Pharmacy-Driven Medication Reconciliation Program Reduces Post-Discharge Errors

“Care Transition Services: A pharmacy-driven
program for medication reconciliation
through the continuum of care”
6/20/2014
Florentina Eller
2015 PharmD Candidate
Medication Reconciliation APPE Rotation

Study Background
• Medication errors
• 22% during admissions
• 66% during transition to or from the intensive care unit
• 12% during discharge
~ 40% of medication errors can cause
• Moderate to severe discomfort
• Clinical deterioration
~ 50% of discharged patients suffered
• ≥ 1 clinically important medication error
• Within 30 day postdischarge
Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program
for medication reconciliation through the continuum of care. Am J Health Syst Pharm. 2014
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Causes of Postdischarge Medication Errors
• Nonadherence
• Potential adverse drug events
• Physician and system errors
• Outpatient pharmacy discrepancies
• Patient safety issues
• Discharge medication confusion
– Health literacy
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Why Pharmacist-Led Medication
Reconciliation?
• Uniquely qualified
• Formal training in obtaining medication histories
• Extensive medication expertise
• Proven to obtain more accurate and
comprehensive medication histories
• Most have training in both hospital and retail
pharmacy settings
• Better understanding of diverse medication distribution
systems
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Purpose of Study
• “To analyze an ongoing inpatient-focused,
pharmacy-driven program—the Care Transitions
Service (CTS)—and its impact on identifying and
resolving medication-related problems (MRPs)
• To evaluate the implementation of a pilot
extension of this service into the outpatient
setting and its impact on MRP identification and
resolution through the continuum of care”
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design
• Single-center descriptive study
• University of New Mexico Hospital (UNMH) and an outpatient
UNMH family clinic
• Analyses of the inpatient service were conducted over a
five-month period (November 2012–March 2013)
• Analyses of the outpatient service were conducted over a
two-month period (January–February 2013)
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design: Eligibility
Inclusion criteria
• Received medication reconciliation services from CTS during the
predefined study periods
• At least 18 years of age and speak English or Spanish
Exclussion criteria
• Lack of extensive medication history (at least three long-term
medications) or
• Patient is scheduled for readmission
• Has a previous admission within the last 14 days and already
received CTS services
• Is unwilling to undergo a medication interview
• Has been discharged to a skilled nursing facility, long-term care
facility, or prison
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Design: Care Transition Service
(CTS)
• An ongoing pharmacy-driven program
• Provides
• 3 phases of inpatient services
• 4th pilot phase of outpatient clinical services
• The outpatient extension offered to patients
• Who received inpatient CTS services
• Were scheduled for postdischarge outpatient family
clinic appointment
• Were independently able to answer questions about
their medications
May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTS
May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTS
Phase 1
• Admission medication reconciliation (Med Rec)
• In addition to other Med Rec performed by a nonpharmacist provider
Phase 2
• Discharge medication review
• Hospital-to-community pharmacist handoff (obtaining consent from the
patient’s PCP to call the patient’s pharmacy and authorize discontinuation
of any prescriptions no longer needed after hospital discharge)
Phase 3
• Follow-up phone call within 72 hours of discharge
• Assesses adherence and tolerance of discharge medications
• Remind patients to take all medication bottles to their follow-up
appointment
Phase 4 (the pilot extension )
• Outpatient Med Rec conducted by a pharmacist at the first postdischarge
appointment

CTS
• Phases 1–3 conducted by CTS team:
• lead inpatient pharmacist
• four PGY1 residents
• and six APPE pharmacy students
• Phase 4 conducted by
• a lead pharmacist
• a PGY2 ambulatory care resident
• APPE students and PGY1 residents were provided extensive training to
ensure consistency of CTS processes
• All members of the CTS team were responsible for identification and
documentation of MRPs
• All documentation was summarized in a written clinical note and posted
in an electronic medical record (EMR)
• APPE students were supervised by the PGY1 residents as MRPs were
identified and documented
• Weekly quality checks were completed by the lead pharmacist
May 15;71(10):802-10. doi: 10.2146/ajhp130589

