Evaluation of a Pharmacist-Specific Intervention on 30-Day Readmission Rates for High-Risk Patients with Pneumonia.

BACKGROUND: Pharmacist interventions have been shown to have an impact on reducing readmission rates, however further research is necessary to target resources to high-risk populations and determine the most effective bundle of interventions. OBJECTIVE: To evaluate the effect of a pharmacist-bundled intervention on 30-day readmission rates for high-risk patients with pneumonia. METHODS: A pilot study with a historical control conducted at a community, teaching-affiliated medical center. Up to 65 selected subjects were included if they had pneumonia and any of the following high-risk criteria: admission within 6 months, at least 5 scheduled home medications, chronic obstructive pulmonary disease (COPD), or heart failure. A retrospective chart review was conducted to compile the historical control group that received usual care between June and November 2013. Patients admitted from December 2013 through March 2014 were reviewed to receive a bundled intervention. The primary outcome was 30-day readmission rates. Risk factors and reasons for readmission, pharmacist clinical interventions, and the time interval between discharge and readmission were also evaluated. RESULTS: A trend toward a reduced 30-day readmission rate was observed in the intervention group (n = 43) compared to those who received usual care (n = 65) (27.9% vs 40.0%; relative risk [RR], 0.6977; 95% CI, 0.3965-1.2278; P = .2119). The most commonly identified high-risk inclusion criteria were having at least 5 scheduled home medications and COPD. The time interval between discharge and readmission did not considerably differ between groups (10.8 vs 10.6 days). CONCLUSIONS: The pharmacist-bundled intervention was associated with a reduced 30-day readmission rate for high-risk patients with pneumonia.

Fatal intracranial bleed potentially due to a warfarin and influenza vaccine interaction.

OBJECTIVE: To report a case of fatal intracranial bleeding possibly due to an interaction between warfarin and inactivated influenza vaccination. CASE SUMMARY: A 64-year-old white male was admitted to the hospital after becoming unresponsive. The family reported a 2-day history of bleeding from the patient's rectum prior to admission. He had no recent changes in medical conditions or medication regimen, which included warfarin for stroke prophylaxis secondary to atrial fibrillation. The patient had received an inactivated influenza vaccine 4(1/2) weeks prior to presentation, at which time his international normalized ratio (INR) was 2.0. Upon admission, the patient's INR was greater than 15; INR values over the previous 6 months had been relatively stable (range 1.4-4.7). A noncontrast computed tomography scan of the head showed a large parenchymal hemorrhagic infarction involving the left temporal, parietal, and occipital lobes. In the emergency department, the patient received a nitroglycerin infusion to maintain systolic blood pressure in the range of 140-160 mm Hg as well as an infusion of 4 units of fresh frozen plasma and 10 mg of vitamin K. Following a neurosurgery evaluation, it was determined that nothing meaningful could be done to alter the patient's outcome positively, and he died approximately 17 hours after admission. DISCUSSION: To date, most reports of concomitant warfarin therapy and influenza vaccination indicate no significant change in average anticoagulation parameters. However, there are reports of individuals who may have experienced increased anticoagulation following influenza vaccination. The reason for these increases is unknown, but may involve only certain components of the vaccine, which is altered almost annually. Our patient's significant INR elevation, after being relatively stable for at least 6 months, was thought to be due to an interaction between warfarin and the influenza vaccination. The Horn Drug Interaction Probability Scale indicated a possible interaction between warfarin and the influenza vaccination. CONCLUSIONS: Considering the outcome in our patient, as well as outcomes in other individuals who have experienced an increased INR in a similar scenario, it appears justified to implement more frequent INR evaluations during the 4-6 weeks following influenza vaccination.

Interactions between warfarin and three commonly prescribed fluoroquinolones.

