Implementation of a peer review process to improve documentation consistency of care process indicators in the EMR in a primary care setting.

BACKGROUND: Kaiser Permanente Colorado is a group model nonprofit HMO that provides health care services to more than 500,000 members. The Primary Care Clinical Pharmacy Services (PCCPS) department consists of 33 clinical pharmacy specialists (CPS), who are located in 19 primary care clinics. OBJECTIVES: To develop and implement a peer review process to (a) improve the consistency of documentation of process indicators in the electronic medical record (EMR), (b) ensure compliance with existing standards, and (c) share best practices among PCCPS with varying geographical locations and practice styles. METHODS: A committee was formed to undertake the peer review process. An audit tool consisting of yes/no questions was created to assess chart documentation by PCCPS and to provide feedback for improvement. Four sections were included in the evaluation tool: (a) content, (b) collaborative drug therapy management, (c) nonformulary reviews, and (d) pharmacy system documentation. Peer reviews occurred quarterly, and all CPS participated. Copies of reviews were distributed to PCCPS clinicians and their supervisors. Questions and inconsistencies regarding the process were identified by the peer review committee to provide feedback to the group to optimize reviews. After completion of each quarter's reviews, error rates were calculated by dividing the total number of "no" answers by the total number of PCCPS notes reviewed that quarter. A 2-tailed Fisher's exact test was used to compare the error rate at the last quarter of each year (2007 to 2010) with baseline (2007 Q1). RESULTS: A total of 1,856 reviews were conducted between 2007 Q1 and 2010 Q2. Significant improvements in documentation were demonstrated over the first 12 months and sustained for the next 2.5 years. From 2007 Q1 to 2010 Q2, the rate of noncompliant elements decreased from 14.1% to 2.5% (P=0.001) in the content section and decreased from 31.3% to 8.3% (P less than 0.001) across all sections. CONCLUSIONS: Over 3 years of follow-up, the peer review process was successful in improving the consistency of documentation by PCCPS and compliance with existing standards. The process was well received by participants. The peer review document is easily adaptable and can be updated to address changes in drug therapy management protocols and nonformulary medication reviews as needed. This process also allows for sharing of best practices among high-functioning PCCPS practitioners who otherwise could remain isolated.

Description of a team-based job improvement process within a large geographically dispersed primary care clinical pharmacy service.

OBJECTIVE: To describe the team-based job improvement process that Primary Care Clinical Pharmacy Services (CPS) used to enhance teamwork and improve job satisfaction during a 4-year period. SETTING: Health maintenance organization in Colorado from 2005 through 2008. PRACTICE DESCRIPTION: Kaiser Permanente Colorado is a group model, not-forprofit health maintenance organization that provides health services to approximately 490,000 members. Highly integrated clinical pharmacy services are offered at each of its 17 primary care medical offices in the Denver-Boulder metropolitan area. PRACTICE INNOVATION: A written survey consisting of three open-ended questions specifically directed at perceived positive and negative job-related features within Primary Care CPS was administered to team members. Six areas of focus emerged that were addressed by Primary Care CPS members within small groups. MAIN OUTCOME MEASURES: Pre- and postsurvey results from six identified focus areas were measured to address any impact of the team-based job improvement process. RESULTS: Positive responses increased from baseline by 48% for communication, 42% for new employee orientation, 25% for teamwork, and 25% for Primary Care CPS meetings (P < 0.05; chi-square test). Positive responses related to clinical practice increased 22%; however, this did not reach statistical significance. Perceived satisfaction with the documentation system for tracking clinical interventions declined 11% from baseline. CONCLUSION: Based on the initial successes with surveys and small-group discussions, Primary Care CPS continues to use this team-based job improvement process to resolve concerns or share best practices.

A descriptive evaluation of routine complete blood count monitoring in patients receiving anticoagulation therapy.

