Pharmacist Assisting at Routine Medical Discharge:

Project PhARMDPreeyaporn Sarangarm, PharmD

Stanley Snowden, PharmDLisa Koselke, PharmD

Thomas Dilworth, PharmDMatthew London, PharmD

Christian Sanchez, PharmD

1PGY1 Pharmacy Practice ResidentsUniversity of New Mexico Hospital

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

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

3Perez A et al. Pharmacotherapy. 2008;28(11): 285e-323e.

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

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

5Benner 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.

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

Methods

7

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

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

Methods: Flow of Patients

10

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

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

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

Methods: Intervention ClassificationDiscontinue 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; 3:695-703.

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

Primary Outcome

Results: 30-day Readmission and ED visits

16

Study Recruitment and Flow

17

Demographics (n=279)

18*All values reported as n (%) unless specified otherwise

CharacteristicControl(n=139)

Intervention

(n=140)P-

value

Age, mean (SD), years 50.4 (16.5)

49.0 (15.8) 0.48

Male 81 (58.3) 75 (53.6) 0.43

Primary Language: English 129 (92.8)

121 (86.4) 0.08

EthnicityWhite, non-HispanicWhite, HispanicAfrican AmericanNative AmericanOther

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 StatusSingleMarriedSeparated/Divorced/Widower

 79 (56.8)40 (28.8)20 (14.4)

  90 (64.3)34 (24.3)16 (11.4)

0.23

Demographics (n=279)

19

CharacteristicControl(n=139)

Intervention

(n=140)P-

value

Current Primary Care Provider 80 (57.8) 84 (60.0) 0.68

InsurancePrivate InsurancePublic InsuranceCounty Provided Healthcare (UNM Care)

No Insurance

19 (13.7)76 (54.7)27 (19.4)17 (12.2)

17 (12.1)45 (32.1)42 (30.0)36 (25.7)

<0.001

Length of stay, mean (SD), days 6.1 (5.2) 7.3 (8.1) 0.14

Previous admission (within 1 year), mean (SD)

0.7 (1.5) 0.8 (1.6) 0.62

Charleson co-morbidity index score, mean (SD)

3.3 (2.9) 2.9 (2.8) 0.22

Distance from the hospital, mean (SD), miles

57.4 (94.0)

79.9 (229.0) 0.29*All values reported as n (%) unless specified otherwise

Intervention Group (n=140)

Declined(n=23)

16%

30-day Readmissions and ED Visits (Univariate Analysis)

Control(n=139)

N (%)

Intervention

(n=140)N (%)

P-value

Combined 30-day readmissions and ED visits30-day hospital readmission 30-day ED visits

24 (17.3)

16 (11.5)11 (7.9)

30 (21.4)

20 (14.3)17 (12.1)

0.34

0.490.24

Related readmission or ED visit

19/24 (79.2)

23/30 (76.7)

0.83

21

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 0.67-2.34), p=0.48

22

Conclusion: 30-day Readmissions and ED visits Pharmacist discharge counseling

services did not significantly improve 30-day hospital readmissions and ED visits

23

Secondary Outcome

Results: Predictors for Readmission and ED Visits

24

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), years 49.7 (15.8) 49.5 (17.5) 0.93

Primary care provider 132 (58.7) 32 (59.3) 0.94

Primary Language: English

202 (89.8) 48 (88.9) 0.85

Male 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 statusMarriedSingleSeparated/DivorcedWidower

65 (28.9)135 (60)17 (7.6)8 (3.6)

9 (16.7)34 (63)7 (13)4 (7.4)

0.14

25*All values reported as n (%) unless specified otherwise

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 valu

e

EthnicityWhiteHispanicBlackNative AmericanOther

73 (32.4)84 (37.3)15 (6.7)

37 (16.4)16 (7.1)

16 (29.6)29 (53.7)

4 (7.4)4 (7.4)1 (1.9)

