residing in a nursing home, with a documented diagnosis of Alzheimer’s disease or dementia, or with a life expectancy less than 6 months also were excluded.
Objectives
Study variables The primary outcome was hospital readmission at 60 days post–hospital discharge, and the independent variable was whether patients had a pharmacist visit within 60 days postdischarge. Pharmacist interventions included discontinuation/ initiation of drug therapy, dosage adjustments, medication counseling, adherence counseling, and laboratory monitoring. Additional clinical (number of medications and number of diseases) and demographic (age, gender, and race/ethnicity) variables also were collected.
The objectives of this retrospective electronic record review were to determine whether a difference existed in hospital readmission rates at 60 days postdischarge between the intervention group (pharmacist visit) and control group (no pharmacist visit) and to describe pharmacist interventions in the intervention group.
Methods
Study sites This retrospective review was conducted through two institutions: CommUnityCare and Seton University Medical Center at Brackenridge (UMCB) from January 2006 to January 2010. An additional organization, the Integrated Care Collaboration (ICC) served as a “data hub” linking demographic, clinical, and encounter information from the above institutions. CommUnityCare is a not-for-profit corporation of community health centers that provides primary health care services to the medically underserved.11 Pharmacy services are provided in 6 of the 18 CommUnityCare health centers in the Austin, TX, area. The pharmacists in these clinics provide services for a broad range of diseases, including diabetes, hypertension, dyslipidemia, heart failure, asthma, chronic obstructive pulmonary disease, hepatitis C, anticoagulation, smoking cessation, and obesity. The services are outlined in CommUnityCare Health Center’s Clinical Pharmacist Drug Therapy Management protocol and delivered upon written referral from a primary care physician. These clinics also are sites for pharmacy resident training and advanced pharmacy practice experiences. Patients who receive care at CommUnityCare health centers also receive care at UMCB. Seton UMCB, located in Austin, TX, also provides care to an underserved population. UMCB is an academic center, level I trauma center, and certified stroke center.12 ICC is a not-forprofit care collaborative in central Texas. 13 The ICare system of ICC serves as the data hub for patients throughout central Texas and provides community health research for quality improvement.13,14 The ICare system contains patient-specific data such as demographic information, provider encounters, and medications.14 This study was approved by the Seton Family of Hospitals Institutional Review Board, ICC, and CommUnityCare clinics of Austin. Informed consent was not required for this retrospective review. Patient names and other identifiers were removed from data collection sheets and all reports in an effort to preserve confidentiality. Inclusion/exclusion criteria Patients were included if they were adults (aged 18–65 years), had a minimum of three prescription medications, were discharged from an acute care setting (i.e., UMCB), and had a primary care physician located at the CommUnityCare clinics. 360 • JAPhA • 5 2 : 3 • M ay / J u n 2012
Data collection ICC identified an initial sample using the inclusion criteria. Of this group, ICC identified patients who had a pharmacist visit within 60 days of discharge (n = 591) and they pulled a random sample of 200 patients to form the intervention group. The control group consisted of patients who met all inclusion criteria, with the exception of not having a pharmacist encounter. A random sample of 200 patients within the same time frame as the intervention group was selected. The researchers developed a data extraction form for data collection from the ICC data file, CommUnityCare clinic electronic medical record, and UMCB electronic medical record. The ICC data file included hospital admission date(s), discharge date(s), and date of pharmacist visit (if applicable). CommUnityCare electronic records were used to collect demographic information, medications, diseases, and documented pharmacist interventions. UMCB electronic records were cross referenced to verify admission and readmission dates and demographic information. No discrepancies in the data were found; however, the researchers were better able to characterize pharmacist interventions through the CommUnityCare records notes section in the electronic record and to verify that hospital admissions met the inclusion criteria. Data were collected using the data extraction form, from the intervention and control groups (200 patients randomly selected for each group) starting with the most recent readmission date. Statistical analysis To assess differences in hospital readmissions between the intervention and control groups, chi-square analyses were used. Descriptive statistics (means and frequencies) were used to describe the number and type of pharmacist interventions. Additional inferential statistics (i.e., t test and chi-square) were used to assess baseline differences in clinical (number of medications and diseases) and demographic (age, gender, and race/ ethnicity) characteristics between the intervention and control groups. To achieve 80% power (a = 0.05), it was estimated that 75 patients per group would be needed to address the study objectives. SAS version 9.1.3 (SAS Institute, Cary, NC) was used for all statistical analysis.
