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Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study.

ABSTRACT: Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.

SUBMITTER: Slazak E

PROVIDER: S-EPMC7151670 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study.

Slazak Erin E Shaver Amy A Clark Collin M CM Cardinal Courtney C Panthapattu Merin M Prescott William A WA Will Samantha S Jacobs David M DM

Pharmacy (Basel, Switzerland) 20200104 1

Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a genera ...[more]

PMID: 31947920

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Project description:INTRODUCTION:In the past decade, direct-acting oral anticoagulants (DOAC) have been introduced to medical practice for several indications, with a wide range of dosing regimens. As both over- and under-dosing might lead to life-threatening events, development of methods promoting safe and effective utilization of these agents is imperative. The Hadassah Clinical Pharmacy team initiated a hospital-wide program, for monitoring and promoting safe and effective prescription of DOAC during hospitalization. This study describes the types of drug related problems addressed and the program's performance in terms of consultation rates and physician acceptance. METHODS:Electronic medical records throughout the hospital were screened for DOAC orders. All DOAC orders were assessed by a clinical pharmacist for potentially-inappropriate prescribing. When potentially-inappropriate prescribing or a drug-related problem was identified, the clinical pharmacist provided consultation on management options. In specific cases, additional guidance was provided by coagulation and pharmacology specialists. Data on patient characteristics, clinical pharmacist consultations, and physician response was retrospectively retrieved for the first six months of 2017. Characteristics of patients with and without consultations were compared, consultations were categorized by the recommended management of the drug related problem, and physician acceptance rates were evaluated by category. RESULTS:During the evaluated period, 585 patients with DOAC orders were identified. Patients were evenly distributed by gender, and age averaged 78?years. Most patients received apixaban (75%) followed by rivaroxaban (14%) and dabigatran (11%), and most (63%) received "reduced dose" regimens. Clinical pharmacists provided 258 consultations for 210 patients, regarding anticoagulation management, such that more than one in three patients on DOAC had potentially inappropriate prescribing or drug related problems. Consultations included alerts regarding potentially inappropriate DOAC doses and recommendations to increase (29%) or decrease (5%) the dose, potentially inappropriate concomitant antiplatelet agents (20%), need for DOAC level monitoring (23%), and alerts regarding other drug related problems (23%). More than 70% of recommendations were accepted by the attending physician. CONCLUSION:Due to the complexity of DOAC management, potentially-inappropriate prescribing and drug related problems are common. Multidisciplinary collaborative projects including review and consultation by clinical pharmacists are an effective method of improving management of patients on DOAC. TRIAL REGISTRATION:Retrospectively registered at clinicaltrials.gov, NCT03527615 .

Project description:ImportancePenicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics.ObjectiveTo evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes.Design, setting, and participantsA pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020.ExposuresThe longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment.Main outcomes and measuresHospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival.ResultsLongitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant.Conclusions and relevancePharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.

Project description:Studies have demonstrated that physician/pharmacist collaboration can improve management of chronic conditions.The purpose of this study was to determine whether a correlation exists between existing clinical pharmacy services within a practice-based research network (PBRN) and provider attitudes and beliefs regarding implementing a new pharmacy intervention based on the Theory of Planned Behavior (TPB).A validated survey was completed by one clinical pharmacist from each office. This instrument evaluated the current clinical pharmacy services provided in the medical office. TPB instruments were developed that measured beliefs concerning implementation of a clinical pharmacy intervention for either blood pressure or asthma. The pharmacy services and TPB surveys were then administered to physicians and pharmacists in 32 primary care offices throughout the United States.Physicians returned 321 (35.9%) surveys, while pharmacists returned 40 (75.5%). The Cronbach's alpha coefficients generally ranged from 0.65 to 0.98. TPB subscale scores were lower in offices rated with lower pharmacy service scores, but these differences were not statistically significant. There was no correlation between clinical pharmacy service score and providers' TPB subscale scores. In both the hypertension and asthma groups, pharmacists scores were significantly higher than physicians' scores on the attitudes subscale in the multivariate analysis (P < 0.001 and P < 0.05, respectively).Pharmacists consistently scored higher than physicians on the TPB, indicating that they felt the hypertension or asthma intervention would be more straightforward for them to implement than did physicians. There was no significant correlation between clinical pharmacy service scores and attitudes toward implementing a future physician/pharmacist collaborative intervention using the TPB. Future studies should investigate the ability of the TPB instrument to predict implementation of a similar intervention in offices of physicians never exposed to clinical pharmacy services.

