Impact of a discharge prescription program on hospital readmissions and patient satisfaction.

OBJECTIVES: Medication nonadherence is prevalent and associated with adverse outcomes, including hospital readmissions. Outpatient pharmacies within health systems are well positioned to intervene and enhance the discharge process by ensuring that patients leave the hospital with all discharge medications. The goal of this study was to evaluate whether a simply designed discharge prescription program (DPP) could reduce readmission rates and increase patient satisfaction scores for participants versus patients who did not participate. METHODS: We conducted a retrospective cohort study across 15 hospital units in a large health system, evaluating inpatient visits from February 2013 to December 2014. Outcomes included the presence of a 7- or 30-day readmission following discharge date and patient satisfaction survey responses. RESULTS: Patients who participated in the DPP during a hospitalization were significantly less likely to be readmitted than patients who did not participate (P < 0.05). Participation in the DPP decreased odds of 7-day readmission by 20% and of 30-day readmission by 16%. An increase in positive responses for care management and overall experience satisfaction questions was also seen. CONCLUSION: A DPP offers a simple and unique opportunity to reduce readmissions and improve patient satisfaction by dispensing discharge medications before patients leave the hospital.

Primary Care Provider Perspectives on Electronic Medication Refill History.

Improvements in health information technology have made aggregate multipayer pharmacy claims data increasingly available through the electronic health record (EHR). The objective of this study was to assess the current awareness, utilization, and impact of pharmacy history data available in the EHR on primary care provider (PCP) decision making. A 14-question survey was distributed to all PCPs in a large medical practice. Of the 55/72 responding PCPs, 47 (85.5%) were aware of the EHR medication history function, and 36 (65.5%) had used it previously. Respondents indicated the medication history could be most useful when considering prescribing a narcotic (33/36, 92%) and when addressing nonadherence concerns (28/35, 80%). Barriers included delays in data loading and the time pressures of clinical practice. Access to aggregate multipayer pharmacy history data has the potential to affect medication reconciliation, yet future implementation should focus on making these data complete and easily available in routine practice.

High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients.

OBJECTIVE: Vancomycin loading doses are recommended; however, the risk of nephrotoxicity with these doses is unknown. The primary objective of this study was to compare nephrotoxicity in emergency department (ED) sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (≤20 mg/kg). METHODS: A retrospective cohort study was performed in three academic EDs. Inclusion criteria were age ≥ 18 years, intravenous vancomycin order, and hospital admission. Exclusion criteria were no documented weight, hemodialysis-dependent, and inadequate serum creatinine (SCr) values for the measured outcome. Analyses compared the incidence of nephrotoxicity for patients who received vancomycin at high dose (>20 mg/kg) versus low dose (≤20 mg/kg). RESULTS: A total of 2,131 consecutive patients prescribed vancomycin over 6 months were identified. Of these, 1,330 patients had three SCr values assessed for the primary outcome. High-dose initial vancomycin was associated with a significantly lower rate of nephrotoxicity (5.8% vs. 11.1%). After age, sex, and initial SCr were adjusted for, the risk of high-dose vancomycin compared to low-dose was decreased for the development of nephrotoxicity (relative risk = 0.60; 95% confidence interval = 0.44 to 0.82). CONCLUSION: Initial dosing of vancomycin > 20 mg/kg was not associated with an increased rate of nephrotoxicity compared with lower doses. Findings from this study support compliance with initial weight-based vancomycin loading doses.

Usefulness of pharmacy claims for medication reconciliation in primary care.

