Discharge Home From Hospital: How DIRE Can It Be?

AIM: An easy-to-use "DIRE" questionnaire tool was developed to predict an adverse event (AE) within 30 days following discharge from a hospital to the community, among frail elderly individuals aged 65+ years. METHODS: Hospital-administered RAI-HC (Residential Assessment Instrument for Home Care) assessment data from 1,433 individuals were used to develop the tool. RESULTS: The DIRE tool outperformed two other instruments that have been used to predict risk in similar populations. Furthermore, the DIRE index was validated on a hold-out sample and in a bootstrapping analysis. DISCUSSION: In addition to its effectiveness in predicting an AE, the added advantages of the DIRE assessment is that only a small amount of data is required and the data are readily available to clinicians at the point of hospital discharge.

Current perspectives on pharmacist home visits: do we keep reinventing the wheel?

The scope of clinical pharmacy services available in outpatient settings, including home care, continues to expand. This review sought to identify the evidence to support pharmacist provision of clinical pharmacy services in a home care setting. Seventy-five reports were identified in the literature that provided evaluation and description of clinical pharmacy home visit services available around the world. Based on results from randomized controlled trials, pharmacist home visit interventions can improve patient medication adherence and knowledge, but have little impact on health care resource utilization. Other literature reported benefits of a pharmacist home visit service such as patient satisfaction, improved medication appropriateness, increased persistence with warfarin therapy, and increased medication discrepancy resolution. Current perspectives to consider in establishing or evaluating clinical pharmacy services offered in a home care setting include: staff competency, ideal target patient population, staff safety, use of technology, collaborative relationships with other health care providers, activities performed during a home visit, and pharmacist autonomy.

Satisfaction survey for a medication management program: satisfaction guaranteed?

BACKGROUND: Providing clinical pharmacy services to patients in their homes after discharge from hospital has been reported to reduce health care costs and improve outcomes. The Medication Management Program of the Fraser Health Authority involves pharmacists making home visits to provide clinical pharmacy services to elderly patients who have recently been discharged from hospital and others considered to be at high risk for adverse drug events. Although clinical and economic outcomes of this program have been evaluated, humanistic outcomes such as satisfaction have not been assessed. Moreover, very little evaluation of patient satisfaction with home pharmacy services has been reported in the literature. OBJECTIVE: To evaluate patient satisfaction with the Medication Management Program. METHODS: A telephone survey instrument, consisting of 7 Likert-scale items and 2 open-ended questions, was developed and administered to patients who received a home pharmacist visit between September 1 and November 23, 2011. In addition to the survey responses, demographic and clinical data for both respondents and nonrespondents were collected. RESULTS: Of the 175 patients invited to participate in the survey, 103 (58.9%) agreed to participate. The majority of respondents agreed or strongly agreed with all of the survey items, indicating satisfaction with the program. For example, 97 (94%) agreed or strongly agreed that they would recommend the pharmacist home visit program continue to be available, and all 103 (100%) agreed or strongly agreed that they were satisfied with the pharmacist home visit. Respondents provided some suggestions for program improvement. CONCLUSIONS: The survey findings demonstrate that patients were satisfied with the home clinical pharmacy services offered through the Fraser Health Medication Management Program.