CONTEXT: The most prevalent side effect associated with warfarin therapy is bleeding. Routine monitoring of laboratory tests, such as complete blood counts (CBC), may provide theoretical benefit in this patient population as a means of detecting occult bleeding through hemoglobin values that decrease compared to baseline. OBJECTIVE: To describe the clinical outcomes associated with routine CBC monitoring in a large, diverse sample of anticoagulated patients. DESIGN: Forty-seven month retrospective, observational study. SETTING: Large non-profit, group-model health maintenance organization with a centralized clinical pharmacy anticoagulation service that routinely orders baseline CBCs on all patients enrolled in the service with follow up CBCs repeated at 3 months and yearly thereafter. PATIENTS: Patients continuously enrolled in the anticoagulation service for warfarin therapy monitoring for at least one year between January 1, 2000 and December 5, 2003. MAIN OUTCOME MEASURES: Medical records were reviewed to determine clinical outcomes associated with hemoglobin decreases of > or =2.0 gm/dL. Clinical outcomes included both overt and occult bleeding events and a determination of major or minor bleeding in these events. RESULTS: Of the 4033 patients included in the analysis, 578 (14.3%) experienced at least one decrease in hemoglobin > or =2.0 gm/dL. Occult bleeding was confirmed in 121 patients (3.0% of all patients monitored) with a decrease of hemoglobin > or =2.0 gm/dL but only 13 of these patients (0.3% of all patients monitored) experienced major bleeding. The annual detection rate of occult bleeding through routine CBC monitoring was 0.8%. CONCLUSIONS: Although routine CBC monitoring provides some utility in detecting occult bleeding, the yield of clinically important decreases in hemoglobin detected was low. For most anticoagulated patients, routine CBC monitoring appears to be clinically unnecessary.

Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy.

CONTEXT: A growing body of reports has documented the ability of anticoagulation management services to help patients receiving warfarin therapy achieve better outcomes compared to the care provided by their personal physicians (ie, usual care). OBJECTIVE: To compare clinical outcomes associated with anticoagulation therapy provided by a clinical pharmacy anticoagulation service (CPAS) to usual care. DESIGN: Retrospective, observational cohort study, 6 months in duration. SETTING: Large nonprofit, group-model health maintenance organization. PATIENTS: A total of 6,645 patients receiving warfarin therapy were included in the final analyses (intervention group, 3,323 patients; control group, 3,322 patients). INTERVENTION: Anticoagulation therapy for patients in the intervention group was managed by a centralized, telephonic CPAS. Therapy for patients in the control group was managed in the usual manner by their personal physicians. MAIN OUTCOME MEASURES: The primary outcome was the occurrence of anticoagulation therapy-related complications. A secondary outcome was the proportion of time spent in the target international normalized ratio (INR) range for each patient. Cox proportional hazards regression analyses were used to examine the risk of complications in relation to the study group. RESULTS: Patients in the CPAS were 39% less likely to experience an anticoagulation therapy-related complication than were patients in the control group (hazard ratio, 0.61; 95% confidence interval, 0.42 to 0.88). The number of patients needed to treat to prevent an anticoagulation therapy complication was 52. Additional analyses revealed that improved outcomes associated with CPAS were mediated largely through improved therapeutic INR control. Patients in the CPAS group spent 63.5% of study period days within their target INR range compared to 55.2% in the control group (p < 0.001). CONCLUSIONS: A centralized, telephonic, pharmacist-managed anticoagulation monitoring service reduced the risk of anticoagulation therapy-related complications compared to that with usual care. The cumulative evidence supporting the superior care associated with implementing a pharmacist-managed anticoagulation monitoring service was sufficient to recommend widespread implementation.

Low myopathy rates associated with statins as monotherapy or combination therapy with interacting drugs in a group model health maintenance organization.

STUDY OBJECTIVE: Because the risk for myopathy increases when 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) are used with other agents known to inhibit cytochrome P450 3A4 in patients with dyslipidemia, we sought to quantify this risk in a diverse, real-world sample of patients receiving statin therapy. DESIGN: Retrospective chart review. SETTING: Kaiser Permanente Colorado (KPCO), a group model health maintenance organization with approximately 360,000 members. PATIENTS: Four hundred sixty-eight patients who were identified as having a diagnosis of myopathy over a 4-year period using KPCO computerized data systems. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed to confirm myopathy cases associated with statin therapy. Of the 468 patients, 61 had received statin therapy before their diagnosis, and 41 (67%) of these patients had confirmed myopathy (documented creatine kinase level>or=1000 IU/L). The prevalence of myopathy was 0.12% with statin monotherapy and 0.22% with statins in combination with interacting drugs. Only 17 of the 41 (41%) patients had confirmed myopathy with no other plausible clinical explanation, such as a muscle injury. Increased risk of myopathy associated with statin therapy in combination with interacting drugs approached statistical significance (p=0.052) but was of minimal clinical significance. CONCLUSION: The prevalence of confirmed myopathy in patients receiving statin therapy is low (<1%). Combining statin therapy with interacting drugs (e.g., fibrates) was not associated with a clinically important increase in the prevalence of myopathy. The risk of developing myopathy during statin therapy is outweighed by the benefits derived from the therapeutic effects of the therapy.