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Impact of the Clinical Pharmacist on Discharge Medication Reconciliation

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Impact of the Clinical Pharmacist on Discharge Medication Reconciliation Impact of the clinical pharmacist on discharge medication reconciliation for bariatric surgery patients Amanda Van Prooyen, PharmD, BCPS1; Jessica Hicks, PharmD, BCPS1; Ed Lin, DO2; Scott Davis Jr., MD2; Arvinpal Singh, MD2; DeAngelo Harris, MD, MS2; Elissa Falconer, MD2; Elizabeth Hechenbleikner, MD2 Emory University Hospital Midtown Department of Pharmacy, Atlanta GA1; Emory Bariatric Center, Atlanta GA2 Goal Patient Population Percentage of Prescribed Discharge Medications by Type 70 • To evaluate the impact of an inpatient pharmacy Included Patients, N=252 62.5 consult service on the discharge medication • Pre-Pharmacy Consult, n=167 60 07/01/2018 – 12/31/2018 reconciliation process for patients following 50 46.2 bariatric surgery • Pharmacy Consult, n=85 06/12/2019 – 12/12/2019 40 33.3 33.3 28.7 30 20 20 Background Pre-Pharmacy Pharmacy 20 Baseline 12.5 • Obesity, defined as a body mass index (BMI) ≥ 30 kg/m2 Consult Consult p-value 9.4 9 6 Characteristic 10 3.5 in adults, was estimated to affect 93.3 million people in (n=167) (n=85) 0 0 1,2 0 the United States in 2016 Average Age, 44.4 44.5 0.98 years • When weight loss goals are not achieved with lifestyle modifications and/or pharmacotherapy, bariatric surgery Female Sex, n. (%) 141 (84.4) 74 (87.1) 0.58 can be considered in adult patients with a BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-related Race, n. (%) African American 96 (57.5) 54 (63.5) comorbidities1 0.36 White 71 (42.5) 31 (36.5) * Met statistical significant (p<0.05) Pre-Consult † Of those patients on medication class at baseline Consult • Anatomic changes following bariatric surgery can alter Average BMI, 2 48.0 46.7 0.71 medication absorption and efficacy (e.g. increased or kg/m Conclusions decreased absorption, more rapid onset of drug effect, Procedure, n. (%) • Clinical pharmacist involvement within the medication reconciliation Roux-en-Y bypass 46 (27.5) 22 (25.9) compromised bioavailability)4. Additionally, post-surgical 0.78 process for inpatient bariatric surgery patients prevented Sleeve gastrectomy 121 (72.5) 63 (74.1) improvements in certain comorbidities (e.g. inappropriate prescribing of modified-release medications hypertension, diabetes mellitus) may necessitate Average number of 6.7 6.8 0.90 • Proactive adjustment of antihypertensive and diabetes medications pharmacotherapy adjustments3 home medications by the pharmacist may prevent potentially life-threatening hypotension and hypoglycemia • Pharmacists are positioned to manage medications for Medication history included high-risk 25 (15.0) 11 (12.9) 0.66 • Further investigations could include evaluation of the patient’s patients following bariatric surgery due to their extensive medication, n.(%) satisfaction with the pharmacist understanding of pharmacokinetics and drug therapy Pharmacy Consult Service Pharmacist Recommendations References • Pharmacists completed a medication history, reviewed 1. Jensen MD, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and Total Recommendations, 130 (85.4) obesity in adults: a report of the American College of Cardiology/American Heart the home medication list for required post-surgical n. (% accepted) Association Task Force on Practice Guidelines and The Obesity Society. Circulation medication changes, created/documented a discharge 2014;129:S102-138. 2. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and medication plan for provider review, and educated the Antihypertensive Adjustment 49 (81.6) youth: United States, 2015–2016. NCHS data brief, no 288. Hyattsville, MD: National patient on the medication plan Formulation Change 41 (78.0) Center for Health Statistics. 2017. 3. English WJ, Williams DB. Metabolic and bariatric surgery. An effective treatment option Diabetes Medication Adjustment 22 (100.0) for obesity and cardiovascular disease Prog Cardiovasc Dis 2018;61(2):253-269. • Pharmacists operated under a protocol which provided Discontinue NSAID 9 (100.0) 4. Bland CM, et al. Long-term pharmacotherapy considerations in the bariatric surgery patient. Am J Health-Syst Pharm 2016;73:1230-42. guidance on how to appropriately adjust medications Discontinue Loop Diuretic 9 (88.9).
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