OBJECTIVE: To critically evaluate a possible increased anticoagulant response during concomitant warfarin and fluoroquinolone therapy. DATA SOURCES: A literature search was conducted using PubMed, International Pharmaceutical Abstracts, and MEDLINE, from inception to January 2008, combining the term warfarin individually with ciprofloxacin, levofloxacin, and moxifloxacin. These 3 quinolones were selected based on their commercial availability and use in the US. STUDY SELECTION AND DATA EXTRACTION: All publication types including human participants and published in English were eligible for review. Reports were selected based on the use of typical treatment courses of fluoroquinolones during concomitant warfarin therapy and the reporting of prothrombin time (PT) or international normalized ratio (INR). DATA SYNTHESIS: Twenty-two publications were evaluated including 16 case reports or case series, 2 retrospective cohort studies, and 4 prospective studies, which included 2 placebo-controlled investigations. Identified reports covered a wide range of patient ages with multiple comorbidities. Changes in PT and INR values were considerably variable and inconsistent during concomitant warfarin and fluoroquinolone therapy. Results from the 6 structured reports demonstrated mean increases in PT and INR values that were clinically insignificant. However, some patients experienced significant increases above the desired therapeutic range. Increased anticoagulation was typically observed within the first week of concomitant fluoroquinolone therapy. Bleeding complications during times of increased anticoagulation were not always observed, but did result in death for 2 patients. CONCLUSIONS: Published data show no consistent increase in anticoagulant effects during concomitant warfarin and 3 commonly prescribed fluoroquinolones. Therefore, more frequent monitoring during concomitant therapy would be prudent.

Moxifloxacin-induced Clostridium difficile-associated diarrhea.

A 22-year-old woman was admitted to the hospital with pneumonia, urinary tract infection, anemia, thrombocytopenia, and leukocytosis. After receiving moxifloxacin for 5 days, she experienced diarrhea with cramping and abdominal pain. She was diagnosed with Clostridium difficile-associated diarrhea (CDAD) after C. difficile toxin was identified in a stool specimen. Metronidazole was begun, and the CDAD resolved with continued moxifloxacin administration. Virtually any antibiotic can lead to development of CDAD through disruption of the normal colonic flora, allowing for overgrowth of C. difficile. Although moxifloxacin is generally well tolerated, clinicians should be aware of its potential for inducing CDAD.

Venous thromboembolism prophylaxis conversion in nonsurgical inpatients.

OBJECTIVE: To provide venous thromboembolism (VTE) prophylaxis according to national consensus guidelines while minimizing associated medication costs. METHODS: Patients admitted to our institution who were receiving VTE prophylaxis with the low-molecular-weight heparin (LMWH) enoxaparin were identified and evaluated for potential conversion to low-dose unfractionated heparin (LDUH). Patients admitted for general medical conditions were targeted for a potential conversion. Factors that excluded patients from conversion were any surgical intervention or evidence of bleeding. For all eligible patients, the treating physician was contacted through written recommendations in an effort to achieve conversion to an LDUH regimen. RESULTS: Throughout a 10-month period, 463 patients were identified as receiving enoxaparin for VTE prophylaxis. Of these, 112 (24%) were candidates for an LDUH regimen. A total of 88 pharmacy recommendations were provided, of which 59 (67%) were accepted. This conversion program resulted in the avoidance of 250 days of enoxaparin prophylaxis and 8495 US dollars of associated medication costs. CONCLUSIONS: Clinical pharmacy programs directed at converting patients from a more costly LMWH regimen for VTE prophylaxis to an LDUH regimen can significantly reduce medication costs while adhering to consensus guidelines.

Evidence for the cardioprotective effects of omega-3 Fatty acids.

OBJECTIVE: To review available literature regarding the cardiovascular effects of marine-derived Omega-3 fatty acids and evaluate the benefit of these fatty acids in the prevention of coronary heart disease. DATA SOURCES: Biomedical literature accessed through a MEDLINE search (1966-April 2002). Search terms included fish oil, omega-3 fatty acid, sudden death, hypertriglyceridemia, myocardial infarction, and mortality. DATA SYNTHESIS: Following an early 1970's observational investigation that Omega-3 fatty acids may reduce the occurrence of myocardial infarction-related deaths in Greenland Eskimos, additional trials have been conducted that support this finding. Epidemiologic and clinical trial data suggest that Omega-3 fatty acids may reduce the risk of cardiovascular-related death by 29-52%. In addition, the risk of sudden cardiac death was found to be reduced by 45-81%. Possible mechanisms for these beneficial effects include antiarrhythmic properties, improved endothelial function, antiinflammatory action, and reductions in serum triglyceride concentrations. Omega-3 Fatty acids are fairly well tolerated; potential adverse effects include bloating and gastrointestinal distress, "fishy taste" in the mouth, hyperglycemia, increased risk of bleeding, and a slight increase in low-density-lipoprotein cholesterol. CONCLUSIONS: Omega-3 Fatty acids may be beneficial and should be considered in patients with documented coronary heart disease. They may be particularly beneficial for patients with risk factors for sudden cardiac death.