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Table 1. Baseline characteristics of patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of hospital discharge Characteristic Intervention Control P n 66 65 Age, years (mean ± SD) 47.7 ± 10.5 46.5 ± 10.7 0.5106 Women (%) 68.2 60.0 0.3290 White (%) 20.0 55.4 <0.0001 No. medications (mean ± SD) 8.5 ± 4.5 5.1 ± 2.1 <0.0001 No. diseases (mean ± SD) 5.1 ± 2.0 2.3 ± 1.5 <0.0001 Hospital readmission (%) 18.2 43.1 0.0020
Results Because of resources and time constraints, data were collected for a total of 134 patients (n = 67/group). Two patients in the control group and one patient in the intervention group were excluded because of missing race/ethnicity data. Baseline demographic and clinical characteristics When comparing the intervention and control groups (Table 1), no significant differences in age (P = 0.5106) or gender (P = 0.3290) were noted. However, the control group had a significantly higher percentage of whites (P < 0.0001), fewer medications (P < 0.0001), and fewer diseases (P < 0.0001). Readmissions Of the 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days compared with 12 of 66 patients (18.2%) in the intervention group. Thus, a significantly higher percentage of patients in the control group were readmitted to the hospital (P = 0.0020). Of patients readmitted in the intervention group, 1 was readmitted twice within 60 days, 2 (3.0%) were readmitted three times within 60 days, and 1 was readmitted nine times within 60 days. Of patients readmitted in the control group, 4(6.2%) were readmitted twice within 60 days, 3 (4.6%) were readmitted three or more times within 60 days, and 1 was readmitted seven times within 60 days. Pharmacist interventions In the intervention group, all patients were referred to a clinical pharmacist by a primary care physician and pharmacy services were delivered under the clinical pharmacist drug therapy management protocol. The predetermined appointment length for each patient was 30 minutes. The total number of pharmacist interventions was 122, and the mean (±SD) number of pharmacist interventions per patient was 1.8 ± 0.7. The most frequently provided pharmacist intervention was medication counseling (88.1%), followed by drug dosage adjustment (52.2%), drug addition and discontinuation upon physician approval (20.0%), and laboratory monitoring (16.4%).
Discussion The rates of readmission at 60 days in the intervention group was significantly lower (18.2%) compared with the control group (43.1%). Previous studies assessing pharmacists’ impact on hospital readmission rates had differing results. AcJournal of the American Pharmacists Association
cording to Dudas et al.,9 10% of patients who received a telephone call after hospitalization had an emergency department visit within 30 days and 15% were readmitted to the hospital within 30 days. These percentages are lower than readmission rates in the current study. Potential reasons for this could be differences in setting, time to follow–up, and pharmacist interventions. Dudas et al. called patients within 48 hours of hospital discharge and assessed readmission rates at 30 days rather than 60 days.9 Pharmacist interventions consisted of telephone interviews and included questions regarding access to medications, medication knowledge, adverse effects, and follow-up appointments.9 A telephone intervention within 48 hours may be a more efficient and convenient method of ensuring adequate follow-up and medication understanding. A sooner follow-up visit with a pharmacist also may contribute to necessary patient understanding and overall patient satisfaction. The association of reduced hospital readmissions in the intervention group compared with the control group requires further review. It is important to note that patients in the control group were on fewer medications and had fewer diseases compared with the intervention group; however, the control group had a higher rate of hospital readmissions. This may have been the result of medication counseling, improved patient understanding, and effective drug therapy management provided by pharmacists in the intervention group. Pharmacists should contribute to processes that maintain pharmaceutical care for individual patients across different practice settings according to ASHP’s Minimum Standard for Pharmaceutical Services in Ambulatory Care. 6 A Joint Commission national patient safety goal for 2012 involves updating medication lists and ensuring clear communication when organizations of a patient’s care change.4 The pharmacist could be the designated individual responsible for ensuring accurate medication lists upon transitions in care. In addition, pharmacists becoming more involved in coordinating and collaborating in maintaining medication management among providers across a variety of settings (including hospital, clinic, and the community) could be an important step toward minimizing medication-related adverse events and subsequent hospital readmissions.
