Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facility.

BACKGROUND: There is a lack of published literature that measures the impact of transitional care pharmacist (TCP) medication-related interventions within the skilled nursing facility (SNF) setting. OBJECTIVES: To evaluate the impact of TCP medication-related interventions on 30-day hospital readmissions among SNF patients compared to current standard of care. METHODS: This was a retrospective pilot study. All patients included in the study were discharged from an inpatient facility to a SNF. The control group received transitional services from a care team with no pharmacist. The intervention group received transitional services from a care team plus a pharmacist. RESULTS: The 30-day readmission rates in the intervention group were 14 (12%)/116 compared to the control group, 19 (16%)/116; however, the difference was not statistically significant (P = .35). The median time to readmission was statistically significantly longer in the intervention group, 17.5 days, compared to the control group, 10 days (P = .02). One hundred seventy-four medication-related interventions were performed in the intervention group during the study period. CONCLUSION: This study demonstrates that TCP interventions in an SNF are associated with a significant delay in readmission. A continuation of the pilot program may show a role in reducing all-cause 30-day readmission and ED visit rates.

Medication regimen complexity and readmissions after hospitalization for heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

OBJECTIVES: Readmission rate is increasingly being viewed as a key indicator of health system performance. Medication regimen complexity index scores may be predictive of readmissions; however, few studies have examined this potential association. The primary objective of this study was to determine whether medication regimen complexity index is associated with all-cause 30-day readmission after admission for heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. METHODS: This study was an institutional review board-approved, multi-center, case-control study. Patients admitted with a primary diagnosis of heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease were randomly selected for inclusion. Patients were excluded if they discharged against medical advice or expired during their index visit. Block randomization was utilized for equal representation of index diagnosis and site. Discharge medication regimen complexity index scores were compared between subjects with readmission versus those without. Medication regimen complexity index score was then used as a predictor in logistic regression modeling for readmission. RESULTS: Seven hundred and fifty-six patients were randomly selected for inclusion, and 101 (13.4%) readmitted within 30 days. The readmission group had higher medication regimen complexity index scores than the no-readmission group (p < 0.01). However, after controlling for demographics, disease state, length of stay, site, and medication count, medication regimen complexity index was no longer a significant predictor of readmission (odds ratio 0.99, 95% confidence interval 0.97-1.01) or revisit (odds ratio 0.99, 95% confidence interval 0.98-1.02). CONCLUSION: There is little evidence to support the use of medication regimen complexity index in readmission prediction when other measures are available. Medication regimen complexity index may lack sufficient sensitivity to capture an effect of medication regimen complexity on all-cause readmission.

Reducing preventable medication safety events by recognizing renal risk.

UNLABELLED: Evidence suggests that medication safety may be improved through more accurate assessment of renal function and appropriate dosing of renally cleared medications. The purpose of this article is to describe patient renal risk groups, associated medication errors, and ways that nurses can improve renal assessment. METHODS: Medication safety data were collected through voluntary reporting, computerized triggers, pharmacist surveillance, and retrospective chart review. Data were analyzed across 3 renal risk groups. RESULTS: Findings indicated that regarding the detected medication errors, elderly women were more likely to have hidden renal risk and that prescribing errors involving a wrong dose occurred more often in patients with high and hidden renal risk. Antibiotic and diabetic medications were the primary drug categories involved in these medication errors. RECOMMENDATIONS: Results indicated that identification of patients with hidden renal risk can be improved by routinely assessing serum creatinine and estimated creatinine clearance levels during renal assessments. Clinical nurse specialists can use this evidence to promote safer nursing care of renal patients.

Reliability evaluation of the adapted national coordinating council medication error reporting and prevention (NCC MERP) index.

PURPOSE: Adapted National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index criteria were used in a study undertaken to evaluate commercial computerized provider order entry (CPOE) system impact on community hospital medication errors. This article describes: (1) adaptation of the Index, (2) classification criteria and processes used to assess the adapted Index, and (3) inter-rater reliability results. METHODS: A random sample of 130 (17%) of 2251 medication safety events (MSEs) were classified based on event type, that is, adverse drug event (ADE) or potential ADE (PADE); preventability, that is, 'yes' or 'no,' and outcome severity. Event outcome severity was categorized using adapted Index categories E-I (ADEs) and B-D (PADEs). Decision rules were used for rule-based classification, while an MSE Case Review Panel used judgment-based classification when decision rules did not apply. Inter-rater reliability for both classification approaches was assessed with kappa coefficients, percentage agreement, and confidence intervals (CI). RESULTS: Level of agreement was substantial for both rule-based and judgment-based MSE classification for event type (6 = 0.70-0.90), preventability (6 = 0.67-0.82), and decision rule application (6 = 0.79). Rule-based agreement for ADE and PADE severity was almost perfect for discrete (6 = 0.83-0.84) and combined (6 = 0.87-0.90) Index categories. Judgment-based agreement was substantial for discrete (6 = 0.63-0.67) and combined (6 = 0.66-0.84) Index categories. CONCLUSIONS: The adapted Index yielded substantial agreement for event type, preventability, and severity. Adaptation of the Index to support classification of non-preventable ADEs was an important improvement.

Computerized provider order entry system field research: the impact of contextual factors on study implementation.

Attention to contextual factors is essential to the conduct of high quality informatics field research. This is particularly true when the research focus is on complex information technology innovations like computerized provider order entry (CPOE) systems. From a field research perspective, CPOE systems are considered an organizational intervention. They are designed, implemented and used within an organizational context that encompasses cultural, economic, social and physical aspects. It is essential that informatics researchers address contextual factors when assessing the impact of CPOE systems. Inclusion of organizational contextual factors in CPOE system field studies permits a more accurate evaluation of the true impact these systems have on medication practice processes and outcomes. The goals of this paper are to: (1) identify contextual factors that influenced implementation of a federally-funded field study undertaken to examine the impact of a community hospital CPOE system on medication error outcomes; and (2) describe how these contextual factors influenced study methodology and implementation.