Pharmacist Assisting at Routine Medical Discharge: Project PhARMD

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 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

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 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

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 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

7. Methods

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

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

10. Methods: Flow of Patients

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

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

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

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. TherClin Risk Manag. 2007; 3:695-703.

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

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

17. Study Recruitment and Flow

18. Demographics (n=279) *All values reported as n (%) unless specified otherwise

19. Demographics (n=279) *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)

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 0.67-2.34), p=0.48

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

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

25. Risk Factors for Combined 30-day ED Visits and Readmissions *All values reported as n (%) unless specified otherwise

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

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

28. Multivariate Regression *Statistically significant (P≤0.05), this regression included risk factors with a P<0.1

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

30. Results: Interventions by Pharmacists Secondary Outcome

31. Intervention Group (n=140)

32. Number of Interventions by Type

33. Number of Interventions by Type (cont.)

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

35. Intervention Acceptance Rate

36. Unaccepted Interventions

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

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

39. Results: Cost-benefit Analysis Secondary Outcome

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

41. Mean Costs per Patient

42. Intervention Outlier Analysis

43. Mean Costs per Patient Excluding Outlier

44. 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

45. Net Benefit Analysis

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

47. Results: Patient Satisfaction Secondary Outcome

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

49. Overall Response Rates

50. Overall Mean Response by Group