Limitations This was a small retrospective review that only included patients admitted to one acute care facility; therefore, patients may have been admitted or readmitted to a different facility, and this was not taken into account because of limited access regarding data collection from other facilities. However, because of the insurance status of the underserved patients, the majority seek care at UMCB because it serves this population primarily. Second, other provider interventions were not considered; thus, attributing positive outcomes regarding hospital readmissions to pharmacists exclusively was not possible. Although patients were chosen randomly, characteristics of the intervention and control groups differed. The control group had significantly more white patients, fewer medications, and fewer diseases. Even with these characteristics, which reflect a population that would be less likely to be rehospitalized, the www. japh a. or g
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group had significantly more readmissions. Thus, these group biases tended to strengthen the study findings. Specific diseases and classes of medications were not included as part of data collection. Identifying specific diseases, reasons for referral to a clinical pharmacist, and types of medications would be important to identifying where pharmacists may have a greater impact after hospital admissions. Details regarding which medications were discontinued or adjusted, specific laboratory parameters, and time allocated to each intervention were not included. A more specific description of the intervention performed by pharmacists would be beneficial to determining potential cost savings and greatest areas of impact. Last, the number of adverse reactions was not collected and included in the results because of difficulty identifying documentation of adverse reactions in the electronic health record. Collecting adverse reactions would be beneficial to making associations with outcomes of adverse events leading to possible hospital admissions.
Conclusion This retrospective review reflected a reduction in hospital readmissions among patients who were on three or more prescription medications, had multiple diseases, and were seen by a pharmacist. Because of limited availability of other provider encounters and interventions, concluding that pharmacist interventions had a direct impact on readmission rates is difficult. The types of medication and diseases need to be considered in future studies to further characterize the strength of pharmacist interventions. Future research is needed to determine whether specific pharmacist interventions have an effect on hospital readmission rates.
3. Resar R. Institute for Healthcare Improvement.Medication reconciliation review. Accessed at www.ihi.org/knowledge/Pages/ Tools/MedicationReconciliationReview.aspx, April 7, 2012. 4. The Joint Commission. Ambulatory health care national patient safety goals. Accessed at www.jointcommission.org/assets/1/6/ NPSG_Chapter_Jan2012_AHC.pdf, April 7, 2012. 5. Rutherford P, Nielson GA, Taylor J, et al. How to guide: improving transitions from the hospital to post-acute care settings to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; 2011. 6. American Society of Health-System Pharmacists. ASHP guidelines: minimum standard for pharmaceutical services in ambulatory care. Am J Health Syst Pharm. 1999;56:1744–53. 7. American Society of Health-System Pharmacists. Medication therapy and patient care: organization and delivery of servicespositions. Accessed at www.ashp.org/DocLibrary/BestPractices/ OrganizationPositions.aspx, January 16, 2011. 8. American Society of Health-System Pharmacists. ASHP HealthSystem Pharmacy Initiative. Accessed at www.ashp.org/DocLibrary/Policy/2015/2015Goals.aspx, January 16, 2011. 9. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111:26–30S. 10. Walker PC, Bernstein SJ, Tucker Jones JN, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169:2003–10. 11. CommUnityCare. Homepage. Accessed at www.communitycaretx.org/about_us.html, January 16, 2011. 12. Seton Healthcare Family. University Medical Center Brackenridge. Accessed at www.seton.net/locations/brackenridge, January 16, 2011.
References
13. Integrated Care Collaboration. About the ICC. Accessed at www. icc-centex.org/aboutus.html, January 16, 2011.
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–28.
14. Integrated Care Collaboration. The ICare system. Accessed at www.icc-centex.org/services.html, January 16, 2011.
2. The Joint Commission. Accreditation program: ambulatory care national patient safety goals. Accessed at www.jointcommission.org/assets/1/6/2011_NPSGs_AHC.pdf, January 9, 2011.
