Effect of a care transition intervention by pharmacists: an RCT

Karen B Farris, Barry L Carter, Yinghui Xu, Jeffrey D Dawson, Constance Shelsky, David B Weetman, Peter J Kaboli, Paul A James, Alan J Christensen, John M Brooks, Karen B Farris, Barry L Carter, Yinghui Xu, Jeffrey D Dawson, Constance Shelsky, David B Weetman, Peter J Kaboli, Paul A James, Alan J Christensen, John M Brooks

Abstract

Background: Pharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.

Methods: Design. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3-5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.

Results: Study groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.

Conclusion: The pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.

Trial registration: Clinicaltrials.gov registration: NCT00513903, August 7, 2007.

Figures

Figure 1
Figure 1
Iowa Continuity of Care Recruitment and Intervention.
Figure 2
Figure 2
Iowa Continuity of Care Study Recruitment Chart.

References

    1. Coleman EA, Smith JK, Raha D, Min SJ. Post-hospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842–1847. doi: 10.1001/archinte.165.16.1842.
    1. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314–323. doi: 10.1002/jhm.228.
    1. Bayoumi I, Howrd M, Holbrook AM, Schabort I. Interventions to improve medication reconciliation in primary care. Ann Pharmacother. 2009;43:1667–1675. doi: 10.1345/aph.1M059.
    1. Flora DS, Parsons PL, Slattum PW. Managing medications for improved care transitions. Generations. 2011;35:37–42.
    1. Ziaeian B, Araujo K, Van Ness PH, Horwitz LI. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. J Gen Intern Med. 2012;27:1513–1520. doi: 10.1007/s11606-012-2168-4.
    1. American Society of Health-system Pharmacists and American Pharmacists Association: ASHP-APhA medication management in care transitions best practices. , Accessed September 22, 2014
    1. Kwan JA, Lo L, Sampson M, Shojania K. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:397–403. doi: 10.7326/0003-4819-158-5-201303051-00006.
    1. Mueller SK, Sponsler KC, Kriplani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172:1057–1069. doi: 10.1001/archinternmed.2012.2246.
    1. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, Liefers J, Vernooij-Dassen M, Wollersheim H. Improving patients handovers form hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417–428. doi: 10.7326/0003-4819-157-6-201209180-00006.
    1. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565–571. doi: 10.1001/archinte.166.5.565.
    1. Institute for Healthcare Improvement: Medication reconciliation to prevent adverse events. , Accessed September 22, 2014
    1. Carter BL, Farris KB, Abramowitz PW, Weetman DB, Kaboli PJ, Dawson JD, James PA, Christensen AJ, Brooks JM. The Iowa continuity of care study: background and methods. Am J Health-Syst Pharm. 2008;65:1631–1642. doi: 10.2146/ajhp070600.
    1. Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv. 1976;6:493–508. doi: 10.2190/UURL-2RYU-WRYD-EY3K.
    1. Ruscin JM, Semla TP. Assessment of medication management skills in older outpatients. Ann Pharmacother. 1996;30:1083–1088.
    1. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74. doi: 10.1097/00005650-198601000-00007.
    1. DeGeest S, Abraham I, Gemoets H, Evers G. Development of the long-term medication behavior self-efficacy scale: qualitative study for item development. J Adv Nurs. 1994;19:233–238. doi: 10.1111/j.1365-2648.1994.tb01076.x.
    1. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, Cohen HJ, Feussner JR. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–1051. doi: 10.1016/0895-4356(92)90144-C.
    1. Bates DW, Cullen DJ, Laird N, Peterson LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, Vander Vliet M, Nemeskal R, Leape LL, for the ADE Prevention Study Group Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29–34. doi: 10.1001/jama.1995.03530010043033.
    1. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico F, Leape LL, Bates DW. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–1564. doi: 10.1056/NEJMsa020703.
    1. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, Janecek E, Comecq C, Greenblatt DJ. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239–245. doi: 10.1038/clpt.1981.154.
    1. Forster AJ, Murff JH, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317–323. doi: 10.1111/j.1525-1497.2005.30390.x.
    1. Farley TM, Shelsky C, Powell S, Farris KB, Carter BL. Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. Int J Clin Pharm. 2014;36:430–437. doi: 10.1007/s11096-014-9917-x.
    1. Dartmouth Atlas of Health Care. , Accessed September 22, 2014
    1. Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal GE, Jones MP, Vaughan-Sarrazin M. Association between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157:837–845. doi: 10.7326/0003-4819-157-12-201212180-00003.
    1. Gerhardt G, Yemane A, Hickman P, Oelschlaeger A, Rollins E, Brennan N. Medicare readmission rates showed meaningful decline in 2012. MMRR. 2013;3:2. doi: 10.5600/mmrr.003.02.b01.
    1. Parry C, Coleman EA, Smith JD, Frank JC, Kramer AM. The care transitions intervention: a patient-centered approach to facilitating effective transfers between sites of geriatric care. Home Health Serv Q. 2003;22(3):1–18. doi: 10.1300/J027v22n03_01.
    1. Kaboli PJ, Hoth AB, McCLimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166:955–964. doi: 10.1001/archinte.166.9.955.
    1. Chilsholm-Burns MA, Lee JK, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Zivin JG, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48:923–933. doi: 10.1097/MLR.0b013e3181e57962.
    1. Altavela JL, Jones MK, Ritter M. A prospective trial of a clinical pharmacy intervention n a primary care practice in a capitated payment system. J Manag Care Pharm. 2008;14:831–843.
    1. Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Inter Med. 2009;21:1748–1755.
    1. Carter BL, Ardery G, Dawson JD, James PA, Bergus GR, Doucette WR, Chrischilles EA, Franciscus CL, Xu Y. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;23:1996–2002. doi: 10.1001/archinternmed.2009.358.
    1. Farris KB, Cote I, Feeny D, Johnson JA, Tsuyuki RJ, Brilliant S, Dieleman l. Enhancing primary care for complex patients: demonstration project using multidisciplinary team. Can Fam Physician. 2004;50:998–1003.
    1. Bogden PE, Abbott D, Willliamson P, Onopa JK, Koontz LM. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension. J Gen Intern Med. 1998;13:740–745. doi: 10.1046/j.1525-1497.1998.00225.x.
    1. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manage Care Pharm. 2010;16:185–195.
    1. Anderegg SV, DeMik DE, Carter BL, Dawson JE, Farris K, Shelsky C, Kaboli P. Acceptance of recommendations by inpatient pharmacy case manager: unintended consequences of hospitalist and specialist care. Pharmacother. 2013;33:11–21. doi: 10.1002/phar.1164.
    1. Israel EN, Farley TM, Farris KB, Carter BL. Under-utilization of cardiovascular medications: lack of effect of a continuity of care program. Am J Health-Sys Pharm. 2013;70:1592–1600. doi: 10.2146/ajhp120786.
    1. Gillepsie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, Kettis-Lindblad A, Melhus H, Morlin C. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169:894–900. doi: 10.1001/archinternmed.2009.71.
    1. Koechler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, Masica AL. Reduction in 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4:211–218. doi: 10.1002/jhm.427.
Pre-publication history
    1. The pre-publication history for this paper can be accessed here:

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe