The Effect of a Care Transition Process to Intervention Pharmacies Versus … · 2016-03-14 · PHARMACY RESEARCH WEBINAR Pharmacists’ Role There is potential for pharmacists to
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PHARMACY RESEARCH WEBINAR WWW.PHARMACISTS.CA
The Effect of a Care Transition Process to
Intervention Pharmacies Versus Usual Care on
Optimal Medication Management
• Welcome• We will begin shortly.
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Pharmacy Research Webinar Series Hosted by:
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Session SpeakerKaitlyn Krahn, BHSc, BSP, ACPR
kaitlyn.krahn@rqhealth.ca
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Session Speaker
Kaitlyn Krahn is a staff pharmacist with the Regina Qu'Appelle Health Region
(RQHR). She received a Bachelor of Health Sciences degree at the University of
Western Ontario and a Bachelor of Science in Pharmacy degree from the
University of Saskatchewan. Following graduation, Kaitlyn then completed a
pharmacy residency with RQHR. During her year of residency, Kaitlyn solidified
her interest in improving patient care during discharge from hospital to home.
Her residency project focuses on the ongoing challenges and opportunities
present during transitions in care.
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Outline
• Background
• Purpose/Objectives
• Methods
• Results
• Discussion
• Limitations
• Opportunities
• Acknowledgements
• Questions
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Risks in Care Transitions
Transitions in care put patients at risk for drug related problems (DRPs)
• In Canadian hospitals, 8.5% of patients readmitted within 30-days 1
• 20% of patients experience an adverse event during transitions in care 2,3
• Adverse drug events most common type of AE following discharge 3
1. Canadian Institute for Health Information. CIHI. Updated 2012. Accessed September/6, 2014.2. HL, et al. Fla Nurse.2000 Mar;48(1):6.3. Forster AJ, et al. Ann Intern Med. 2003;138(3):161-167.
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Pharmacists’ Role
There is potential for pharmacists to positively impact patient care
• 30 minutes with clinical pharmacist in high risk patients decreased rate of 60-day readmission by 25% (ARR 0.249) 1
• Significant reduction in 7- and 14-day post-discharge readmission rates 2
• Significant reductions in 30-day readmission rates 3
1. Bellone JM, et al. JAPhA. 2012;52(3):358-362.
2. Kilcup M, et al. JAPhA. 2013;53(1):78-84.
3. AS, et al. Am J Health Syst Pharm.2014 Sep 1;71(17):1469-79.
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Purpose
To investigate the effects of a discharge transition in
care process involving a suite of interventions at the
community pharmacy (CP) level, on medication
management in high risk patients at 7- and 45-day
post-discharge as compared to normal care.
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Primary Objectives
To determine the number and classification of DRPs patients experience at 7- and 45-days post-discharge
• Patient-reported
• Principal investigator-reported
• Community pharmacist-reported for intervention patients
• Classification according to Institute for Safe Medication Practices (ISMP) Canada
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Secondary Objectives
• Number of patient-reported CP interventions
• Time between hospital discharge to first prescription fill, and patient-reported pick-up or delivery
• Patient-reported readmission to hospital
• Usefulness of the discharge prescription
• Patients’ loyalty to pharmacy
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Inclusion and Exclusion CriteriaPATIENTS
INCLUSION EXCLUSION
• 65 years or older• Minimum of 5 prescription
medications• Discharged from hospitalist
service• Resident of Regina, SK• Diagnosed with chronic
pulmonary obstructive disease (COPD), heart failure (HF), pneumonia, atrial fibrillation (AF) or diabetes
• Lacking telephone access• Residence in a nursing
home• Documented Alzheimer’s
disease or dementia• Unable to speak English
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Inclusion and Exclusion CriteriaCOMMUNITY PHARMACIES
INCLUSION EXCLUSION
• One or more pharmacist(s)with valid educator designation (diabetes or respiratory), hospital residency training, or ADAPT certification
• At least 5 patient consultations in the last three months
• Agreement to perform study interventions