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Journal of the American Pharmacists Association
Postdischarge interventions by pharmacists and impact on hospital readmission rates Jessica M. Bellone, Jamie C. Barner, and Debra A. Lopez
Received October 28, 2010, and in revised form April 19, 2011. Accepted for publication April 22, 2011.
Abstract Objectives: To determine whether a difference exists in hospital readmission rates at 60 days postdischarge between patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of discharge and to describe the number and type of pharmacist interventions. Design: Retrospective electronic record review. Setting: Austin, TX, from January 2006 to January 2010. Patients: 131 adult patients aged 18 to 65 years who were on at least three prescription medications. Intervention: Pharmacist visit within 60 days post–hospital discharge. Main outcome measure: Hospital readmission rates at 60 days postdischarge. Results: The intervention and control groups did not differ regarding age or gender, but the control group had a higher percentage of whites, fewer medications, and fewer diseases. Chi-square analyses revealed that of 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days of discharge compared with 12 of 66 (18.2%) intervention group patients (P = 0.0020). Pharmacists provided approximately two interventions per patient. The most frequently provided pharmacist interventions were medication counseling (88.1%) and drug dosage adjustment (52.2%). Conclusion: Patients on multiple prescription medications and with chronic diseases may benefit from a pharmacist visit within 60 days of hospital discharge. However, future studies are needed to further determine the effectiveness of pharmacists’ interventions post–hospital discharge. Keywords: Continuity of care, interventions, hospital readmissions. J Am Pharm Assoc. 2012;52:358–362. doi: 10.1331/JAPhA.2012.10172
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Jessica M. Bellone, PharmD, BCACP, was PGY-2 Ambulatory Care Pharmacy Resident/ Clinical Instructor, College of Pharmacy/ Blackstock Family Practice, University of Texas at Austin, at the time this study was conducted; she is currently Assistant Clinical Professor, Harrison School of Pharmacy, Auburn University, Mobile, AL. Jamie C. Barner, PhD, BSPharm, is Professor, College of Pharmacy, University of Texas at Austin. Debra A. Lopez, PharmD, CDE, BCACP, is Clinical Pharmacist/Clinical Associate Professor, College of Pharmacy/Blackstock Family Practice, University of Texas at Austin. Correspondence: Jessica M. Bellone, PharmD, BCACP, Harrison School of Pharmacy, Auburn University, 650 Clinic Dr., Room 2100, Mobile, AL 36688. Fax: 251-445-9341. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Bob Brown, MS, BSPharm; Anjum Khurshid, PhD, MB BS; and Daniel Brown, MHA, for technical support and data collection. Previous present ation: Alcalde Pharmacy Residency and Leadership Conference, Galveston, TX, April 8–9, 2010.
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hospital readmission rates Research
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he Medicare Payment Advisory Commission reported that up to $12 billion per year are spent on potentially preventable rehospitalizations.1 According to Medicare claims data from 2003 to 2004, patient rehospitalization rates at 60 days were 31.1%, while only 19.6% of patients were rehospitalized at 30 days.1 Of the patients rehospitalized within 30 days, 50.1% did not have an outpatient visit bill.1 The authors concluded that the differences in rehospitalizations were likely a result of increased rates of hospitalization over time, as well as the lack of follow-up care.1 Several organizations have recognized that continuity of care is necessary in providing optimal patient care and reducing hospital readmissions.2–6 The Joint Commission recognizes that communication errors can increase when changes in patient care personnel occur.2 Lack of communication when a patient moves between health care settings has been associated with up to 50% of medication errors in hospitals and up to 20% of adverse drug events.3 A 2011 national patient safety goal for ambulatory health care (NPSG.08.01.01) describes reconciling any medications whenever new medications are ordered or current medications are adjusted upon a patient’s transition of care.2 Clear communication of an accurate medication list when transferring between organizations is an element of performance for ambulatory health care NPSG.03.06.01.4 The Institute for Healthcare Improvement’s How-to Guide for Improving Transitions from the hospital to post–acute care settings incorporates an effective coordination of care plan at discharge
At a Glance Synopsis: Patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of discharge from a hospital were compared to determine whether they differed regarding hospital readmission rates. Of 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days of discharge compared with 12 of 66 (18.2%) intervention group patients (P = 0.0020). The most frequently provided pharmacist interventions were medication counseling (88.1%) and drug dosage adjustment (52.2%). Analysis: Although patients on multiple prescription medications and with chronic diseases may benefit from a pharmacist visit within 60 days of hospital discharge, more research is needed to further determine the effectiveness of pharmacists’ interventions post–hospital discharge. Pharmacists should contribute to processes that ensure each patient’s pharmaceutical care is maintained across care settings. Increased pharmacist involvement in coordinating and collaborating in maintaining medication management among providers across a variety of settings (including hospital, clinic, and the community) could be an important step toward minimizing medication-related adverse events and subsequent hospital readmissions.