CONTEXTE: La prestation de services de pharmacie clinique aux patients à domicile après leur congé de l'hôpital réduirait les coûts de soins de santé et améliorerait les résultats selon des rapports. Dans le cadre du Programme de gestion des médicaments de la Fraser Health Authority, des pharmaciens se rendent au domicile de patients âgés ayant récemment obtenu leur congé de l'hôpital et d'autres patients considérés comme à risque élevé d'événements indésirables liés aux médicaments pour leur fournir des services de pharmacie clinique. Bien qu'on ait évalué les incidences cliniques et économiques de tels services, l'aspect humain, comme la satisfaction, n'a pas fait l'objet d'évaluations. En outre, on trouve très peu de données dans la littérature sur l'évaluation de la satisfaction des patients à l'égard des services de pharmacie clinique à domicile. OBJECTIF: Évaluer la satisfaction des patients à l'égard du Programme de gestion des médicaments. MÉTHODES: Un questionnaire à sept énoncés évalués sur une échelle de Likert et à deux questions ouvertes a été développé et utilisé pour réaliser un sondage téléphonique auprès des patients qui avaient reçu la visite à leur domicile d'un pharmacien entre le premier septembre et le 23 novembre 2011. En plus des réponses au sondage, des données démographiques et cliniques ont été collectées à propos des répondants et des non-répondants. RÉSULTATS: Des 175 patients invités à participer au sondage, 103 (58,9 %) ont accepté. La majorité des répondants étaient d'accord ou tout à fait d'accord avec tous les énoncés du sondage, indiquant ainsi leur satisfaction à l'égard du programme. Par exemple, 97 (94 %) étaient d'accord ou tout à fait d'accord pour recommander que l'on continue d'offrir le programme de pharmacie clinique à domicile et la totalité des 103 (100 %) participants étaient d'accord ou tout à fait d'accord pour dire qu'ils étaient satisfaits de la visite du pharmacien à domicile. Les répondants ont formulé quelques suggestions pour améliorer le programme. CONCLUSIONS: Les résultats du sondage indiquent que les patients étaient satisfaits des services de pharmacie clinique à domicile offerts dans le cadre du Programme de gestion des médicaments de la Fraser Health Authority. [Traduction par l'éditeur].

Pharmacists making house calls: innovative role or overkill?

BACKGROUND: The Medication Management Program was established at the Fraser Health Authority in 2005, in response to evidence suggesting that having pharmacists provide care to patients in their homes after discharge from hospital could reduce subsequent utilization of health service resources. OBJECTIVE: To determine the effectiveness of the Medication Management Program in its first 2 years of operation. METHODS: For patients who had received a home visit by a pharmacist, the utilization of health services (admissions to hospital, physician office visits, and dispensed medications) in the year before the home visit was compared with utilization during the year after the intervention. The net cost of the program was also determined. RESULTS: In the first 2 years of the Medication Management Program (2005/2006 and 2006/2007), a total of 1171 patients received a home visit from a pharmacist. Of these, 836 (71%) were included in the before-and-after analysis. The median per-patient cost for utilization of health services was $11 014 lower in the year after the intervention than in the year preceding the intervention. After the costs of the program were taken into account, this resulted in a net median cost reduction of $3047.43 per patient. CONCLUSION: The Medication Management Program was effective as a clinical program in its first 2 years.

Pharmacists' participation in an inhaled respiratory medication program: reimbursement of professional fees.

BACKGROUND: An intervention (termed Initiative) was initiated to facilitate converting beneficiaries of a public drug insurance program in the province of Nova Scotia from respiratory nebulization medications to inhalers. Community pharmacists provided patient education and billed professional fees for conversions or optimizing inhaled respiratory medication technique. OBJECTIVE: To determine community pharmacists' self-reported participation rate and identify facilitators and barriers to billing for professional fees. METHODS: A survey was developed and mailed to Nova Scotia pharmacists. Information on demographics, work environment, professional experience, financial aspects, billing experiences, and the billing process was collected. Quantitative and qualitative data were evaluated using bivariate and multivariate analyses, and a thematic process, respectively. RESULTS: Two hundred ninety-seven pharmacists responded. Self-reported billing rates for fees were 34% (switching delivery devices), 58% (optimizing AeroChamber use), and 37% (follow-up when replacing Aerochambers). Awareness of fees and the perception of consistent claim reimbursement were associated with billing for each fee (p < 0.05). Predisposing billing factors included awareness of fees, identifying situations requiring education, owner/manager position, male gender, perception that billing for education for optimizing technique is a minimum standard of practice, and prescription volume. Themes identified as barriers included inefficient billing process, inadequate fees, and lack of Initiative awareness. CONCLUSIONS: Predisposing factors were the most important facilitators of community pharmacists' participation in this program, while a cumbersome and time-consuming billing process was the primary barrier. Further research should determine the impact of the professional fee on patient health outcomes.