• Absence of:o Prescription delivery
serviceo Compliance packaging
serviceo Access to lab viewing
software
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“Suite” of Interventions
• Identification and resolution of DRPs
• Medication assessment (SMAP), or follow-up
• Medication counseling
• Laboratory monitoring
• Provision of information to patient, family physician, and/or hospital, as required
• 2 weeks adherence phone-call
• Compliance packaging, if necessary
• Facilitation in acquiring a family physician, if necessary
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Outcome Assessment
• 7-, and 45-day post-discharge phone calls to the patient
• Pharmaceutical Information Program (PIP) profile review at 45-days post-discharge
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Results
323• Number of patients screened
15• Number of patients meeting study eligibility
5• Patients provided consent
5• Follow-up completed
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Baseline Characteristics Patient
#Age Sex
Admitting Diagnosis
Length of Stay (days)
# of Meds on
Admission
Doses Per Day on
Admission
Med Changes
Meds on Discharge
Doses /Day on
Discharge
Choice of CP
(I or R)
1 73 F AECOPD 7 21 30 5 19 33 R
2 81 M AECOPD 7 13 16 6 14 16 R
3 82 F
Post nephrecto
my hematoma
14 11 11 9 8 14 R
4 85 MUrinary
Retention3 8 7 0 8 7 R
5 83 FAcute
cholecystitis
15 17 21 9 20 32 Iˆ
Mean (SD)
81 9.2 (4.6) 14 (4.6) 17 (8.0) 6 (3.7) 14 (5.2) 20 (10.3)
AECOPD: acute exacerbation of COPD; F: female; I: intervention community pharmacy; M: male; R: regular community pharmacy; SD: standard deviation; ^: patient’s regular pharmacy was an intervention community pharmacy
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Question 1:
In your experience do you find that patients remain loyal to their community pharmacy?
a) Yes
b) No
c) Not Sure
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Number and Classification of Drug-Related Problems at 7-days and 45-days Post-Discharge
Patient #
DRPs Reported by:
Community Pharmacist PatientPrincipal
Investigator
17 days
N/A0 N/A
45 days 0 2
2
7 days
N/A0 N/A
45 days 0 0
3
7 days
N/A
0 N/A
45 days 0 0
4
7 days
N/A0 N/A
45 days 1 1
57 days 7 0 N/A
45 days 0 1 0
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Community Pharmacist Interventions at 7-days and 45-days Post-Discharge
Patient #
Patient-Reported
Community
Pharmacist
Interventions
Patient-Reported Type of Intervention
Community
Pharmacist-
Reported
Interventions
17 days 3
Lab monitoring, Medication Education,Compliance Packaging N/A
45 days 1 Compliance Packaging
27 days 0 None
N/A45 days 0 None
37 days 0 None
N/A45 days 1 Compliance Packaging
4
7 days 0 NoneN/A
45 days 2Medication Education, Compliance
Packaging
5
7 days 1Delivery
7
45 days 3Medication Education, Compliance
Packaging, Delivery
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Time to Prescription Fill, and Pick-Up or Delivery
Patient Reported
Patient #Visited Community Pharmacy?
(Y/N)
Prescriptions Filled?
(Y/N)
Picked up?
(Y/N)
Delivered?
(Y/N)
17 days Y Y N N
45 days N N N N
2
7 days N N N N
45 days Y Y Y N
3
7 days Y Y Y N
45 days N Y Y N
47 days N Y N N
45 days Y Y Y N
57 days N Y N Y
45 days N Y N Y
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Question 2:
Are you surprised that many patients sent a representative to the community pharmacy on their behalf?
a) Yes
b) No
c) Not Sure
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Time to Prescription Fill, and Pick-Up or Delivery
Intervention Community Pharmacist-
Reported
From Pharmaceutical Information
Profile
Patient #Time from Discharge to Pick-up or Delivery
(days)Time to Prescription Fill (days)
17 days
N/A Time to first fill: 13
45 days Time to first refill: 28
27 days
N/ATime to first fill: 1
45 days Time to first refill: 20
37 days
N/ATime to first fill: 0
45 days Time to first refill: 17
4
7 days
N/ATime to first fill: 0
45 days Time to first refill: 23
57 days
0Time to first fill: 0
45 days Time to first refill: 26
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Our Population and DRP-PotentialMean of 14 (± 4.6) medications on admission with 6 (± 3.7) medication changes
•Farrell et al., (n=51; mean age 81 years) 1
– mean of 15 medications on admission
– 8.9 DRPs/patient
•Harris et al. (n=96; mean age 78.1 years) 2
–7 medications on admission
– 4.1 medication changes/patient1. FB, et al. Can Fam Physician.2011 Feb;57(2):168-9.