Journal of the American Pharmacists Association
across settings in an effort to reduce rehospitalizations.5 Interventions include assessment of postdischarge needs, enhanced teaching and learning, enhanced communication at discharge, and timely follow-up.5 According to the American Society of Health-System Pharmacists (ASHP) Minimum Standards for Pharmaceutical Services in Ambulatory Care, pharmacists should consistently be involved in processes that maintain pharmaceutical care for individual patients across different practice settings.6 The ASHP practice policy for continuity of care is “to recognize that continuity of patient care is a vital requirement for appropriate use of medications.”7 ASHP’s 2015 initiative includes pharmacists routinely counseling patients with complex high-risk medication regimens in 95% of health systems providing clinic care as a goal. 8 Adopting these goals may be one step toward reducing hospital readmissions among patients with multiple and highrisk medications. Few studies exist that assess the impact of pharmacist interventions on hospital readmission rates. These studies primarily focus on pharmacist interventions via telephone followup. Dudas et al.9 investigated whether telephone follow-up to patients within 48 hours after hospitalization improved patient satisfaction and decreased hospital readmissions. During telephone calls, pharmacists addressed patient questions regarding hospital stay, follow-up appointments, and medications. The pharmacist was responsible for addressing problems and notifying the inpatient medical team if warranted.9 Of the 71 patient satisfaction surveys received in the telephone followup group, 86% were very satisfied with medication instruction compared with 61% in the control group (P = 0.007).9 In addition, patients who received a follow-up telephone call from a pharmacist were significantly less likely to have an emergency department visit within 30 days compared with the control group (10% vs. 24%, P = 0.005).9 Although not statistically significant, patients in the telephone group also had a lower frequency of hospital readmissions within 30 days compared with the control group (15% vs. 25%, P = 0.07).9 Another study reviewed pharmacists’ impact on medication discrepancies at discharge and subsequent emergency department visits within 72 hours, 14 days, and 30 days of discharge and hospital readmission rates within 14 days and 30 days.10 Duties of pharmacists included participating in interdisciplinary discharge rounds, interviewing patients, assessing medication lists, performing medication reconciliation, ensuring that a follow-up plan was in place, providing medication counseling, verifying patient understanding, communicating updated medication lists, and providing a follow-up telephone call within 72 hours and 30 days after hospital discharge.10 Medication discrepancies were less likely to occur in the intervention group compared with the control group (33.5% vs. 59.6%, P < 0.001). However, no significant difference in hospital readmission rates at 14 days (P = 0.65) and 30 days (P = 0.17) was observed between the two groups.10 In addition, no significant differences occurred between the two groups regarding emergency department visits within 72 hours (P = 0.60), 14 days (P = 0.51), and 30 days (P = 0.23).10 Although these studies have www. japh a. or g
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shown the impact of pharmacist interventions at discharge and postdischarge telephone follow-up, more information is needed to understand the impact of face-to-face pharmacist visits postdischarge and to characterize the types of interventions provided.
Patients admitted for dialysis treatment, chemotherapy or radiation treatment, or an invasive procedure were excluded. Patients residing in a nursing home, with a documented diagnosis of Alzheimer’s disease or dementia, or with a life expectancy less than 6 months also were excluded.