0.19

Distance from the hospital, mean (SD), miles

71.4 (186.14) 57.1 (120.98) 0.59

Length of hospital stay, mean (SD) 6.4 (6.35) 7.7 (8.48) 0.20

Previous hospital admissions, mean (SD)

0.6 (1.18) 1.3 (2.40) 0.002

Charlson comorbidity index, mean (SD)

2.9 (2.73) 3.5 (3.21) 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) 0.10

26*All values reported as n (%) unless specified otherwise

Multivariate RegressionLogistic regression for ED visits and readmissions within 30 days post-discharge

Risk factors OR 95% CI P value

Previous hospital admissions*NoYes

--1.26

--1.06-1.49

0.008

27

*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1 (gender, previous hospitalization)

Multivariate Regression Readmissions within 30-daysRisk factors OR 95% CI P value

Length of stay* 1.06 1.01-1.12 0.015

ED visits within 30-daysRisk factors OR 95% CI P value

Previous hospital admissions*

1.23 1.01-1.48 0.035

Divorced* 5.67 1.42-22.66 0.014*Statistically significant (P≤0.05), this regression included risk factors with a P<0.1

28

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

Secondary Outcome

Results: Interventions by Pharmacists

30

Intervention Group (n=140)

Number of Interventions by Type

#%

totalType of Intervention

66 33.3% Add drug: untreated condition

29 14.6% Change dosing: incorrect or inappropriate

23 11.6%Discontinue drug: medication without indication

19 9.6% Other intervention

15 7.6% Discontinue drug: therapeutic duplication

12 6.0% Incomplete prescription

12 6.0% Cost-savings or third party intervention

10 5.1%Add drug: prevent or treat adverse drug reaction

12 6.0% Cost-savings or third party intervention32

Number of Interventions by Type (cont.)

#%

totalType of Intervention

6 3.0% Change dosing: dosage form or route

4 2.0% Change dosing: renal adjustment

1 0.5% Change drug: drug interaction

1 0.5% Change drug: reverse auto-substitution

1 0.5% Allergy clarified or updated

0 0.0% Change dosing: hepatic adjustment

0 0.0% Change dosing: drug interaction

0 0.0% Allergy avoided

33

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

Intervention Acceptance Rate198 Total number of interventions attempted

- 13 Interventions not accepted

185 Total number of accepted interventions

93.4% Intervention acceptance rate

35

Unaccepted InterventionsIntervention #

unaccepted/total

% unaccepted

Add drug: Untreated condition

4/66 6.1%

Discontinue drug:Medication w/o indication

4/23 17.4%

Cost-savings/third-party 2/12 16.7%Change dosing: incorrect 1/29 3.4%Reverse auto-sub 1/1 0%Change dosing: renal 1/4 25%

36

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

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

Secondary Outcome

Results: Cost-benefit Analysis

39

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

Mean Costs per PatientMean (SD) in

dollarsDifference in dollars

All patients Control (n=139)

Intervention

(n=140) (95% CI)

P valu

e

Combined readmissions and ED visits

$1,897.65 ($5,998.90

)

$2,859.39 ($10,194.9

7)

$961.74 (-$2,935.04 to $1,011.56)

0.34

Only patients who incurred cost

Control (n=24)

Intervention (n=30) (95% CI)

P valu

e

Combined readmissions and ED visits

$10,990.50 ($10,565.9

6)

$13,343.80 ($3,800.43)

$2,353.26 (-$10,981.23to $6,274.72)

0.59

41

Intervention Outlier Analysis

OutlierInterventionMean (SD)

Combined cost for readmissions and ED visits in patients who incurred cost

$98,042$13,343.80 ($3,800.43)

Initial Length of Stay (days)

56 7.3 (8.1)

42

Mean Costs per Patient Excluding Outlier

Mean (SD) in dollars

Difference in dollars

All patientsControl (n=139)

Intervention

(n=139) (95% CI)

P valu

e

Combined readmissions and ED visits

$1,897.65 ($5,998.90

)

$2,174.62 ($6,210.31)

$276.97 (-$1,718.71 to $1,164.77)