CTS: Data Collection
MRPs
• Identified and documented by a CTS member during the admission
reconciliation process
• Classified only once
• Outpatient MRPs were also documented
– medication continuance despite discontinuation orders at discharge
– patient self-discontinuation of medications despite continuation
orders at discharge
– NVS (Newest Vital Sign) was assessed and recorded
Interventions
• Performed independently of provider review
• Based on protocols agreed on by the pharmacy department and inpatient
family medicine service
Communication with providers
• Phone calls
• Pages
• Alerts in the EM Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven program
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Interventions and Recommendations
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Outcomes
Primary endpoint
• To evaluate the numbers and types of MRPs identified by
pharmacists at hospital admission
Secondary endpoints
• Inpatient services evaluation
– Medication classes most commonly associated with MRPs
and patient-specific predictors of MRPs
• Outpatient services evaluation
– Types and frequencies of new or persistent MRPs
– From hospital discharge to the first follow-up appointment
– Association of health literacy and MRPs
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Statistical Analysis
• Descriptive analyses
– To characterize the types and rates of medication
reconciliation discrepancies between the inpatient and
outpatient settings and the health literacy of CTS patients
• Univariate Poisson regression models
– To determine variables that would be retained for testing
in the final model
– With a priori level of significance of 0.2
• To prevent the elimination of variables too soon
• Multivariate Poisson regression model
– With a priori level of significance of 0.05
– To determine patient-specific predictors of MRPs
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Patient Characteristics
Inpatient CTS sample (5 months evaluation)
• 191 total patients received admission Med Rec (CTS
phase 1)
• Mean age was 61 years, 48% were male
• ~ 50% of patients were of Hispanic/Latino ethnicity,
• ~50% received discharge medication review and
hospital-to-community pharmacist handoff (CTS phase
2)
• 24 % received a follow-up phone call (CTS phase 3)
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Patient Characteristics
Outpatient CTS sample ( 2 months pilot testing)
• 30 were eligible for phase 4 of the CTS
• 7 of the 30 patients failed to attend their scheduled
postdischarge appointment
• 3 patients were ineligible for the service because they were
unable to independently answer questions
• 1 patient deferred the service
• Missed opportunity, due to external factors occurred in 3
patients
• Only 16 patients received outpatient CTS services and were
included in the analysis
• Those patients had a mean age of 57.8 years, 56% were male,
and 50% were Hispanic/Latino
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Inpatients
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Outpatients
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Identified Medication Related
Problems (MRPs)
Inpatient CTS sample
• 1140 MRPs were identified during admission Med Rec
• 6 MRPs per patient
• 49% of MRPs due to:
– Patient variables: safety, appropriateness, effectiveness
– Nonadherence
• Common medication classes associated with MRPs :
– Cardiovascular agents (22%)
– Gastrointestinal–genitourinary
– Central nervous system (CNS)
– Analgesic and endocrine–metabolic agents
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Identified MRPs
Outpatient CTS sample
• 28 MRPs were identified with an average of 1.56 per
patient
• In 37.5% of patients a maximum of 3 MRPs were identified
• In 18.8% no MRPs were identified
• ~75% of the MRPs identified were related to patient
variables and nonadherence
• In over 80% of patients, fewer MRPs were identified at the
follow-up appointment than had been identified during
their admission to the hospital
• 86% of all postdischarge MRPs were newly identified MRPs,
while 14% had persisted through the continuum of care
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Interventions
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Pharmacy Recommendations
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Predictor of Inpatient MRPs
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Predictor of Inpatient MRPs ( Cont.)
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Results: Health Literacy and MRPs
• 69% of patients who completed the NVS health literacy
assessment during the phase 4 outpatient service
evaluation were found to have a high likelihood of
limited health literacy (defined as NVS score of 0 or 1)
• 31% of patients were found to have adequate health
literacy (an NVS score or 4 or 5)
• MRPs were identified in patients with limited health
literacy as well as those with adequate health literacy
( small sample sizes limits the ability to make an
association between high NVS scores and MRPs)
May 15;71(10):802-10. doi: 10.2146/ajhp130589

Study Limitations
• Inability to classify MRPs based on potential to cause harm
due to short study duration
• The short duration of the study limits the ability to assess the
clinical impact of identified MRPs on readmission rates or
patient outcomes.
• The results might not apply to the majority of US hospitals
because the CTS services are offered only to patients eligible
for the UNMH inpatient family medicine services
• The results might not be reproducible due to inconsistencies
in data collection associated with multiple staff pharmacists
that offer CTS
Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-driven
program for medication reconciliation through the continuum of care. Am J Health

Discussion and Conclusion
• There is a need for a Med Rec pharmacist at admitting to
take a thorough history
• If staff shortages: target patients with cognitive, physical,
financial constraints to improve adherence and reduce
MRPs during hospital and 30 days post admitting
• Consider patients with transportation difficulties and
cultural belief-barriers
• High risk patients for MRPs are those taking more than 3
medications, those receiving medications that require
monitoring , have no insurance or have private insurance
May 15;71(10):802-10. doi: 10.2146/ajhp130589

References
Conklin JR, Togami JC, Burnett A, et.al. Care Transitions Service: a pharmacy-
driven program for medication reconciliation through the continuum of care.
Am J Health Syst Pharm. 2014 May 15;71(10):802-10. doi:
10.2146/ajhp130589

Pharmacy-Driven Medication Reconciliation Program Reduces Post-Discharge Errors

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