Objectives
Study variables The primary outcome was hospital readmission at 60 days post–hospital discharge, and the independent variable was whether patients had a pharmacist visit within 60 days postdischarge. Pharmacist interventions included discontinuation/ initiation of drug therapy, dosage adjustments, medication counseling, adherence counseling, and laboratory monitoring. Additional clinical (number of medications and number of diseases) and demographic (age, gender, and race/ethnicity) variables also were collected.
The objectives of this retrospective electronic record review were to determine whether a difference existed in hospital readmission rates at 60 days postdischarge between the intervention group (pharmacist visit) and control group (no pharmacist visit) and to describe pharmacist interventions in the intervention group.
Methods
Study sites This retrospective review was conducted through two institutions: CommUnityCare and Seton University Medical Center at Brackenridge (UMCB) from January 2006 to January 2010. An additional organization, the Integrated Care Collaboration (ICC) served as a “data hub” linking demographic, clinical, and encounter information from the above institutions. CommUnityCare is a not-for-profit corporation of community health centers that provides primary health care services to the medically underserved.11 Pharmacy services are provided in 6 of the 18 CommUnityCare health centers in the Austin, TX, area. The pharmacists in these clinics provide services for a broad range of diseases, including diabetes, hypertension, dyslipidemia, heart failure, asthma, chronic obstructive pulmonary disease, hepatitis C, anticoagulation, smoking cessation, and obesity. The services are outlined in CommUnityCare Health Center’s Clinical Pharmacist Drug Therapy Management protocol and delivered upon written referral from a primary care physician. These clinics also are sites for pharmacy resident training and advanced pharmacy practice experiences. Patients who receive care at CommUnityCare health centers also receive care at UMCB. Seton UMCB, located in Austin, TX, also provides care to an underserved population. UMCB is an academic center, level I trauma center, and certified stroke center.12 ICC is a not-forprofit care collaborative in central Texas. 13 The ICare system of ICC serves as the data hub for patients throughout central Texas and provides community health research for quality improvement.13,14 The ICare system contains patient-specific data such as demographic information, provider encounters, and medications.14 This study was approved by the Seton Family of Hospitals Institutional Review Board, ICC, and CommUnityCare clinics of Austin. Informed consent was not required for this retrospective review. Patient names and other identifiers were removed from data collection sheets and all reports in an effort to preserve confidentiality. Inclusion/exclusion criteria Patients were included if they were adults (aged 18–65 years), had a minimum of three prescription medications, were discharged from an acute care setting (i.e., UMCB), and had a primary care physician located at the CommUnityCare clinics. 360 • JAPhA • 5 2 : 3 • M ay / J u n 2012
Data collection ICC identified an initial sample using the inclusion criteria. Of this group, ICC identified patients who had a pharmacist visit within 60 days of discharge (n = 591) and they pulled a random sample of 200 patients to form the intervention group. The control group consisted of patients who met all inclusion criteria, with the exception of not having a pharmacist encounter. A random sample of 200 patients within the same time frame as the intervention group was selected. The researchers developed a data extraction form for data collection from the ICC data file, CommUnityCare clinic electronic medical record, and UMCB electronic medical record. The ICC data file included hospital admission date(s), discharge date(s), and date of pharmacist visit (if applicable). CommUnityCare electronic records were used to collect demographic information, medications, diseases, and documented pharmacist interventions. UMCB electronic records were cross referenced to verify admission and readmission dates and demographic information. No discrepancies in the data were found; however, the researchers were better able to characterize pharmacist interventions through the CommUnityCare records notes section in the electronic record and to verify that hospital admissions met the inclusion criteria. Data were collected using the data extraction form, from the intervention and control groups (200 patients randomly selected for each group) starting with the most recent readmission date. Statistical analysis To assess differences in hospital readmissions between the intervention and control groups, chi-square analyses were used. Descriptive statistics (means and frequencies) were used to describe the number and type of pharmacist interventions. Additional inferential statistics (i.e., t test and chi-square) were used to assess baseline differences in clinical (number of medications and diseases) and demographic (age, gender, and race/ ethnicity) characteristics between the intervention and control groups. To achieve 80% power (a = 0.05), it was estimated that 75 patients per group would be needed to address the study objectives. SAS version 9.1.3 (SAS Institute, Cary, NC) was used for all statistical analysis.