0.71

Only patients who incurred cost

Control (n=24)

Intervention (n=29) (95% CI)

P valu

e

Combined readmissions and ED visits

$10,990.54 ($10,565.9

6)

$10,423.17 ($10,051.7

7)

$567.37 (-$5,131.50 to $6,266.24)

0.84

43

Intervention Costs Total pharmacist time cost

Pharmacist cost plus benefits = $68.14 / hour

Total hours = 111.55 hrs Total cost = $7,601.02 Cost per patient

$7,601.02 / 140 patients = $54.93 / patient

44

Net Benefit AnalysisNet benefit per

patientBenefit to Cost

Ratio

All patients -$961.74 -17.5

All patients who incurred cost

-$2,353.26 -42.8

All patients who incurred cost

excluding outlier$567.37 10.3

45

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

Secondary Outcome

Results: Patient Satisfaction

47

Survey Items1. Explanation of what your medications are for2. Explanation of how to take your medications3. Information the healthcare provider gave you about your

problem or condition4. Information the healthcare provider gave you about possible

medication side effects5. Overall rating of the information you received during discharge6. Knowledge of the healthcare provider who taught you7. Friendliness/courtesy of healthcare provider who taught you8. Answers provided by the healthcare provider to your questions9. Overall rating of the healthcare provider giving discharge

teaching

Likert response scale1=Very Bad, 2=Bad, 3=Fair, 4=Good, 5=Very Good

48

Overall Response Rates

49

50

Overall Mean Response by Group

Type N

Mean of Summed Responses

(max score 45) tP

value

Control 76 40.37 -3.99

7

<0.0001Interventio

n97 43.14

51

Mean Rank by Group

Type NMean Rank

Sum of Ranks

P value

ControlIntervention

7697

72.3098.52

54959556

<0.0001

Response Means by Group

52

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 discharge53

Secondary Outcome

Results: Primary Medication Adherence

54

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

UNM Care Patients

56

UNM Care Demographics (n=66)

CharacteristicControl (n=27)

Intervention (n=39)

P-value

Age, mean (SD), years 47.6 (16.8) 47.9 (13) 0.25

Male (%) 18 (66.7) 23 (59) 0.52

Primary Language: English (%)

26 (96.3) 33 (84.6) 0.13

Ethnicity (%)White, Non-Hispanic White, HispanicAfrican AmericanNative AmericanAsianOther

10 (37)13 (48.1)

2 (7.4)2 (7.4)0 (0)0 (0)

11 (28.2)18 (46.2)4 (10.3)2 (5.1)1 (2.6)3 (7.7)

0.63

Current Primary Care Provider (%)

15 (55.6) 27 (69.2) 0.2657

UNM Care Demographics (n=66)

CharacteristicControl (n=27)

Intervention (n=39)

P-value

Marital Status (%)Single MarriedDivorcedWidower

16 (59.3)6 (22.2)4 (14.8)1 (3.7)

26 (66.7)6 (15.4)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 RiskMildModerateSevere

6 (22.2)9 (33.3)5 (18.5)7 (25.9)

10 (25.6)12 (30.8)12 (30.8)5 (12.8)

0.51

58

Ordered Discharge Prescriptions

CharacteristicControl (n=27)

Intervention (n=39)

P-value

Number of medications, mean (SD)

3.58 (1.84) 4.13 (2.4) 0.95

Number of scheduled medications, mean (SD)

3.04 (1.71) 3.49 (2.37) 0.41

Number of PRN medications,

mean (SD)

0.54 (0.76) 0.64 (0.87) 0.63

59

Primary Adherence by Therapeutic Class

60

Nu

mb

er

of

Rx’s

Primary Medication Adherence Rate

Control (n=27)

Intervention

(n=39)

Primary medication adherence rate (mean, %)

58.5 75.7

61

62

Mean Rank by Group

Type N Mean Rank Sum of Ranks

P value

ControlIntervention

2739

27.9636.36

7271418

0.05

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

Discussion

64

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

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

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

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