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

BackgroundImproper 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.ObjectiveThis 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.MethodsGuided 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.ResultsOf 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.ConclusionAn 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.     

临床药师开展药物重整的药学服务实践

目的:为临床药师开展药物重整的药学实践提供参考。方法:探讨临床药师在实践工作中如何通过掌握用药史,及引入诺氏评估量表进行不良反应分析为切入点实现药物重整的药学服务实践。结果和结论:临床药师在药物重整工作中扮演着重要的角色。在临床实践中,临床药师获取精确的用药清单,加强专业知识地学习,借助一些适当的工具,才能实现药物重整。     

Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting

ObjectivesTo determine the effect of formal medication therapy management (MTM) services on pharmacist workload, as well as to describe the population receiving MTM, describe the services provided, and determine the reimbursement rate for billed MTM services.Data sourcesMTM Current Procedural Terminology (CPT) code claims, electronic medical records, and pharmacist MTM logs.Data synthesisA retrospective review of all MTM charges from January 1, 2010, to March 31, 2010, was performed. Data collected included location of the MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time to complete and document the MTM visit, and rate of reimbursement.ResultsIn the 3-month period, 239 MTM visits were completed. It took pharmacists a median of 20 minutes (range 15–127) of face-to-face time and 18 minutes (5–90) for documentation per visit. To date, no claims for MTM have been rejected, and reimbursement rates range from 47% to 79% depending on the insurance provider.ConclusionsMTM in the ambulatory clinic is feasible despite the increase in pharmacist workload from documenting and billing. The increased visibility of clinical pharmacy services justifies the extra time required for formal MTM.     

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation

ObjectivesTo describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.DesignObservational case series study.SettingIndigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.Patients219 adults presenting for follow-up medical visits and self-reporting medication use.InterventionMedication reconciliation as part of patient interview and concurrent chart review.Main outcome measuresFrequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.ResultsOf 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.ConclusionPharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.     

Communication networks of medication management in an ambulatory care setting

Background

Systems approaches in healthcare address complexities of care related to medication safety. Adverse drug events can be prevented by communication between providers. Thus, methods that depict the structures and processes of communications are foundational for prevention efforts. Social network analysis is a methodology applied in healthcare settings to describe and quantify communication patterns. Knowledge of the structures and processes surrounding medication management communications will be useful to explain and intervene on related quality or safety outcomes.

Encouraging safe medication disposal through student pharmacist intervention

ObjectivesTo (1) determine the public's current method of medication disposal, (2) identify the public's knowledge of the environmental impact of inappropriate medication disposal, (3) determine whether student-facilitated education improves the public's awareness of safe medication disposal, and (4) determine whether the public recognizes student pharmacists as a public health information resource for issues such as safe disposal of medications.DesignCross sectional.SettingAlbany, NY, pharmacies during August and September 2009.Participants242 patrons at 13 Albany College of Pharmacy and Health Sciences Community Pharmacy Advanced Pharmacy Practice Experience (CPAPPE) sites (2 mass merchandiser, 5 community chain, and 6 grocery store pharmacies).InterventionNine-question baseline and five-question postintervention anonymous surveys were administered to a convenience sample of store patrons 18 years of age or older.Main outcome measuresMedication disposal practices before and after education, beliefs on the environmental importance of inappropriate disposal practices, and perceptions of student pharmacists as sources of information.ResultsStudents from CPAPPE sites completed 242 educational interventions. Respondents were primarily women (72%). At baseline, 12.8% of patients disposed of medication appropriately. Respondents frequently flushed medications down the toilet (27.2%) or incorrectly dumped medications in the trash (34.6%). Only 30.9% had received previous advice on safe medication disposal. Posteducation survey results indicated that 80.1% of respondents were willing to change their disposal methods. Increased numbers of respondents viewed inappropriate medication disposal as a moderate to substantial problem (from 57.2% preeducation to 83.9% posteducation). Of participants, 59.7% strongly agreed that student pharmacists were a good resource for information on safe medication disposal.ConclusionAdditional public education on safe medication disposal is needed. Student pharmacists produced positive outcomes toward reducing this environmental and potential public health risk.     

Documenting clinical pharmacist intervention before and after the introduction of a web-based tool

Objectives To develop a database for documenting pharmacist intervention through a web-based application. The secondary endpoint was to determine if the new, web-based application provides any benefits with regards to documentation compliance by clinical pharmacists and ease of calculating cost savings compared with our previous method of documenting pharmacist interventions. Setting A tertiary care hospital in Saudi Arabia. Method The documentation of interventions using a web-based documentation application was retrospectively compared with previous methods of documentation of clinical pharmacists?? interventions (multi-user PC software). Main outcome measure The number and types of interventions recorded by pharmacists, data mining of archived data, efficiency, cost savings, and the accuracy of the data generated. Results The number of documented clinical interventions increased from 4,926, using the multi-user PC software, to 6,840 for the web-based application. On average, we observed 653 interventions per clinical pharmacist using the web-based application, which showed an increase compared to an average of 493 interventions using the old multi-user PC software. However, using a paired Student??s t-test there was no statistical significance difference between the two means (P = 0.201). Using a ??² test, which captured management level and the type of system used, we found a strong effect of management level (P < 2.2 × 10^?C16) on the number of documented interventions. We also found a moderately significant relationship between educational level and the number of interventions documented (P = 0.045). The mean ± SD time required to document an intervention using the web-based application was 66.55 ± 8.98 s. Using the web-based application, 29.06% of documented interventions resulted in cost-savings, while using the multi-user PC software only 4.75% of interventions did so. The majority of cost savings across both platforms resulted from the discontinuation of unnecessary drugs and a change in dosage regimen. Data collection using the web-based application was consistently more complete when compared to the multi-user PC software. Conclusions The web-based application is an efficient system for documenting pharmacist interventions. Its flexibility and accessibility, as well as its detailed report functionality is a useful tool that will hopefully encourage other primary and secondary care facilities to adopt similar applications.     

