Pharmacist Interventions and Healthcare Utilization and Cost Amanda Lewis, Natasha Gregory, Ernest McDonald, Juan Sotolongo, Grashma Vadakkel, Lalita Rayaprolu

Objective Need for pharmacist interventions Reduce healthcare utilization and cost Provide evidence based information Provide what types of pharmacist interventions increase medication adherence, and reduce healthcare utilization, and by how much

The Importance of Pharmacist Interventions “...enhanced role of advocating for proper use of medications to avoid medication errors and achieve desired outcomes.” Decreasing health care cost and utilization Medication adherence Patient education Effective communication & establishing patient relationships Medication therapy management Being a member of a healthcare team

Reducing Healthcare Utilization: Physician Drug therapy consultant Patient/doctor drug therapy liaison Reduce drug related litigation events Well visits Community setting Follow-ups

Reducing Healthcare Utilization: Hospitalizations & ED Visits Medication errors occurred in 5.22% of patients admitted to hospitals. In 2008 it was estimated that hospital medication errors cost over $17.1 billion. How can pharmacists help reduce these numbers? -http://onlinelibrary.wiley.com/doi/10.1592/phco.22.3.134.33551/abstract -http://www.sciencedirect.com/science/article/pii/S1098301512042660 -In 2009 it was estimated that hospital medication errors cost over 1 billion dollars. -Ideally, the pharmacist should collaborate with the prescriber in developing, implementing, and monitoring a therapeutic plan to produce defined therapeutic outcomes for the patient. -It is also vital that the pharmacist devote careful attention to dispensing processes to ensure that errors are not introduced at that point in the medication process….ASHP Guidelines on Preventing Medication Errors in Hospitals -A total of 429,827 medication errors were evaluated from 1081 hospitals (study population). Medication errors occurred in 5.22% of patients admitted to these hospitals each year. Hospitals experienced a medication error every 22.04 hours (every 19.13 admissions). These findings suggest that at minimum, 90,895 patients annually were harmed by medication errors in our nation's general medical-surgical hospitals. -Factors associated with increased medication errors/occupied bed/year were drug-use evaluation (slope = 0.0023476, p=0.006), increased staffing of hospital pharmacy administrators/occupied bed (slope = 29.1972932, p<0.001), and increased staffing of dispensing pharmacists/occupied bed (slope = 19.3784148, p<0.001). Factors associated with decreased medication errors/occupied bed/year were presence of a drug information service (slope = −0.1279301, p<0.001), pharmacist-provided adverse drug reaction management (slope = −0.3409332, p<0.001), pharmacist-provided drug protocol management (slope = −0.3981472, p=0.013), pharmacist participation on medical rounds (slope = −0.6974303, p<0.001), pharmacist-provided admission histories (slope = −1.6021493, p<0.001), and increased staffing of clinical pharmacists/occupied bed (slope = −9.5483813, p<0.001). As staffing increased for clinical pharmacists/occupied bed from the 10th percentile to the 90th percentile, medication errors decreased from 700.98 ± 601.42 to 245.09 ± 197.38/hospital/year, a decrease of 286%.

Reducing Healthcare Utilization: Cost One year evaluation of 5 healthcare teams 3 teams included pharmacist Average cost saving for team that include pharmacist- 377$ per inpatient admission Increase in medication adherence Lower on average LOS Benefit-to-Cost Ratio 6.03:1 Pharmacist provide population-based pharmaceutical care Switches to generic medications and switches from RX to OTC Disease management programs Negotiations with health plans and P/A Implemented EHR Patients with controlled BP increased from 45-60% Saved 450,000$ in inpatient cost for DVT That article was from1993 https://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed?myncbishare=usfhslib&dr=abstract&holding=usfhslib&term=8135233&search=Search http://slny.japha.org/article.aspx?articleid=1043570

Evidence-base Interventions: Reduce patient mortality The role of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: A prospective, nonrandomized controlled trial using propensity score methods Results Pharmacist intervention caused all cause mortality to fall from 1.8% and 1.1%. There was no statistical difference in the control group. Conclusion Pharmacist identified drug related problems, and physician’s correction of a drug-related problem after pharmacist advice caused a significant decrease in all-cause mortality in cardiac patients. http://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/25546163

Evidence-based Interventions: Hospital Length of Stay Clinical pharmacists and inpatient medical care Results: Of the 36 studies reviewed, there was a shortened length of stay in 9 of the studies. Reductions seen in adverse drug events and medication errors Improvements seen in medication adherence and knowledge Conclusion: Implementing a clinical pharmacist in an inpatient setting greatly improved care without any harm This was a systematic review that looked at 36 studies and they were categorized based on the clinical pharmacy services: patient care unit where pharmacists were on rounds, admission/discharge, med recon, and drug-class specific services Looking specifically at the results for the admission/discharge and med recon. When the medication history was taken by a pharmacist opposed to a nurse there was more accurate medication and allergy information. Pharmacists were faster and could catch any interactions or errors. Pharmacy discharge counseling showed that patients were more adhering to their medications and were aware of what they were taking.

Summary Reduce healthcare utilization by corresponding with physicians and providing different services (ex: drug therapy consultations) Decrease the amount of medication errors, ultimately decreasing hospital admissions and lengths of stay, and patient mortality Incorporating pharmacists as part of a patient’s healthcare team, can reduce cost In terms of the future: Studies with a larger sample size, reproducible interventions and identifying patient-specific factors that led to improved outcomes

References Kelly W, Peterson A. Leadership and Management if Pharmacy Practice. CRC Press, 2015. American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305–14. Bond, C. A., Raehl, C. L. and Franke, T. (2002), Clinical Pharmacy Services, Hospital Pharmacy Staffing, and Medication Errors in United States Hospitals. Pharmacotherapy, 22: 134–147. doi: 10.1592/phco.22.3.134.33551 Bjornson DC, Hiner WO, Potyk RP, et al. Effect of pharmacists on health care outcomes in hospitalized patients. Am J Hosp Pharm. 1993;50(9):1875-84. Devine EB, Hoang S, Fisk AW, Wilson-norton JL, Lawless NM, Louie C. Strategies to optimize medication use in the physician group practice: the role of the clinical pharmacist. J Am Pharm Assoc (2003). 2009;49(2):181-91. Zhai XB, Tian DD, Liu XY. The role of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: A prospectve, nonrandomized controlled trial using propensity score methods. Int J Clin Pharamcol Ther. 2015; 53(3): 220-9. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient care. JAMA Intern Med. 2006 May:166: 955-964.

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