Reduced emergency room and hospital utilization in persons with multiple chronic conditions and disability receiving home-based primary care.

BACKGROUND: Persons with multiple chronic conditions and disability face access barriers to office-based primary care and have very high rates of emergency department (ED) use and hospital admissions. Home-based primary care (HBPC) has been proposed as a way to improve disease management and prevent health crises. HYPOTHESIS: Enrollment of patients with disability and multiple chronic conditions in a HBPC program is associated with a subsequent decrease in ED visits and hospital admissions. METHODS: We abstracted electronic medical record (EMR) data among patients receiving HBPC and compared rates per 1000 patient days for ED visits, admissions, 30-day readmissions, and inpatient days for up to three years before and after enrollment. RESULTS: Of 250 patients receiving HBPC, 153 had admission data recorded in our EMR prior to enrollment. One year after HBPC enrollment, the rate of admissions dropped by 5.2 (95% confidence interval 4.3, 6.0), 30-day readmissions by 1.8 (1.3, 2.2) and inpatient days by 54.6 (52.3, 56.9) per 1000 patient-days. Three years post-enrollment, rates remained below baseline by 2.2 (1.3, 3.1) for admissions, 0.5 (0.04, 1.0) for 30-day readmissions and 32.2 (29.8, 34.7) for inpatient days. Among 91 patients with pre-enrollment ED data, the rate of ED visits also dropped at one and three years by 5.5 (4.6, 6.4) and 2.7 (1.7, 3.7), respectively. CONCLUSION: Provision of HBPC for persons with multiple chronic conditions and disability is associated with a persistent reduction in ED and hospital use.

Pharmacist-driven renal medication dosing intervention in a primary care patient-centered medical home.

PURPOSE: The purposes of this population management intervention were to identify patients with stage 3, 4, or 5 chronic kidney disease (CKD) and to improve care in a patient-centered medical home (PCMH). Objectives of the intervention were to (i) increase the identification of CKD, (ii) increase the use of aspirin and angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers (ARBs) in patients with CKD, and (iii) ensure that all medications prescribed to patients with CKD were dosed appropriately based on renal function. SETTING: This intervention was completed at a National Committee for Quality Assurance tier 3 PCMH associated with a major, academic health system. PATIENTS: A list of 328 patients with an estimated glomerular filtration rate of < 60 mL/min per 1.73 m(2) was generated using the electronic medical record; 146 patients underwent the intervention. MEASUREMENTS AND OBSERVATIONS: A pharmacist review of the electronic medical record was completed to confirm stage 3, 4, or 5 CKD based on estimated glomerular filtration rate, to ensure that ACE-Is/ARBs and aspirin were prescribed, and to ensure that all medications were dosed appropriately based on renal dosing adjustment recommendations. Recommendations were made to improve medication use and safety in patients with CKD. Before intervention, 73% of patients were prescribed an ACE-I/ARB and 72% of patients were prescribed aspirin. After the intervention, use of these medications increased to 77% and 82% of patients, respectively. Pharmacist recommendations to adjust medication dosing based on Cockcroft-Gault calculated creatinine clearance were made for 138 medications (0.95 medication per patient); 90 (65.2%) recommendations were accepted by the patients' physicians. CONCLUSION: These results demonstrate the impact of a pharmacist-driven renal medication dosing intervention within a PCMH on medication use and safety for patients with CKD.

Design and implementation of a randomized controlled trial of genomic counseling for patients with chronic disease.

We describe the development and implementation of a randomized controlled trial to investigate the impact of genomic counseling on a cohort of patients with heart failure (HF) or hypertension (HTN), managed at a large academic medical center, the Ohio State University Wexner Medical Center (OSUWMC). Our study is built upon the existing Coriell Personalized Medicine Collaborative (CPMC®). OSUWMC patient participants with chronic disease (CD) receive eight actionable complex disease and one pharmacogenomic test report through the CPMC® web portal. Participants are randomized to either the in-person post-test genomic counseling-active arm, versus web-based only return of results-control arm. Study-specific surveys measure: (1) change in risk perception; (2) knowledge retention; (3) perceived personal control; (4) health behavior change; and, for the active arm (5), overall satisfaction with genomic counseling. This ongoing partnership has spurred creation of both infrastructure and procedures necessary for the implementation of genomics and genomic counseling in clinical care and clinical research. This included creation of a comprehensive informed consent document and processes for prospective return of actionable results for multiple complex diseases and pharmacogenomics (PGx) through a web portal, and integration of genomic data files and clinical decision support into an EPIC-based electronic medical record. We present this partnership, the infrastructure, genomic counseling approach, and the challenges that arose in the design and conduct of this ongoing trial to inform subsequent collaborative efforts and best genomic counseling practices.

Improving herpes zoster vaccination rates through use of a clinical pharmacist and a personal health record.

BACKGROUND: Preventative health services, including herpes zoster vaccination rates, remain low despite known benefits. A new care model to improve preventative health services is warranted. The objective of this study is to investigate whether the functions of an electronic medical record, in combination with a pharmacist as part of the care team, can improve the herpes zoster vaccination rate. METHODS: This study was a 6-month, randomized controlled trial at a General Internal Medicine clinic at The Ohio State University. The 2589 patients aged 60 years and older without documented herpes zoster vaccination in the electronic medical record were stratified on the basis of activated personal health record status, an online tool used to share health information between patient and provider. Of the 674 personal health record users, 250 were randomized to receive information regarding the herpes zoster vaccination via an electronic message and 424 were randomized to standard of care. Likewise, of the 1915 nonpersonal health record users, 250 were randomized to receive the same information via the US Postal Service and 1665 were randomized to standard of care. After pharmacist chart review, eligible patients were mailed a herpes zoster vaccine prescription. Herpes zoster vaccination rates were compared by chi-square tests. RESULTS: Intervention recipients had significantly higher vaccination rates than controls in both personal health record (relative risk, 2.7; P = .0007) and nonpersonal health record (relative risk, 2.9; P = .0001) patient populations. CONCLUSIONS: Communication outside of face-to-face office visits, by both personal health record electronic message and information by mail, can improve preventative health intervention rates compared with standard care.