1. Does Pharmacist-Led Medication Review Improve Health Outcomes? Evaluation of a Quality Improvement Project February 19, 2015 Quality Forum Corinne M Hohl MD FRCP MHSc Attending Physician, Dept of Emergency Medicine, VGH Associate Professor, Dept of Emergency Medicine, University of British Columbia Scientist, Centre for Clinical Epidemiology and Evaluation CIHR New Investigator

2. ADE: unintended and harmful effects of medications. Most common cause of preventable iatrogenic morbidity. Patients with ADEs commonly present to EDs: –12% of ED visits amounting to 20,000 visits per year to VCHA –35-40% of are not attributed to medication use by MDs –50% greater odds of spending additional days in hospital/month. Leading cause of unplanned admissions.

3. Co-funded by BC HSPO & VCHA in 2011 Aim: To evaluate the effect of pharmacist-led medication review in high-risk ED patients on health outcomes compared to usual care (medication reconciliation). Innovation: A new model of delivering pharmacy care to ensure that patients receive optimal medication therapy from when they arrive.

7. Design: –Prospective comparator study, non-blinded that was nested within a continuous quality improvement project at 3 sites. Population: –High-risk adults presenting to a participating ED at a time an ADE pharmacist was present (including evenings and weekends)

8. Intervention: Medication Review by Clinical Pharmacists –Best-possible medication history & initiated med reconciliation –Review of medications critically to identify ADEs, and medication-related problems –Communication with emergency MD/GP/geriatric triage nurse if discharged or emergency/admitting MD if admitted. Control: –Med reconciliation by admitting/consultant services & medication review on the ward among admitted.

9. Reconciliation an accurate medication history from a variety of sources based on which medications are re- prescribed. Aim: to avoid medication errors at care transitions. Review an accurate medication history followed by a structured, critical examination of a patient’s medications Aim: to reach agreement on the goals of therapy, minimize errors, optimize medication effectiveness, identify medication-related problems and ADEs.

10. Outcomes: 1 o Proportion of days spent in hospital within 30 days of the index ED visit (encompasses index admission and days readmitted) 2 o Proportion admitted Unplanned ED visits within 7d Mortality (all-cause)

11. ED visits (VGH, LGH, RH) (n=135,323) Excluded (n=124,516) ▪ Low-risk or unknown (n=95,837 ) ▪ Age < 19yrs (n=882) ▪ Pharmacist not available (n=22,675) ▪ CTAS=1 unknown (n=236) ▪ Multisystem Trauma (n=302) ▪ Scheduled re-visit (n=1,643) ▪ Sexual assaults (n=4) ▪ Post-operative complications (n=224) ▪ Social problems (n=317) ▪ Pregnancy-related complication (n=18) ▪ Death on arrival/in ED (n=406) ▪ Repeat visits (n=1,964) ▪ Unresolved linkage (n=1) ▪ Left Against Medical Advice/Missing data (n=9) High-Risk eligible (n=10,805) Med Rev (n=6,416) Control (n=4,389) Systematic Allocation Patient Flow

12. Med Rev (n=6,416) Control (n=4,389) Median age, yrs 7169 Female, % 56.455.1 Mean No. Meds 8.17.7 Lowest SES quintile, % 11.711.2 Ambulance Arrival, % 37.132.9 Daytime Arrival, % 61.261.3 Weekend Arrival, % 13.212.4 Baseline Characteristics – Overall

13. Med Rev (n=6,416) Control (n=4,389) Median age, yrs 7169 Female, % 56.455.1 Mean No. Meds 8.17.7 Lowest SES quintile, % 11.711.2 Ambulance Arrival, % 37.132.9 Daytime Arrival, % 61.261.3 Weekend Arrival, % 13.212.4 Baseline Characteristics – Overall

14. Median No. Hospital Days over 30 Days of Follow-Up Difference in Days ( 95% CI) p-value All Sites -0.48 days (-0.96 to 0.0) 0.058 <80 yrs -0.6 days (-1.17, -0.06) 0.03

15. Pts in the medication review group spent a median of 12h in hospital less over 30d, p=0.058 0 3 6 9 12 15 18 21 24 30 days 0 3 6 9 12 15 18 21 24 30 days

16. Days in Hosp over 30d AdmissionsED RevisitsMortality Median Difference ( 95% CI) p- value OR (95% CI) p- value OR (95% CI) p- valu e OR (95% CI) p- value All Sites -0.48 (-0.96 to 0.0) 0.05 8 0.98 (0.90, 1.06) 0.54 0.98 (0.85,1.13 ) 0.82 1.11 (0.96,1.30 ) 0.16 <80 -0.60 (-1.17, - 0.06) 0.03

17. % Days in Hospital over 30d Admission Rate ED Revisits Mortality All Sites 8.5% reduction in hosp days over 30d No Difference <80 yrs 11.5% reduction in hosp days over 30d

18. At VGH: –n=1,928 high-risk patients whose medications were reviewed in the ED & who were admitted. Avoided 1041 hospital days (0.54 days/patient). Resulted in avoided costs of $468,000 ($450/hospital day). Costs of maintaining the program: $400,957 in pharmacy salaries. The cost of nursing salaries & administrative costs (IT, coordinator, evaluation) removed after implementation period. –Pharmacist-led medication review in ED was cost avoidant by reducing hospital days.

19. We have an opportunity to implement best-evidence and meet the Accreditation Canada ROP: 1. We have developed evidence-based clinical decision rules to identify high-risk ED patients, and have implemented them at VGH, LGH and RH to identify & select high-risk patients. 1. Our results suggest that if pharmacists review the medications of high-risk patients, this will lead to LOS reduction and get patients home sooner.

20. Intervention was not fully optimized because of rotating staffing model: time spent on training new staff & relationship building can be reduced. Calculations do not take into account any other benefit of the program.

21. Where next?

22. Status Quo: Medication Information in BC Health Care Provider Ministry of Health PharmaNetPharmaNet HospitalsHospitals OthersOthers CommunityBasedCommunityBased Outpatient Pharmacies OutpatientMedications Medications dispensed Medications Computer-based/automatedPaper-based/patient-driven

23. Vision: Medication & ADE Information Health Care Provider Ministry of Health PharmaNetPharmaNet HospitalsHospitals OthersOthers CommunityBasedCommunityBased Outpatient Pharmacies OutpatientMedications ADEs/Medication-related problems PharmaNet becomes a “de facto” provincial medication information “EHR”

24. Pharmacists and Nurses at all sites Pharmacy Departments Nilu Partovi, Fruzsina Pataki, Mark Collins, Terri Betts, Robert McCollum, Ruth Tsang, Susanne Moadebi, Jane de Lemos Emergency Physicians, Hospitalists, Internists VCHA SET: Jeff Coleman, Duncan Campbell BC HSPO: Les Vertesi