Executive Management: Examples of Data and Indicators

Engaging the C-suite to Advance Pharmacy PracticeProviding quality patient care throughprogressive pharmacy practice

Executive Management: Examples of Data and IndicatorsRita Shane, Pharm.D., FASHP, FCSHPChief Pharmacy Officer Cedars-Sinai Medical CenterAssistant Dean, Clinical Pharmacy Services, at the University of California, San Francisco, School of Pharmacy

Pharmacy Core Functions: Safe, Effective, Efficient Medication

Use

Patient Care and Risk Reduction

Resource Management

Transitions of Care

Medication Management and Regulatory Compliance

Drug Expenditures

FY 09 FY 10 FY 11 FY 12

Inpatient Drug Expenditures Outpatient Drug Expenditures

Transp

lant

Oncology

Heart

Shorta

ge

Inflammato

ry Bowel D

isease

Anti-snak

e venom

Vaccine

Orphan Drug

Heparin In

duced Thrombocyt

openiaStr

oke -

200,000 400,000 600,000 800,000

1,000,000 1,200,000 1,400,000 1,600,000

Total Variance $6,915,000

Drug Expense Variance FY11 Year to Date

Drug Cost Summary – 2011 Price Increases

Drug Price↑ Primary UsePorfimer sodium 624% Photodynamic therapy of tumors; Barrett’s

esophagusFactor VII 33% Cardiac surgery, liver pts, factor deficiencyAlteplase 11% StrokeInfliximab 21% Rheumatoid Arthritis, Crohn’s, Ulcerative ColitisBasiliximab 66% Kidney transplant induction

Bortezomib 53% Transplant desensitization/rejection, multiple myeloma

Aldesleukin 38% Renal Cell Carcinoma, Metastatic MelanomaNesiritide 78% Acute decompensated heart failureFilgrastim 13% Chemo-induced neutropenia

Mycophenolate IV 1560% Heart, lung, kidney transplant immunosuppression

Inpatient Drug Expenditures and Transplant Volumes

Heart Transplant ↑ 230%, Allogenic BMT ↑ 81% from FY09 to FY12

FY09 FY10 FY11 FY120

50100150200250300350400450500

$0 $5,000,000 $10,000,000 $15,000,000 $20,000,000 $25,000,000 $30,000,000 $35,000,000 $40,000,000 $45,000,000 $50,000,000

Total BMT Total Solid Inpatient Drug Expenditures

Epoetin (000)

FY11 FY12 FY13 FY14$0

$200

$400

$600

$800

$1,000

$1,200

$998

$731

$534

$389

Pharmacy Protocol to start medication on day #8 and reduce standard dose to 50 units/Kg three times/week

Pharmacy Protocol to limit dose to 10,000 units

Hepatitis B Immune Globulin (both inpatient and outpatient)

FY13 FY14$0

$50

$100

$150

$200

$250

$300

$350

$400 $337,000

$95,000

Based on UHC data, reduced # doses/pt.

6.2 Doses/Pt

2.2 Doses/Pt

(000)

Value ExamplesMedication Opportunity Identified and Pharmacist Intervention Cost

SavingsCMV-IVIG

Pt with CMV viremia who had response to change in antiviral from ganciclovir to foscarnet. Intervention: Discontinued CMV-IVIG

$75,000

Glucarpidase Pt with methotrexate toxicity. Intervention: Dose rounding

$24,805

Panhemitin

Pt without lab confirmation of acute intermittent porphyria. Intervention: Hold therapy pending lab results. Labs returned negative.

$24,984

IVIG Pt with HIV, hepatitis C, ITP; received 3 doses of IVIG as outpatient. Admitted with bruising and headache, platelet count of 9000/µL. MD ordered 2 more doses, however platelets were increasing.Intervention: Discontinue IVIG order

$15,074

Idursulfase Pt with VP shunt malfunction repair. Receives idursulfase weekly as an outpatient.Intervention: Contacted patient’s medical geneticist to administer dose post-discharge.