Use of gastrointestinal preventive therapy among elderly persons receiving antiarthritic agents in Nova Scotia, Canada.

BACKGROUND: Two different strategies, referred to as gastrointestinal (GI) preventive therapy (GIPT), have been recommended for high-risk patients to prevent GI complications associated with antiarthritic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs): (1) use of a gastroprotective agent (GPA) along with the NSAID or (2) use of a cyclooxygenase-2-selective inhibitor (COX-2SI). The COX-2SIs rofecoxib and celecoxib have been shown to be as effective as traditional NSAADs for pain relief, but with an improved GI safety profile. OBJECTIVE: The purpose of this study was to examine the utilization of GIPT by elderly persons in Nova Scotia who were taking antiarthritic medications and to identify the factors associated with their use of GIPT. METHODS: A retrospective, cross-sectional study was conducted using administrative data from the Nova Scotia Seniors' Pharmacare Program database. Study participants were aged >or=65 years and had filled a prescription for a COX-2SI, a traditional NSAID, or high-dose aspirin at some point between January 1, 2001 and August 31, 2002. Subjects with at least 1 risk factor (as defined by our study) who received GIPT were classified as receiving appropriate therapy. Subjects with risk factors who did not receive GIPT were classified as potential underutilizers of GIPT. Subjects without risk factors who received GIPT were classified as potential overutilizers of GIPT. Descriptive statistics were presented, and factors independently associated with receiving GIPT were assessed using logistic regression. RESULTS: The study included 14,587 seniors: 3647 used COX-2SIs, 9412 used traditional NSAIDs alone, and 1528 used traditional NSAADs plus a GPA. Subjects were predominantly female (age range, 65-74 years). In subjects with at least 1 risk factor, 63% were classified as potential underutilizers of GIPT. Thirty-three percent of subjects with no risk factors were classified as potential overutilizers of GIPT. Factors significantly associated with receiving a GIPT included Female gender, annual income >$50,000, urban residence, age >or=75 years, GI complication in the previous year, and concomitant use of warfarin or corticosteroids. CONCLUSION: Potential under utilization of GIPT in this subject population was more prevalent than potential overutilization of GIPT. Although all hypothesized risk factors were significantly associated with receiving GIPT, physician education on GI risk factors might improve prescribing of GIPT for elderly persons in Nova Scotia.

Validation of four clinical indicators of preventable drug-related morbidity.

BACKGROUND: Clinical indicators are tools that assess quality issues related to the use of medicines. At this time, validated clinical indicators for preventable drug-related morbidity (PDRM) are lacking. OBJECTIVE: To assess the validity and reliability of using population administrative claims data to identify the extent of PDRM in older adults in Canada. METHODS: Four indicators of PDRM related to cerebrovascular and cardiovascular care were chosen for validation. A random sample of cases that represented the indicators and fit the criteria (hits) for PDRM from the retrospective operationalization of the study database and those that did not fit the criteria (near hits) were selected for chart review. One-page abstracts of the cases were prepared for review by a panel of 5 clinical pharmacists. Validity was assessed by calculating sensitivity, specificity, and positive and negative predictive value. Reliability was assessed using reviewers' agreement scores (kappa statistics). RESULTS: Overall, 119 case abstracts were reviewed by each panelist. The sensitivity ranged from 33% to 100% and the specificity from 51% to 71%. Predictive values ranged from 5.3% to 43% (positive) and 90% to 100% (negative). The overall kappa statistic was fair (0.21). CONCLUSIONS: The validity of the 4 assessed PDRM indicators varied. The reliability was fair; however, these indicators may be useful to screen older adults for PDRM.