老年科住院患者药物重整中药师的作用

目的:总结分析临床药师对老年医学科病房的医嘱干预内容,提高药学服务质量,促进老年患者用药合理性。方法:收集并统计分析2014年1月至2015年12月两年间北京协和医院老年医学科临床药师医嘱干预记录。结果:临床药师共干预老年医学科医嘱993例,涉及问题类型较多的是不良反应(ADR)相关问题(22.2%)、药物选择(20.5%)及用法用量(19.4%)等,涉及药物种类以心血管系统用药(25.8%)、内分泌系统用药(17.6%)、神经精神系统用药(12.3%)及抗感染药物(11.8%)居多。结论:本文突出了临床药师对老年人医嘱审核干预及药物重整,避免用药相关问题的重要角色,强调医生与药师合作的重要性。     

以药物重整为基础的肿瘤患者围手术期药学监护模式

目的 建立以药物重整为基础的围手术期药学监护服务模式,为促进肿瘤患者围手术期安全、合理用药提供参考。方法 调取本院2017年3月1日至3月31日全部肿瘤患者的择期手术病历2057例,统计患者基础疾病用药和既往化疗用药情况,通过查阅药品说明书、指南、文献,整理所涉及药物的围手术期药物重整核查要点,建立择期手术的肿瘤患者围手术期药学监护流程。结果 在2057例择期手术肿瘤患者中,术前因基础疾病长期使用的药物共13类,接受的抗肿瘤治疗药物7类。根据药品说明书、指南及文献,明确以上药物在围手术期的药物重整核查要点。参照药物重整基本步骤与核查要点,建立以药物重整为基础的围手术期药学监护流程,即获取完整用药史、整理治疗药物清单、分析和分享治疗药物清单、围手术期药学监护和出院药物重整。结论 以药物重整为基础的药学监护模式,能为围手术期肿瘤患者提供标准化的监护流程,提高药学监护质量,保障肿瘤患者围手术期安全、促进合理用药。     

临床药师干预对老年科患者用药合理性的效果分析

目的:探讨临床药师干预对老年患者用药合理性的作用。方法:采用回顾性分析的方法,随机抽取南京大学医学院附属鼓楼医院老年科2016年1至3月出院的100例患者作为对照组,抽取2017年1至3月出院的100例患者作为干预组。对2组患者的不合理医嘱、住院期间用药种类、处方金额和个体化给药情况进行对比分析。结果:经临床药师干预后,干预组总不合理医嘱率、用药种类、注射剂种类、处方金额均较对照组均明显降低,差异有统计学意义(χ~2=28. 19, t=5. 12、5.68、8.94, P <0.01);干预组进行个体化给药的例次明显高于对照组,差异有统计学意义(χ~2=15.99, P <0.01)。结论:临床药师干预对提高老年科患者用药合理性具有重要意义。     

Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge

Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30- and 90-day medication lists. Main outcome measure Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist’s intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.     

Evaluation of pharmacist clinical interventions in a Dutch hospital setting

Objective Assessing the relevance of a clinically active pharmacist method compared to the traditional working method. Method The study was carried out in a general internal/gastro-enterology unit during two 8-weeks periods in 2004. It was an observational, non-randomized prospective study. Outcome measures were compared before and during the intervention. The intervention was the active presence of a junior hospital pharmacist on the unit. The pharmacist focused on the pharmacotherapy of the individual patient. Patients were included when they used 5 or more medicines on day 1 or 2 of their stay at the ward and/or used at least 1 high-risk drug. Clinical pharmacist interventions were counted and classified. A hospital pharmacist and an internal medicine specialist assessed the clinical relevance of all clinical pharmacist interventions retrospectively. The degree of acceptance of the interventions by physicians was measured. Finally, time associated with the clinical activities was measured. Main outcome measures Number of interventions (related to number of medication orders), clinical relevance and degree of acceptance. Results In the pre-intervention period 79 patients were included versus 84 in the during-intervention period. About 82 interventions in the pre-intervention period were made compared to 173 during the during-intervention period. There was little agreement between the professional raters (weighted κ_A–E = 0.30 and weighted κ_1–5 = 0.20). Nevertheless both ratings showed a substantial increase of clinically relevant interventions. The number of interventions accepted by the physician increased from 16 in the pre-intervention period to 75 in the during-intervention period. Working with this method took over 4 h a day. Conclusion Clinical pharmacy services provided by a junior hospital pharmacist on an internal medicine ward contribute to rationalization of drug therapy and are therefore likely to increase medication safety.     

对心内科患者中进行药物重整基础上的出院带药教育及应用评价

目的:评估药物重整基础上的出院带药教育的作用。方法:对入住北京医院心内科病房的患者进行筛选并随机分组,仅对对照组患者提供出院带药教育资料,对试验组患者入院和出院进行药物重整服务,出院时在提供出院用药教育资料的基础对用药差异(包括有意差异和未修改的无意差异)和高风险药物进行面对面交流教育。患者出院后3个月进行对患者的再住院率、ADE、用药依从性、知识问卷评分进行随访调研。结果:两组间患者临床特征无显著差异。试验组入院药物重整发现医嘱差异351个,出院发现86个。知识问卷评分、依从性评分、患者报告的药品不良事件/用药错误次数(ADE/ME)试验组明显优于对照组。患者再住院两组无显著差异。结论:药师在药物重整基础上的进行患者出院带药教育,可以显著提高患者用药知识素养,同时降低院内外用药错误,增加患者院外的用药依从性。