OBJECTIVES: Methods for efficient medication reconciliation are increasingly important in primary care. Aggregated pharmacy data within the native electronic health record (EHR) may create a new opportunity for efficient and systematic medication reconciliation in practice. Our objective was to identify the prevalence and predictors of medication discrepancies between pharmacy claims data and the medication list in a primary care EHR. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective cohort study of patients prescribed a new antihypertensive in a large primary care practice network between January 2011 and September 2012. We compared patients' active medications recorded in the practice EHR with those listed in pharmacy claims data available through the EHR. The primary outcome was the presence of a medication discrepancy. RESULTS: Of 609 patients, 468 (76.9%) had at least 1 medication discrepancy. Significant predictors of discrepancies included the total medication count (odds ratio [OR], 2.18; 95% CI, 1.85-2.57) and having a recent emergency department visit (OR, 2.58; 95% CI, 1.03-6.45). The identified discrepancies included 171 patients (28.1%) with 229 controlled substance discrepancies. CONCLUSIONS: Our study revealed a high rate of discrepancies between pharmacy claims data and the provider medication list. Aggregated pharmacy claims data available through the EHR may be an important tool to facilitate medication reconciliation in primary care.

Using aggregated pharmacy claims to identify primary nonadherence.

OBJECTIVES: Aggregate pharmacy claims available within an electronic health record (EHR) provide an opportunity to understand primary nonadherence in real time. The objective of this study was to use pharmacy claims data available within the EHR to identify the prevalence and predictors of primary nonadherence to antihypertensive drug therapy in a multi-payer primary care network. STUDY DESIGN: We conducted a retrospective cohort study of patients prescribed a new antihypertensive medication in a large primary care practice network between January 2011 and September 2012. METHODS: We matched prescriptions for the new antihypertensive to pharmacy claims listed in the EHR. The primary outcome was the presence of a fill for the new medication within 30 days of the prescription. RESULTS: Of 791 patients in our study cohort, two-thirds (522; 66%) filled their prescription within 30 days. The majority (409; 78.4%) of that group filled the prescription on the day it was issued. Lower diastolic blood pressure and Medicare coverage increased the probability of nonadherence. CONCLUSIONS: Medication fill data within the provider EHR can identify primary nonadherence in clinical practice. As adoption of this technology increases, it provides an opportunity to identify nonadherence, allowing for the effective design of interventions to improve adherence to therapy.

Treating pain in addicted patients: recommendations from an expert panel.

Clinicians may face pragmatic, ethical, and legal issues when treating addicted patients. Equal pressures exist for clinicians to always address the health care needs of these patients in addition to their addiction. Although controversial, mainly because of the lack of evidence regarding their long-term efficacy, the use of opioids for the treatment of chronic pain management is widespread. Their use for pain management in the addicted population can present even more challenges, especially when evaluating the likelihood of drug-seeking behavior. As the misuse and abuse of opioids continues to burgeon, clinicians must be particularly vigilant when prescribing chronic opioid therapy. The purpose of this article is to summarize recommendations from a recent meeting of experts convened to recommend how primary care physicians should approach treatment of chronic pain for addicted patients when an addiction specialist is not available for a referral. As there is a significant gap in guidelines and recommendations in this specific area of care, this article serves to create a foundation for expanding chronic pain guidelines in the area of treating the addicted population. This summary is designed to be a practical how-to guide for primary care physicians, discussing risk assessment, patient stratification, and recommended therapeutic approaches.

Patient interpretations of prescription order quantitative statements.

OBJECTIVES: To characterize the variability in patient understanding and interpretation of quantitative statements from prescription orders and to evaluate the influence of sociodemographic characteristics on how patients interpret quantitative statements. METHODS: Participants were recruited in both a clinic and pharmacy setting in Kentucky. Patients were given a survey that asked for general background information and two questions pertaining to their experience with topical products. Then, patients were read a scenario and asked to use a provided tube of cream and squeeze out what they considered a small amount. RESULTS: 100 eligible patients participated in the study, with the majority having previous counseling on the use of topical products. The mean (±SD) cream weight representing a small amount was 0.36 ± 0.50 g. Regression analysis demonstrated a significant nonlinear relationship for two of the patient characteristics, age and body mass index (BMI), with the greatest effect in the middle of age and BMI distributions (at approximately age 50 years and BMI 30 kg/m²). No evidence indicated that gender, race, education, or previous experience with or education about topical products had any effect on cream weight perception. CONCLUSION: Patients demonstrated tremendous variability in the interpretation of a small amount of topical product cream. Further research should be conducted to determine whether policy changes are warranted to require more specific prescription order instructions in the outpatient setting.