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Reductions in 30-day readmission, mortality, and costs with inpatient–to–community pharmacist follow-up

Published:November 22, 2018DOI:https://doi.org/10.1016/j.japh.2018.11.005

      Abstract

      Objectives

      To determine the impact of pharmacist-provided continuous care and electronic communication on readmissions among a group of high-risk patients.

      Design

      Pragmatic interventional study with 5:1 matched control.

      Setting and participants

      Patients discharged from any of 4 hospitals with chronic obstructive pulmonary disease, pneumonia, heart failure, acute myocardial infarction, or diabetes within Pennsylvania. Patients in the intervention group received consultative services from inpatient pharmacists before discharge and inpatient–to–community pharmacist communication of hospitalization information facilitated with the use of a secure messaging system. After discharge, patients received up to 5 in-person or telephonic medication management consultations with their community pharmacists.

      Main outcome measures

      The principal end point was 30-day readmission. Secondary end points included time to event (readmission, emergency department [ED] visit, death, or composite of hospitalization, ED, or death) over 90 days after discharge. Financial feasibility and sustainability were also assessed with the use of a return-on-investment (ROI) model based on information within the subset of patients with health plan coverage.

      Results

      Among patients who received inpatient intervention plus consultation with community pharmacists compared with matched control patients, we observed a lower 30-day readmission rate (9% vs. 15%, respectively; P = 0.02), 30-day all-cause mortality (2% vs. 5%; P = 0.04), and composite 30-day end point of readmission, ED visit, or death (22% vs. 28%; P = 0.09). Differences between the groups diminished and no longer maintained statistical significance at 90 days. An estimated average ROI of 8.1 was also observed among the subset with health plan information (worst base case range 1.9–16.3).

      Conclusion

      Connecting community pharmacists to inpatient pharmacists during the transitional hospital-to-home time frame is feasible and resulted in lower 30-day readmissions and significant ROI, that is, significant impact on health care utilization and total health care costs. Results of this study have broad implications for improving the care of high-risk patients moving from hospital to home, most notably in the engagement of community pharmacists after discharge to assure medication use and follow-up to reduce readmissions and total costs of care.
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      References

        • Henry J.
        • Kaiser Family Foundation
        Health care costs, a primer: key information on health care costs and their impact.
        (Updated 2012. Available at:)
        • Price Waterhouse Coopers’ Health Research Institute
        The price of excess: identifying waste in healthcare.
        (Available at:)
        • Medpac Medicare Payment Advisory Commission
        Report to congress: reforming the delivery system.
        (Updated 2008. Available at:)
        • Jiang J.H.
        • Russo A.
        • Barrett M.L.
        Nationwide frequency and costs of potentially preventable hospitalizations.
        (2006. Updated 2009. Available at:)
        • Forster A.J.
        • Murff H.J.
        • Peterson J.F.
        • Gandhi T.K.
        • Bates D.W.
        The incidence and severity of adverse events affecting patients after discharge from the hospital.
        Ann Intern Med. 2003; 138: 161-167
        • McDonnell P.J.
        • Jacobs M.R.
        Hospital admissions resulting from preventable adverse drug reactions.
        Ann Pharmacother. 2002; 36: 1331-1336
        • Centers for Medicare and Medicaid Services
        Readmissions reduction program.
        (Available at:)
        • Zuckerman R.B.
        • Sheingold S.H.
        • Orav E.J.
        • Ruhter J.
        • Epstein A.M.
        Readmissions, observation, and the hospital readmissions reduction program.
        N Engl J Med. 2016; 374: 1543-1551
        • Rennke S.
        • Nguyen O.K.
        • Shoeb M.H.
        • Magan Y.
        • Wachter R.M.
        • Ranji S.R.
        Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.
        Ann Intern Med. 2013; 158: 433-440
        • Ensing H.T.
        • Stuijt C.C.M.
        • van den Bemt
        • Bart J.F.
        • et al.
        Identifying the optimal role for pharmacists in care transitions: a systematic review.
        J Manag Care Spec Pharm. 2015; 21: 614-636
        • Cutrona S.L.
        • Choudhry N.K.
        • Fischer M.A.
        • et al.
        Modes of delivery for interventions to improve cardiovascular medication adherence.
        Am J Manag Care. 2010; 16: 929-942
        • Rodrigues C.R.
        • Harrington A.R.
        • Murdock N.
        • et al.
        Effect of pharmacy-supported transition-of-care interventions on 30-day readmissions: a systematic review and meta-analysis.
        Ann Pharmacother. 2017; 51: 866-889
        • Gernant S.A.
        • Zillich A.J.
        • Snyder M.E.
        Access to medical records’ impact on community pharmacist–delivered medication therapy management: a pilot from the Medication Safety Research Network of Indiana (Rx-Safenet).
        J Pharm Pract. 2018; 31: 642-650
        • Jones L.
        • Greskovic G.
        • Grassi D.
        Medication therapy disease management: Geisinger’s approach to population health management.
        Am J Health Syst Pharm. 2017; 74: 1422-1435
        • Maeng D.D.
        • Graf T.R.
        • Davis D.E.
        • Tomcavage J.
        • Bloom F.J.
        Can a patient-centered medical home lead to better patient outcomes? the quality implications of Geisinger’s ProvenHealth Navigator.
        Am J Med Qual. 2012; 27: 210-216
        • Steele G.D.
        • Haynes J.A.
        • Davis D.E.
        • et al.
        How Geisinger’s advanced medical home model argues the case for rapid-cycle innovation.
        Health Aff (Millwood). 2010; 29: 2047-2053
        • Bulger J.
        • Maynor K.
        • Frazier S.
        The Geisinger transitions of care initiative: overview of an interdisciplinary quality improvement process.
        Clin Med Res. 2010; 8: 43-44
        • Snodgrass B.
        • Babcock C.K.
        • Teichman A.
        The impact of a community pharmacist conducted comprehensive medication review (CMR) on 30-day re-admission rates and increased patient satisfaction scores: a pilot study.
        Inov Pharm. 2013; 4: 138
        • Luder H.R.
        • Frede S.M.
        • Kirby J.A.
        • et al.
        TransitionRx: impact of community pharmacy postdischarge medication therapy management on hospital readmission rate.
        J Am Pharm Assoc. 2015; 55: 246-254
        • Agrawal D.M.T.
        • Chen C.
        • Dravenstott R.W.
        • et al.
        Predicting patients at risk for 3-day postdischarge readmissions, ED visits, and deaths.
        Med Care. 2016; 54: 1017-1023
        • Pellegrin K.L.
        • Krenk L.R.P.
        • Oakes S.J.
        • et al.
        Reductions in medication-related hospitalizations in older adults with medication management by hospital and community pharmacists: a quasi-experimental study.
        J Am Geriatr Soc. 2017; 65: 212-219
        • Matzke G.
        • Czar M.
        • Lee W.
        • Moczygemba L.
        • Harlow L.
        Improving health of at-risk rural patients project: a collaborative care model.
        Am J Health Syst Pharm. 2016; 73: 1760-1768
        • Gupta A.
        • Allen L.
        • Bhatt D.
        Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure.
        JAMA Cardiol. 2017; 3: 44-53
        • Pellegrin K.
        • Lee E.
        • Uyeno R.
        • Ayson C.
        • Goo R.
        Potentially preventable medication-related hospitalizations: a clinical pharmacist approach to assessment, categorization, and quality improvement.
        J Am Pharm Assoc. 2017; 57: 711-716
        • Polinski J.
        • Moore J.
        • Kyrychenko P.
        An insurer’s care transition program emphasizes medication reconciliation, reduces readmissions and costs.
        Health Aff (Millwood). 2016; 35: 1222-1229
        • Campbell D.T.
        • Stanley J.C.
        Experimental and Quasi-experimental Designs for Research.
        Rand McNally Co., Chicago, IL1963