Project description:BackgroundA cluster randomised controlled trial (cRCT) performed from July 2018 to March 2019 demonstrated the clinical impact of a community pharmacist delivered minor ailment service (MAS) compared with usual pharmacist care (UC). MAS consisted of a technology-based face-to-face consultation delivered by trained community pharmacists. The consultation was guided by clinical pathways for assessment and management, and communication systems, collaboratively agreed with general practitioners. MAS pharmacists were trained and provided monthly practice support by a practice change facilitator. The objective of this study was to assess the cost utility of MAS, compared to UC.MethodsParticipants recruited were adult patients with symptoms suggestive of a minor ailment condition, from community pharmacies located in Western Sydney. Patients received MAS (intervention) or UC (control) and were followed-up by telephone 14-days following consultation with the pharmacist. A cost utility analysis was conducted alongside the cRCT. Transition probabilities and costs were directly derived from cRCT study data. Utility values were not available from the cRCT, hence we relied on utility values reported in the published literature which were used to calculate quality adjusted life years (QALYs), using the area under the curve method. A decision tree model was used to capture the decision problem, considering a societal perspective and a 14-day time horizon. Deterministic and probabilistic sensitivity analyses assessed robustness and uncertainty of results, respectively.ResultsPatients (n = 894) were recruited from 30 pharmacies and 82% (n = 732) responded to follow-up. On average, MAS was more costly but also more effective (in terms of symptom resolution and QALY gains) compared to UC. MAS patients (n = 524) gained an additional 0.003 QALYs at an incremental cost of $7.14 (Australian dollars), compared to UC (n = 370) which resulted in an ICER of $2277 (95% CI $681.49-3811.22) per QALY.ConclusionEconomic findings suggest that implementation of MAS within the Australian context is cost effective.Trial registration Registered with Australian New Zealand Clinical Trials Registry (ANZCTR) and allocated the ACTRN: ACTRN12618000286246. Registered on 23 February 2018.

Project description:BackgroundDuring transitions of care, older adults are at risk of adverse drug events which could lead to avoidable hospital visits. Pharmacists are increasingly involved in care teams at various stages of the continuum of care. The types and frequency of clinical interventions performed by pharmacists in the geriatric practice setting remain poorly documented.ObjectivesThis study aimed to describe the current integration of pharmacist interventions during transitions of care of older adults admitted in short-term geriatric units (STGUs) and to explore barriers and facilitators to their implementation in clinical practice. The secondary objective was to explore associations between certain patient characteristics and pharmacist-led interventions during transitional care.MethodsA mixed methods study was conducted with pharmacists practicing in STGUs in the Montreal area, Canada. The application of 8 pharmaceutical interventions was assessed using a self-administered questionnaire, along with as a retrospective chart review. Four semi-structured group interviews were conducted in order to identify perceived barriers and facilitators.ResultsThirteen pharmacists participated in the study. In the questionnaire, medication reconciliation on admission and at discharge was reported as being performed at least half the time by 12 (92%) and 7 (54%) pharmacists, respectively. The retrospective chart review revealed that these interventions were documented in 95 (98%) and 25 (26%) files, respectively. While 35% of patients had a documented pharmaceutical care plan on admission, none was documented at discharge. Several barriers to implementing clinical interventions were identified such as lack of time, technical support, communication and standardization.ConclusionsPharmacists are involved at different periods of transitional care; however, certain barriers should be addressed in order to expand their role in discharge planning. Providing guidelines on what is expected at discharge and post-discharge, and having a practice focused on delegation and collaboration would help pharmacists increase their role throughout the transition of care of older adults.

Dataset Information

Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study.

Publications

Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study.

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