Medication Reconciliation and Management[1] - Care for...
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Transcript of Medication Reconciliation and Management[1] - Care for...
David Putney, PharmD., BCPSCardiology Clinical Specialist IIDepartment of Pharmacy
C iti l El t f T iti f C W kCritical Elements of Transitions of Care Work:
Medication Reconciliation and Management
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Objectives
♥ To describe the impact of adverse drug events (ADE) on the patient.♥ To describe the barriers to effective medication reconciliation.♥ To review the latest clinical trials involving medication reconciliation gand the impact on patient care.♥ To apply key concepts to patient case.
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Medications the #4 Killer
Heart disease 743,460 deadCancer 529,904 deadStroke 150,108 deadStroke 150,108 deadMedicationsMedications 137,000 dead137,000 deadPulmonary disease 101 077 deadPulmonary disease 101,077 deadAccidents 90,523 deadPneumonia 75,719 dead
Lazarou J, et al. Incidence of Adverse Drug Reactions in Hospitalized Patients:
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A Meta‐analysis of Prospective Studies. JAMA. 1998;279:1200‐1205.
National Patient Safety Goal (NPSG) 8
• NPSG 08.01.01• At the time patient enters the hospital or is admitted‐a complete list
of medications is created• Dose• Route• Frequency
• Patient and family is involved in creating list• Documentation is required• Currently not a measured item
National Patient Safety Goal (NPSG) 8
• NPSG 08.02.01• Patient’s most current reconciled medication list communicated to
next provider of service• Either within or outside the hospital
• NPSG 08.03.01• Upon discharge the current list of reconciled medications are
provided and explained to patient• Reminder to discard old list• Update records with providers and retail pharmacies
Cost Associated
• Sample Model• Medications History (10 minutes) from family primary care• Medications History (10 minutes)—from family, primary care physicians, chart, and patient
• Nursing Salary ($30/hr)• Total= $5Total $5
• Clinical Pharmacist Interview• Estimates of 30 minutes• Estimates of 30 minutes• $25 per patient
• Approx $30 dollars and 40 minutes• Approx. $30 dollars and 40 minutes
• Is this cost prohibitive? or justifiable?
6Schenkel S. The Unexpected Challenges of Accurate Medication Reconciliation. Annals of Emergency Med. 2008;52:493‐495.
Barriers
• Multiple changes to medication regimens• Discontinuity of care• Short hospitalizationsp• Inadequate patient education
• Medications history taken at admission have 54‐67% discrepancies y pbetween medication history by admitting clinicians vs. actual pre‐admission regimen.• 27‐59% of these discrepancies have the potential to cause harm• 50% of preventable adverse drug events at 30 days post discharge
are linked to drug related problems at discharge
Poon EG, et al. Design and Implementation of an Application and Associated Service to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare Delivery Network. J Am Med Inform Assoc. 2006;13:581‐592.
Predicting Admission Reconciliation Errors
8Pippins JR, et al. Classifying and Predicting Errors of Inpatient Medication Reconciliation. J Gen Intern Med. 2008;23(9):1414‐22.
Literature Review% of patientsStudy Sample Size Error Type % of patients with ≥ 1 error Comments
Incorrect Drug 73% had ≥ 1 error with prescription
Badowski et al 80 Name, Strength, and
Dose
57with prescription
and nonprescription
included
Beers et al 122 Omission and Commission 60 52% had errors of
omissionOmission,
Cornish et al 151Commission, Incorrect
strength, and Dose
54 ‐
Dose
Lua et al 304 Omission and Commission 67 61% had errors of
omission
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Tam VC, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510‐5.
Examples of Errors
10Tam VC, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510‐5.
Effect of Inappropriate Medications in the Elderly
11Page RL, et al. The Risk of Adverse Drug Events and Hospital‐Related Morbidity and Mortality Among Older Adults with Potentially Inappropriate Medication Use. The Am J of Geriatric Pharmcotherapy. 2006;4:297‐305.
Addressing the Problem
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Facilitating the Transition for the Elderly
• Setting: General Medicine wards at three hospitals (an academic medical center, a community teaching hospital, and a community‐based nonteaching hospital)
• Intervention: (5 core elements)• Admissions form with geriatric cues• Facsimile to primary care provider• Interdisciplinary worksheet to identify barrier to discharge• Pharmacist‐physician collaborative medication reconciliation• Predischarge planning appointments
• Outcomes: 30 day readmission or return to ED and patient satisfaction
Dedhia P, et al. A Quality Improvement Intervention to Facilitate the
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Transition of Older Adults from Three Hospitals Back to Their Homes. J Am Geriatric Soc. 2009;57:1540‐1546.