$10,500

MedicationsPrior to Admit Medication ListAs well as new

ordersDrug

IndicationDoseRoute

FrequencyDosage form

Duration

Patient Characteristics

Age-Pediatrics-Geriatrics

GenderHeight/Weight

AllergiesKidney/Liver

FunctionCurrent labs

Previous admissions

Special ConsiderationsHigh risk patients or therapies such

as: Chemotherapy

Blood thinners

AntibioticsDrugs with narrow therapeutic index

ICU

Pharmacist’s Role in Evaluating Medications

Prescribing Errors Intercepted September ‘11 – June ’13

Septem

ber '11

October

'11

November

'11

December

'11

January

'12

Febru

ary '1

2

March '1

2

April '12

May '1

2

June '12

July '12

August

'12

Septem

ber '12

October

'12

November

'12

December

'12

January

'13

Febru

ary '1

3

March '1

3

April '13

May '1

3

June '13

0

500

1000

1500

2000

2500

3000

3500CPOE Implementation

Sept - Feb Average/Month: 1633

(76.6/1,000 pt days)

Prescribing Errors Intercepted/1,000 OrdersIOM: 2.87

CSMC: 10.4 (pre-CPOE)

Prescribing Errors Intercepted/1,000 OrdersIOM: 2.87

CSMC: 15.6 (post-CPOE)

May ‘12-June’13 Average/Month:2431

(116/1,000 pt days)49% Increase

Methodology

Low Capacity for Harm

Serious/Significant

Life Threatening

Prescribing Errors Intercepted by Pharmacists ORDER RECEIVED ACTION TAKEN OUTCOME AVOIDED SEVERITY

RATINGHYDROmorphone PCA dose 2.4mg q8 minutes. Current dose= 0.2mg

Recommended 0.3mg Narcotic overdose, leading to respiratory failure and possible death.

Life Threatening

MD note included plan to start antibiotics for R/O meningitis. No antibiotics ordered.

Recommended to start antibiotics at meningitis dosing.

Potential undertreatment of meningitis

Life Threatening

Methotrexate 10mg daily and patient on weekly dose for RA.

Recommended continuing weekly dose.

Potential antineoplastic overdose and possible death.

Life Threatening

Fentanyl patch ordered upon admission. Per SNF, patient was not on fentanyl patch

Recommended discontinuing.

Potential narcotic overdose, leading to respiratory failure and possible death.

Life Threatening

Medication Reconciliation Across Transitions of Care

Changing clinical conditions require continually evaluating the medication lists at each transition

15

40% of resolved DRPs were classified as life-threatening or serious/significant

7.4 Drug-Related Problems Identified Per Patient Based on Medication History

21% of inpatient orders were changed due to DRPs identified

Resolution of Drug-Related Problems (DRPs) in

High-Risk Hospitalized Patients

PTA Drug-Related Problems (DRPs)

16

Medication on PTA List Drug-Related Problem DRP Type Capacity for

Harm

Flecainide PTA List: Med not listed on PTA med listFinding: Pt reports taking flecainide 50 mg BID

Omission of Medication Life-Threatening

Plavix PTA List: Med not listed on PTA med listFinding: Pt reports taking Plavix 75 mg daily

Omission of Medication Serious/Significant

Prednisone PTA List: Prednisone 20 mg dailyFinding: Pt reports it was d/ced by MD 6 months ago

Extraneous Medication Serious/Significant

Furosemide PTA List: Furosemide 40 mg BID Finding: Pt reports taking 60 mg BID (CHF pt)

Wrong Dose Serious/Significant

Mycophenolate PTA List: Mycophenolate 360 mg BIDFinding: Pt reports taking 720 mg BID Wrong Dose Serious/Significant

Midodrine PTA List: Midodrine 100 mg TIDFinding: Pt reports taking 30 mg TID Wrong Dose Life-Threatening

Hospitalist-Pharmacist Transitions of Care Collaboration

Evaluation of Medication List Accuracy, Adherence, and Literacy

Identify High- Risk Patients

Validate Medication

History∙∙∙∙

Assess Adherence

and Literacy∙∙∙∙

Educate Patient

Notify MD Regarding

DRPs Identified along with Recommen

d-ations

Post-Discharge Follow-Up within 72

Hrs:-Med Rec

-Adherence & Literacy

Reinforcement

-Education

Additional Calls up to

30 Days Based on

Risk Assessment

Criteria to Determine Need for Post-Discharge Follow-Up Medication Adherence and Literacy

Literacy 

AdherenceHigh literacy Intermediate

literacy Low literacy

High adherence No post-DC f/u needed

Educate pt. No post-DC f/u

neededPost-DC f/u needed

Intermediate adherence

Educate pt. No post-DC f/u

needed

Educate pt. No post-DC f/u needed?

vs. Post-DC f/u needed?