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Table 1. Baseline characteristics of patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of hospital discharge Characteristic Intervention Control P n 66 65 Age, years (mean ± SD) 47.7 ± 10.5 46.5 ± 10.7 0.5106 Women (%) 68.2 60.0 0.3290 White (%) 20.0 55.4 <0.0001 No. medications (mean ± SD) 8.5 ± 4.5 5.1 ± 2.1 <0.0001 No. diseases (mean ± SD) 5.1 ± 2.0 2.3 ± 1.5 <0.0001 Hospital readmission (%) 18.2 43.1 0.0020
Results Because of resources and time constraints, data were collected for a total of 134 patients (n = 67/group). Two patients in the control group and one patient in the intervention group were excluded because of missing race/ethnicity data. Baseline demographic and clinical characteristics When comparing the intervention and control groups (Table 1), no significant differences in age (P = 0.5106) or gender (P = 0.3290) were noted. However, the control group had a significantly higher percentage of whites (P < 0.0001), fewer medications (P < 0.0001), and fewer diseases (P < 0.0001). Readmissions Of the 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days compared with 12 of 66 patients (18.2%) in the intervention group. Thus, a significantly higher percentage of patients in the control group were readmitted to the hospital (P = 0.0020). Of patients readmitted in the intervention group, 1 was readmitted twice within 60 days, 2 (3.0%) were readmitted three times within 60 days, and 1 was readmitted nine times within 60 days. Of patients readmitted in the control group, 4(6.2%) were readmitted twice within 60 days, 3 (4.6%) were readmitted three or more times within 60 days, and 1 was readmitted seven times within 60 days. Pharmacist interventions In the intervention group, all patients were referred to a clinical pharmacist by a primary care physician and pharmacy services were delivered under the clinical pharmacist drug therapy management protocol. The predetermined appointment length for each patient was 30 minutes. The total number of pharmacist interventions was 122, and the mean (±SD) number of pharmacist interventions per patient was 1.8 ± 0.7. The most frequently provided pharmacist intervention was medication counseling (88.1%), followed by drug dosage adjustment (52.2%), drug addition and discontinuation upon physician approval (20.0%), and laboratory monitoring (16.4%).
Discussion The rates of readmission at 60 days in the intervention group was significantly lower (18.2%) compared with the control group (43.1%). Previous studies assessing pharmacists’ impact on hospital readmission rates had differing results. AcJournal of the American Pharmacists Association
cording to Dudas et al.,9 10% of patients who received a telephone call after hospitalization had an emergency department visit within 30 days and 15% were readmitted to the hospital within 30 days. These percentages are lower than readmission rates in the current study. Potential reasons for this could be differences in setting, time to follow–up, and pharmacist interventions. Dudas et al. called patients within 48 hours of hospital discharge and assessed readmission rates at 30 days rather than 60 days.9 Pharmacist interventions consisted of telephone interviews and included questions regarding access to medications, medication knowledge, adverse effects, and follow-up appointments.9 A telephone intervention within 48 hours may be a more efficient and convenient method of ensuring adequate follow-up and medication understanding. A sooner follow-up visit with a pharmacist also may contribute to necessary patient understanding and overall patient satisfaction. The association of reduced hospital readmissions in the intervention group compared with the control group requires further review. It is important to note that patients in the control group were on fewer medications and had fewer diseases compared with the intervention group; however, the control group had a higher rate of hospital readmissions. This may have been the result of medication counseling, improved patient understanding, and effective drug therapy management provided by pharmacists in the intervention group. Pharmacists should contribute to processes that maintain pharmaceutical care for individual patients across different practice settings according to ASHP’s Minimum Standard for Pharmaceutical Services in Ambulatory Care. 6 A Joint Commission national patient safety goal for 2012 involves updating medication lists and ensuring clear communication when organizations of a patient’s care change.4 The pharmacist could be the designated individual responsible for ensuring accurate medication lists upon transitions in care. In addition, pharmacists becoming more involved in coordinating and collaborating in maintaining medication management among providers across a variety of settings (including hospital, clinic, and the community) could be an important step toward minimizing medication-related adverse events and subsequent hospital readmissions.
