Evaluation of pharmacist-led transition of care program in patients with acute coronary syndrome.

BACKGROUND: Guideline-directed medical therapies (GDMTs), initiated in-hospital and continued during the transition to outpatient care, are paramount to successful outcomes for patients with acute coronary syndrome (ACS). Incomplete discharge medication prescribing and delayed follow-up lead to worse cardiovascular outcomes. OBJECTIVES: We investigated a system of care using inpatient and outpatient clinical pharmacists to close GDMT gaps, ensure seamless transition to outpatient care, improve patient education, and optimize therapies. METHODS: We conducted a pre-post cohort analysis of patients with ACS pre- versus post-intervention to compare process metrics and key outcomes using electronic health record data. RESULTS: There were 181 and 135 patients in the pre- and post-intervention cohorts, respectively. Patients post-intervention were significantly more likely to have appropriately-timed follow-up visits scheduled with cardiology (79% vs. 51%, P < 0.0001) and primary care (57% vs. 43%, P = 0.01), to be discharged with prescriptions for P2Y12 inhibitors (87% vs. 64%, P < 0.0001), high dose statins (86% vs. 70%, P = 0.001), and beta blockers (87% vs. 76%, P = 0.01), and significantly less likely to have 30-day all-cause hospital readmissions (4% vs. 12%, P = 0.02) and emergency department (ED) visits (10% vs. 18%, P = 0.04). CONCLUSIONS: The integration of advanced practicing pharmacists into a cardiology team at transition and post-hospitalization resulted in improved rates of posthospital follow-up visits, optimization of GDMT medications, and significantly lower 30-day hospital readmission and ED utilization.

Pre-emptive pharmacogenomics implementation among polypharmacy patients 65 years old and older: a clinical pilot.

Aim: Pre-emptive testing of pharmacogenomic (PGx) variations has potential to improve medication safety and effectiveness; however, testing is not routine. Given the newfound payor coverage of multigene testing and the potential value of testing within aging patients, it is imperative to test local PGx testing capabilities, report results to patients and providers, and determine the value of testing. Materials & methods: We designed a randomized clinical pilot of a pre-emptive PGx testing process using the electronic health record compared with usual care among an aging primary care population. Results & conclusion: The impact of the program on prescribing patterns, healthcare utilization and costs of care will be evaluated. We hypothesize that implementation of a pre-emptive multigene PGx panel is feasible among elderly, polypharmacy, primary care patients, measured by the number of enrolled patients with PGx results entered in the medical record. Health system wide PGx implementation, including capacity needed to integrate these valuable results, is also described.

Medication use and comorbidities in an increasingly younger osteoarthritis population: an 18-year retrospective open-cohort study.

OBJECTIVES: As understanding of the pathogenesis and treatment strategies for osteoarthritis (OA) evolves, it is important to understand how patient factors are also changing. Our goal was to examine demographics and known risk factors of patients with OA over time. DESIGN: Open-cohort retrospective study using electronic health records. SETTING: Large US integrated health system with 7 hospitals, 2.6 million outpatient clinic visits and 97 300 hospital admissions annually in a mostly rural geographic region. PARTICIPANTS: Adult patients with at least two encounters and a diagnosis of OA or OA-relevant surgery between 2001 and 2018. Because of geographic region, over 96% of participants were white/Caucasian. INTERVENTIONS: None. PRIMARY AND SECONDARY OUTCOME MEASURES: Descriptive statistics were used to examine age, sex, body mass index (BMI), Charlson Comorbidity Index, major comorbidities and OA-relevant prescribing over time. RESULTS: We identified 290 897 patients with OA. Prevalence of OA increased significantly from 6.7% to 33.5% and incidence increased 37% (from 3772 to 5142 new cases per 100 000 patients per year) (p<0.0001). Percentage of females declined from 65.3% to 60.8%, and percentage of patients with OA in the youngest age bracket (18-45 years) increased significantly (6.2% to 22.7%, p<0.0001). The percentage of patients with OA with BMI ≥30 remained above 50% over the time period. Patients had low comorbidity overall, but anxiety, depression and gastro-oesophageal reflux disease showed the largest increases in prevalence. Opioid use (tramadol and non-tramadol) showed peaks followed by declines, while most other medications increased slightly in use or remained steady. CONCLUSIONS: We observe increasing OA prevalence and a greater proportion of younger patients over time. With better understanding of how characteristics of patients with OA are changing over time, we can develop better approaches for managing disease burden in the future.