 Use clinical judgment

Post-DC f/u needed

Low adherence Post-DC f/u needed Post-DC f/u needed Post-DC f/u needed

Post-Discharge Metrics

20

Post-DC f/u Call Completed

Readmissions Prevented*

# of Patients 207 16%

Average DRPs/Pt 2.9

*Validated by MD Review

Post-Discharge Findings• 58% of pts had discrepancies between their discharge medication

list and what they were taking• 33% of pts were taking more medications than were prescribed

(excludes vitamins, herbals, etc)

Examples of Post-Discharge Follow-up

21

Reason for Admission Drug-Related Problems Identified Post-Discharge and Pharmacist Intervention

Adverse Outcome Prevented

54 y/o w/ HTN & DVT admitted for sickle cell crisis & left parietal stroke

Issue discovered: Pt had self-d/ced warfarin, amlodipine, and carvedilol

Intervention: Contacted MD and confirmed that warfarin and anti-hypertensives should be re-started. Pharmacist contacted pt and instructed to take all meds as was prescribed at d/c; do not self-start, self-d/c, self-dose, or adjust any med w/o speaking to MD first; educated pt on the importance of compliance to avoid complications

Avoided potential occurrence of thromboembolism, readmission, and/or death

92 y/o w/ altered mental status found to have a UTI & toxic digoxin level, also w/ arrhythmias & low blood pressure

Issue discovered: Pt had continued taking medications that had been stopped, including digoxin, metoprolol, and zolpidem

Intervention: Instructed patient to d/c these medications

Avoided potential drug toxicity, life- threatening arrhythmias, recurrence of confusion, and/or death

Enhanced Care Program forSkilled Nursing Facilities (SNF)

Identification of Patients Discharged

to SNF

Medication Reconciliation:

Discharge Medication List vs

SNF MAR-

Pharmacist Clinical Evaluation

-NP consults

Drug-Related Problems

Communicated to NP for Follow Up

SNF Post-Discharge Follow-Up

Data Period: 1/22/13 -6/30/14

ECP Pharmacy Data Summary

2013 1st Quarter2014

2nd Quarter2014

Total

# of Patients 708 241 223 1172

# of Serious/ Significant Drug-Related Problems (DRPs) Identified

560 275 2451080

(14 were life- threatening)

% of Patients Requiring Intervention

41%(293/708)

56%(134/241)

54% (120/223)

47%(547/1172)

25

Reason for Hospital Admission

Drug-Related Problems Identified Post-Discharge and Pharmacist Intervention

Adverse Outcome Prevented

98 y/o M from home w/ hip fracture and multiple medical issues.

Issue discovered: Pt was a new start on fentanyl 25mcg in house. Dose was increased to 50mcg 1 hour prior to discharge. Intervention: Called SNF to d/c fentanyl 50mcg order. Informed SNF RN that the patch was already placed on the pt. SNF RN was unaware.

Avoided severe respiratory depression or death due to potential supra-therapeutic dose of fentanyl.

79 y/o M w/ ESRD - HD on TuThSat - with catheter-related S. aureus bacteremia.

Issue discovered: Per ID, vancomycin after dialysis to be continued after d/c and was on discharge medication list. There was an order at the SNF for vancomycin but not at the dialysis center. Pt dialyzed on Sat after d/c but did not receive vancomycin.

Intervention: Ensured vancomycin administration occurred.

Avoided progression of bacteremia and catheter re-infection d/t missed doses of antibiotics.

89 y/o F w/multiple medical problems including pulmonary hypertension.

Issue discovered: Sildenafil 25mg PO TID was listed on discharge medication list but not continued at the SNF.

Intervention: Pharmacist recommended re-initiation of medication for the pt, who also required an oxygen mask at the SNF.

Avoided worsening of respiratory status and potential progression of condition and organ damage.

Examples of ECP Pharmacist Post-Discharge Follow-Up

Readmissions Dashboard

26

Baseline Jan 2013 Feb 2013 Mar 2013

SNF

30-day All-Cause Readmissions Rate

20% 17% 21% 12%

6SE Heart Failure

30-day All-Cause Readmissions Rate

21% 22% 18% 15%

Interdisciplinary Team Results

QUESTIONS