Limitations This was a small retrospective review that only included patients admitted to one acute care facility; therefore, patients may have been admitted or readmitted to a different facility, and this was not taken into account because of limited access regarding data collection from other facilities. However, because of the insurance status of the underserved patients, the majority seek care at UMCB because it serves this population primarily. Second, other provider interventions were not considered; thus, attributing positive outcomes regarding hospital readmissions to pharmacists exclusively was not possible. Although patients were chosen randomly, characteristics of the intervention and control groups differed. The control group had significantly more white patients, fewer medications, and fewer diseases. Even with these characteristics, which reflect a population that would be less likely to be rehospitalized, the www. japh a. or g
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group had significantly more readmissions. Thus, these group biases tended to strengthen the study findings. Specific diseases and classes of medications were not included as part of data collection. Identifying specific diseases, reasons for referral to a clinical pharmacist, and types of medications would be important to identifying where pharmacists may have a greater impact after hospital admissions. Details regarding which medications were discontinued or adjusted, specific laboratory parameters, and time allocated to each intervention were not included. A more specific description of the intervention performed by pharmacists would be beneficial to determining potential cost savings and greatest areas of impact. Last, the number of adverse reactions was not collected and included in the results because of difficulty identifying documentation of adverse reactions in the electronic health record. Collecting adverse reactions would be beneficial to making associations with outcomes of adverse events leading to possible hospital admissions.
Conclusion This retrospective review reflected a reduction in hospital readmissions among patients who were on three or more prescription medications, had multiple diseases, and were seen by a pharmacist. Because of limited availability of other provider encounters and interventions, concluding that pharmacist interventions had a direct impact on readmission rates is difficult. The types of medication and diseases need to be considered in future studies to further characterize the strength of pharmacist interventions. Future research is needed to determine whether specific pharmacist interventions have an effect on hospital readmission rates.
3. Resar R. Institute for Healthcare Improvement.Medication reconciliation review. Accessed at www.ihi.org/knowledge/Pages/ Tools/MedicationReconciliationReview.aspx, April 7, 2012. 4. The Joint Commission. Ambulatory health care national patient safety goals. Accessed at www.jointcommission.org/assets/1/6/ NPSG_Chapter_Jan2012_AHC.pdf, April 7, 2012. 5. Rutherford P, Nielson GA, Taylor J, et al. How to guide: improving transitions from the hospital to post-acute care settings to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; 2011. 6. American Society of Health-System Pharmacists. ASHP guidelines: minimum standard for pharmaceutical services in ambulatory care. Am J Health Syst Pharm. 1999;56:1744–53. 7. American Society of Health-System Pharmacists. Medication therapy and patient care: organization and delivery of servicespositions. Accessed at www.ashp.org/DocLibrary/BestPractices/ OrganizationPositions.aspx, January 16, 2011. 8. American Society of Health-System Pharmacists. ASHP HealthSystem Pharmacy Initiative. Accessed at www.ashp.org/DocLibrary/Policy/2015/2015Goals.aspx, January 16, 2011. 9. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111:26–30S. 10. Walker PC, Bernstein SJ, Tucker Jones JN, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169:2003–10. 11. CommUnityCare. Homepage. Accessed at www.communitycaretx.org/about_us.html, January 16, 2011. 12. Seton Healthcare Family. University Medical Center Brackenridge. Accessed at www.seton.net/locations/brackenridge, January 16, 2011.
References
13. Integrated Care Collaboration. About the ICC. Accessed at www. icc-centex.org/aboutus.html, January 16, 2011.
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–28.
14. Integrated Care Collaboration. The ICare system. Accessed at www.icc-centex.org/services.html, January 16, 2011.
2. The Joint Commission. Accreditation program: ambulatory care national patient safety goals. Accessed at www.jointcommission.org/assets/1/6/2011_NPSGs_AHC.pdf, January 9, 2011.
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