2. HC, et al. J Patient Saf.2013 Sep;9(3):150-3..
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Caregivers at the Front-linesMost patients sent a delegate to the community pharmacy on their behalf
• More than 1/3 of older adults receive assistance with doctors visits or prescribed medications, or both 1
• Nine in ten caregivers in the United States identify that recipients take prescription medications and 48% of recipients require help to take medications 2
• Caregivers identify keeping prescriptions filled post-discharge a challenge 1
1. WJ, et al. J Gerontol B Psychol Sci Soc Sci.2014 Nov;69 Suppl 1:S65-72.
2. National Alliance for Caregiving. Caregiving in the U.S. 2009.
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Discrepancies in perception?
Patients did not report community pharmacist involvement in recognition and resolution of DRPs at 7-days
• Braund et al., of 1,374 prescriptions 344 prescriptions required pharmacist action, and 396 individual DRPs found 1
• Eichenberger et al, pharmacy students found that 27% of 264 discharge prescriptions had DRPs 2
1. BR, et al. Int J Clin Pharm.2014 Jun;36(3):498-502..
2. EP, et al. Pharm World Sci.2010 Jun;32(3):362-72...
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Limitations• Population size
• Unequal distribution in each project arm
• Assessment of fill date using PIP
– Community pharmacy integration
– Each medication reported separately
• Principal investigator assessment of DRPs
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Conclusions
• Challenges with population size
• Caregivers often interact with community pharmacists
• There appear to be DRPs on discharge
• Patients are loyal to their community pharmacies
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Future Opportunities
• Replication of this study on a different ward
• The role of caregivers in medication management for older adults
• The standard level of care for community pharmacists
• The role of a standard discharge prescription or summary for communication
• Exploration of factors contributing to patient-pharmacy loyalty
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Question 3:Which area would you focus future research opportunities on?
a) Replication of this study on a different ward
b) The role of caregivers in medication management for older adults
c) The standard level of care for community pharmacists
d) The role of a standard discharge prescription or summary for communication
e) Exploration of factors contributing to patient-pharmacy loyalty
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Acknowledgments
• Core Project Committee:
Bill Semchuk
Jennifer Bolt
Zack Dumont
• Steering Committee:
Myla Wollbaum, Pharmacy Association of Saskatchewan
Ray Joubert, Saskatchewan College of Pharmacy
Arlene Kuntz, Government of Saskatchewan
Kimberly Sentes, Towers Community Pharmacy
Ron Taylor, RQHR Hospitalist
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Acknowledgments
• Ali Bell
• RQHR Hospitalists
• Intervention Group Pharmacists
• Regina Qu’Appelle Health Region
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Questions?
• Please contact Kristina Allsoppat research@pharmacists.ca
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Canadian Pharmacists Conference
The Canadian Pharmacists Conference 2016 will be jointly hosted by the Canadian Pharmacists Association (CPhA) and the Alberta Pharmacists Association (RxA).
Looking forward to seeing you in Calgary, June 24–28, 2016.
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Next Pharmacy Research Webinar
There will be three more pharmacy practice research webinars presented during the spring 2016.
The topic and speaker of the next webinar will be announced soon. Please check pharmacists.ca/cpprg for topics and dates.
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Previously Recorded Pharmacy Research Webinars
The UBC Pharmacists Clinic - A Catalyst for Pharmacists Practice Change
CO-OPP1 – Collaborative Community Offsite Pharmacy Practice Phase 1: Influenza Immunization
The Medication Assessment Centre: A New Resource for Students,Patients and Practising Pharmacists
Promoting the Development and Evaluation of Innovative Practices in Community Pharmacy: The STAT Network
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Previously Recorded Pharmacy Research Webinars (continued)
Tips for Designing Pharmacy Practice Research
Minor Ailment Services – From Research to Practice
Pharmacy, Practice and Policy: Conducting and Translating OPEN Research
Pharmacists Prescribing Across Practice Areas in Alberta
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Previously Recorded Pharmacy Research Webinars (continued)
Pharmacists Providing Comprehensive Medication Management
The Evolution of Pharmacists Prescribing in Scotland
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THANK YOU!
To register upcoming or view previously recorded webinars go to: pharmacists.ca/cpprg
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