Associations of Healthcare Utilization and Costs with Increasing Pain and Treatment Intensity Levels in Osteoarthritis Patients: An 18-Year Retrospective Study.

INTRODUCTION: Osteoarthritis (OA) is a complex disease, and prior studies have documented the health and economic burdens of patients with OA compared to those without OA. Our goal was to use two strategies to further stratify OA patients based on both pain and treatment intensity to examine healthcare utilization and costs using electronic records from 2001 to 2018 at a large integrated health system. METHODS: Adult patients with ≥1 pain numerical rating scale (NRS) and diagnosis of OA were included. Pain episodes of ≥90 days were defined as mild (0-3), moderate (4-6), or severe (7-10) based on initial NRS. Patients were initially classified as mild and moved to moderate-severe OA if any of eight treatment-based criteria were met. Outpatient visits (OP), emergency department visits (ED), inpatient days, and healthcare costs (both all-cause and OA-specific) were compared among pain levels and OA severity levels as frequencies and per-member-per-year rates, using generalized linear regression models adjusting for age, sex, and body mass index, with contrasts of p < 0.05 considered significant. RESULTS: We identified 127,656 patients, 92,576 with pain scores. Moderate and severe pain were associated with significantly higher rates of OA-related utilization and costs, and all-cause ED visits and pharmacy costs. Moderate-severe OA patients had significantly higher OA-related utilization and costs, and all-cause OP, ED and pharmacy costs. CONCLUSIONS: Pain and treatment intensity were both strongly associated with OA-related utilization but not consistently with all-cause utilization. Our results provide promising evidence of better criteria and approaches for predicting disease burden and costs in the future.

Evaluation of an educational strategy to improve medication reconciliation in ambulatory care.

BACKGROUND: Improper medication reconciliation can result in inaccurate medication lists. When medication lists are inaccurate, it can result in drug-drug interactions, dosing errors, and medication duplication. Interventions targeting medication reconciliation have had varying levels of success. OBJECTIVE: This study aimed to describe the medication reconciliation educational program, its implementation in a health care system, pharmacist and clinic personnel perception of the program, and its impact on clinic personnel knowledge and practice. METHODS: Guided by the Conceptual Model of Implementation Research, a partially mixed sequential dominant status evaluation of a pharmacist-led educational program on evidence-based practices for medication reconciliation implemented into all primary care clinic sites by examining implementation outcomes was conducted. The implementation outcomes measured include penetration, fidelity, acceptability, appropriateness, feasibility, and adoption. Data were collected through program data and direct observations, pre- and postsurveys, and semistructured interviews of pharmacists and clinic personnel. RESULTS: Of 46 primary care sites, 37 primary care sites (80%) implemented the pharmacist-delivered medication reconciliation education from April to June 2021 with representation from each of Geisinger's regions. Ten clinic sites (27%) completed the medication reconciliation educational program as originally designed, with the remainder adapting the program. A total of 296 clinic personnel completed the presurvey, and 178 completed the postsurvey. There were no differences in baseline characteristics between clinic personnel who completed the pre- versus postsurvey. All clinic personnel interviewed felt satisfied with the educational program and felt it was appropriate because it directly affected their job. Clinic personnel felt the educational program was acceptable and appropriate; two major concerns were discussed: a lack of patient knowledge about their medications and a lack of time to complete the medication reconciliation. The adherence rate to the elements of the medication reconciliation that were covered in the education program ranged from 0% to 95% in the 55 observations conducted. CONCLUSION: An educational program for medication reconciliation was found to be acceptable and appropriate but was often adapted to fit site-specific needs. Additional barriers affected adoption of best practices and should be addressed in future studies.

Evaluation of a Web-Based Medication Reconciliation Application Within a Primary Care Setting: Cluster-Randomized Controlled Trial.

BACKGROUND: Despite routine review of medication lists during patient encounters, patients' medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources. OBJECTIVE: We aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT). METHODS: We conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews. RESULTS: Overall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement. CONCLUSIONS: The use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.