      Biography

      Eric A. Wright, PharmD, MPH, Professor and Director, Center for Pharmacy Innovation and Outcomes, Geisinger, Forty Fort, PA; at time of study: Associate Professor, Department of Pharmacy Practice, Wilkes University, Wilkes-Barre, PA

      Biography

      Jove H. Graham, PhD, Assistant Professor, Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA

      Biography

      Daniel Maeng, PhD, Assistant Professor, University of Rochester Medical Center, Rochester, NY; at time of study: Assistant Professor, Epidemiology and Health Services Research, Geisinger, Danville, PA

      Biography

      Lorraine Tusing, BA, Research Project Manager, Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA

      Biography

      Lori Zaleski, BS, RPh, Enterprise Pharmacy Outpatient Services, Retail Pharmacy Administration, Geisinger, Wilkes-Barre, PA

      Biography

      Richard Martin, MD, Staff Physician, Family Medicine Mount Pleasant, Geisinger, Scranton, PA

      Biography

      Rick Seipp, PharmD, Vice President of Pharmacy Operations, Weis Markets, Sunbury, PA

      Biography

      Bruce Citsay, RPh, BSPharm, MTM Clinical Services Coordinator, Weis Markets, Lancaster, PA

      Biography

      Bette McDonald, RPh, BS, Business Optimization Advisor, Cardinal Health, Dalton, PA; at time of study: Senior Business Consultant, Medicine Shoppe International, Dalton, PA

      Biography

      Kelly Bolesta, PharmD, BCPS, Regional Director Northeast, Enterprise Pharmacy, System Pharmacy Support Services, Geisinger, Wilkes-Barre, PA

      Biography

      Kim Chaundy, BS, ITIL, Senior Director, Health Information Exchange, IT External Customer Relations, Geisinger, Danville, PA

      Biography

      Charles J. Medico, PharmD, BCPS, Director, Medical Outcomes Specialist, Pfizer Innovative Health, New York, NY; at time of study: Pharmacy Clinical Coordinator, Inpatient Pharmacy, Geisinger, Danville, PA

      Biography

      Steve Gunderman, AS, EHR System Analyst, IT Health Info Tech Personnel, Geisinger, Danville, PA

      Biography

      Fred Leri, PharmD, MBA, BS, BCPS, Clinical Coordinator Pharmacy, Pharmacy Services, Geisinger, Scranton, PA

      Biography

      Kelly Guza, PharmD, BCPS, BCPPS, Director, Acute Clinical Pharmacy Program, System Pharmacy Support Services, Geisinger, Danville, PA

      Biography

      Rebecca Price, BS, Research Project Manager I, Healthcare Reengineering, Danville, PA; at time of study: Research Assistant, Center for Health Research, Geisinger, Danville, PA

      Biography

      Christina Gregor, BS, Research Assistant, Geisinger Center for Pharmacy Innovation and Outcomes, Danville, PA

      Biography

      Dean T. Parry, RPh, Clinical Informatics, Care Support Services Administration, Geisinger, Danville, PA

      Linked Article

      • The issue of 30 days: A health outcomes critique of 30-day metrics
        Journal of the American Pharmacists AssociationVol. 59Issue 6
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          An article published in the March–April 2019 issue, “Reductions in 30-day readmission, mortality, and costs with inpatient–to–community pharmacist follow-up,” by Wright et al. reported that high-risk patients who received at least 1 pharmacist visit after discharge to home were significantly less likely to have a 30-day readmission and 30-day all-cause mortality compared with a usual-care matched cohort.1 The 30-day time frame is not unfamiliar in pharmacy practice—most prescriptions are dispensed in 30-day increments.
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