Facilitating the Transition for the Elderly
Dedhia P, et al. A Quality Improvement Intervention to Facilitate the
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Transition of Older Adults from Three Hospitals Back to Their Homes. J Am Geriatric Soc. 2009;57:1540‐1546.
Improving Hospital Discharge
• Development of a integrated medicines management (including tools and activities for medication reconciliation and review).
• Key focus on improving quality of information provided to patient at discharge from hospital to primary and community care
15Bergkvist A, et al. Improved quality in the hospital discharge summary reduced medication errors‐LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol. 2009;65:1037‐1046.
Errors Identified at Discharged
Bergkvist A, et al. Improved quality in the hospital discharge summary
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reduced medication errors‐LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol. 2009;65:1037‐1046.
Reengineered Discharge Program
• Settings: General medical service at an urban, academic, safety‐net hospital
• Intervention: Nurse discharge advocate facilitated follow‐up appointments, confirm medication reconciliation, and conducted patient education. Clinical pharmacist would call patients 48 to 96 hours after discharge
• Measure: Visits to ED and hospitalizations within 30 days• Measure: Visits to ED and hospitalizations within 30 days• Results
• Usual Care (n=368) = 0.451 visits per month• Intervention (n=370) = 0 314 visits per month• Intervention (n=370) = 0.314 visits per month• RR 0.70 (0.51‐0.94), p=0.0009
17Jack BW, et al. A Reenineered Hospital Discharge Program to Decrease Rehospitalization. Ann Intern Med. 2009;150(3):178‐187.
Reengineered Discharge Program
18Jack BW, et al. A Reenineered Hospital Discharge Program to Decrease Rehospitalization. Ann Intern Med. 2009;150(3):178‐187.
Reengineered Discharge Program
19Jack BW, et al. A Reenineered Hospital Discharge Program to Decrease Rehospitalization. Ann Intern Med. 2009;150(3):178‐187.
Reconciliation at Skilled Nursing Facility
• Setting: Health maintenance organization (HMO) patients discharged from skilled nursing facility to home
• Intervention: Pharmacist managed medication reconciliation program within 48 hours or greater than 48 hours vs. usual care
• Measure: Death and ambulatory care visits
Delate T, et al. Clinical Outcomes of a Home‐Based Medication Reconciliation
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Program After Discharge from a Skilled Nursing Facility. Pharmacotherapy. 2008;28(4):444‐452.
Errors and Outcomes
21Delate T, et al. Clinical Outcomes of a Home‐Based Medication Reconciliation Program After Discharge from a Skilled Nursing Facility. Pharmacotherapy. 2008;28(4):444‐452.
Cardiovascular Errors
• Post hoc analysis of 2 randomized clinical controlled trials (heart failure and hypertension)( yp )
• Intervention: Pharmacist education of medication with oral and written instructions vs. control
Murray MD, et al. Effect of a Pharmacist on Adverse Drug Events and
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Medication Errors in Outpatients With Cardiovascular Disease. Arch Intern Med. 2009;169(8):757‐763.
Adverse Events
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Case
• TM is a 80 yo male who presents to the ED with chest pain and shortness of breath. He has ECG finds of ST segement elevations in V1‐V4. He is taken to the cardiac catheterization suite and PCI is
f d ith d l ti t t (DES)performed with a drug eluting stent (DES).
• PMH: CAD (1995) HTN (1990)• CAD (1995), HTN (1990)
• MPTA:• Aspirin 81 mg daily
L i (M ) 40 b d i• Lovastatin (Mevacor) 40mg at bedtime• Metoprolol (Lopressor) 50mg twice daily
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Case
• Upon discharge from the hospital the following medication list is provided to the patient:
• Aspirin 325 mg daily• Carvedilol (Coreg) 6.25 mg twice daily• Atorvastatin (Lipitor) 80 mg daily• Lisinopril (Prinivil) 10 mg daily• Pantoprazole (Protonix) 40 mg daily
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Can you identify the problems?
Pre Admission Post AdmissionPre Admission• Aspirin 81 mg daily• Lovastatin (Mevacor) 40mg
Post Admission• Aspirin 325 mg daily• Carvedilol (Coreg) 6.25 mg
at bedtime• Metoprolol (Lopressor)
50mg twice daily
twice daily• Atorvastatin (Lipitor) 80
mg daily• Lisinopril (Prinivil) 10 mg
daily• Pantoprazole (Protonix) 40 p
mg daily
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Thank you for your attention.A Q ti ?Any Questions?
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