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Impact of Pharmacist Involvement in the Transitional Care of High‐ ORIGINAL RESEARCH Impact of Pharmacist Involvement in the Transitional Care of High-Risk Patients Through Medication Reconciliation, Medication Education, and Postdischarge Call-Backs (IPITCH Study) Arti Phatak, PharmD, BCPS1, Rachael Prusi, PharmD1, Brooke Ward, PharmD, BCPS1, Luke O. Hansen, MD, MPH2, Mark V. Williams, MD3, Elizabeth Vetter, PharmD1, Noelle Chapman, PharmD1, Michael Postelnick, RPh, BCPS AQ ID1* 1Pharmacy Department, Northwestern Memorial Hospital, Chicago, Illinois; 2Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; 3Department of Internal Medicine, University of Kentucky, Lexington, Kentucky. BACKGROUND: Previous data suggest that direct pharma- to-face medication reconciliation, a patient-specific phar- cist interaction with patients through medication reconcilia- maceutical care plan, discharge counseling, and postdi- tion, discharge counseling, and postdischarge phone calls scharge phone calls on days 3, 14, and 30 to provide decreases the number of adverse drug events (ADEs) and education and assess study endpoints. plays an overall positive role in transitional care. Previous RESULTS: A total of 278 patients were included in the final studies have evaluated pharmacist involvement in improv- analysis, with 141 in the control group and 137 in the study ing transitional care, but these studies did not include multi- group. Fifty-five patients (39%) in the control arm experi- ple postdischarge follow-up phone calls. enced an inpatient readmission or ED visit within 30-days OBJECTIVES: The objectives of this study were to assess postdischarge compared to 34 patients (24.8%) in the study the impact of pharmacist involvement in transitions of care arm (P 5 0.01). Eighteen patients (12.8%) in the control as measured by decreased medication errors (MEs) and group experienced an ADEs or MEs compared to 11 ADEs, patients’ knowledge related to communication about patients (8%) in the study group (P > 0.05). The HCAHPS their medications as measured by improvement in the Hos- scores during the study period showed a 9% improvement pital Consumer Assessment of Healthcare Providers and for the assessed questionnaire domain (P > 0.05). Systems (HCAHPS) scores, and 30-day all-cause inpatient CONCLUSIONS: This study demonstrated that pharmacist readmissions and emergency department (ED) visits. involvement in hospital discharge transitions of care had a METHODS: This was a prospective, randomized, single- positive impact on decreasing composite inpatient readmis- period longitudinal study that occurred from November sions and ED visits. Statistically significant difference in 2012 through June 2013 at an urban, tertiary, academic medication-related events and HCAHPS scores were not medical center. Patients admitted to 2 designated internal observed. Patients with moderately complex medication medicine units on high-risk medications or with greater than regimens benefited from a continuity of care involving a 3 prescription medications upon discharge were included pharmacy team during transitions in care. Journal of Hospi- for randomization. The control group received the usual tal Medicine 2016;11:39–44. VC 2015 Society of Hospital hospital standard of care. The study group received face- Medicine Hospital readmissions have a significant impact on the Pharmacists, by optimizing patient utilization of medi- healthcare system. Medicare data suggest a 19% all- cations, can play a valuable role in contributing to cause 30-day readmission rate, of which 47% may be preventing readmissions.3 preventable.1,2 The Centers for Medicare & Medicaid Lack of acceptable transitional care is a serious Services continue to expand their criteria of disease problem that is consistently identified in the litera- states that will be penalized for readmissions, now ture.4 Transitional care involves 3 domains of trans- reducing hospital reimbursement rates up to 3%. fer: information, education, and destination. A breakdown in any of these components can negatively impact patients and their caregivers. *Address for correspondence and reprint requests: Michael Postelnick, Prior studies consistently demonstrated a high likeli- RPh, BCPS AQ ID, Clinical Practice Manager, Senior Infectious Diseases hood of adverse drug events (ADEs) and patients’ lack Pharmacist, Northwestern Memorial Hospital, 251 E. Huron LC-700, Chicago IL 60014; Telephone: 312-926-7965; Fax: 312-926-7956; of knowledge regarding medications postdischarge, E-mail: [email protected] both of which can lead to readmission. Forster and Additional Supporting Information may be found in the online version of colleagues found that 19% to 23% of patients experi- this article enced an ADE within 5 weeks of discharge from an Received: April 15, 2015; Revised: September 1, 2015; Accepted: inpatient visit, 66% to 72% of which were drug September 9, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2493 related, and approximately one-third were deemed 5,6 Published online in Wiley Online Library (Wileyonlinelibrary.com). preventable. One survey found that less than 60% An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 11 | No 1 | January 2016 39 Phatak et al | Pharmacist Impact on Transitional Care of patients knew the indication for a new medication and were given the Rapid Estimate of Adult Literacy prescribed at discharge, whereas only 12% reported in Medicine revised (REALM-R) assessment to evalu- knowledge of an anticipated ADE.7 ate health literacy. The REALM-R is a word recogni- Pharmacists can play a large role in the information tion test designed to identify patients at risk for poor and education aspect of transitional care. Previous stud- health literacy skills. Patients with REALM-R scores ies demonstrate that pharmacist involvement in the dis- of 6 or less are considered to have low health liter- charge process can reduce the incidence of ADEs and acy.15 Patients were randomized to receive either the have a positive impact on patient satisfaction. There are usual care or pharmacist-directed medication evalua- conflicting data regarding the effect of comprehensive tion and management as described in Table 1. Patients medication education and follow-up calls by pharmacy included in the study were contacted by phone postdi- team members on ADEs and medication errors scharge, with 3 attempts on consecutive days. Patients (MEs).3,8,9 Although overall pharmacist participation who were readmitted as an inpatient or had an ED has shown positive patient-related outcomes, the visit were not contacted for the study after that point. impact of pharmacists’ involvement on readmissions Patients enrolled in the control group received the has not been consistently demonstrated.10–14 usual standard of care by a clinical pharmacist. This Our study evaluated the impact of the pharmacy included a medication reconciliation completed from team in the transitions-of-care settings in a unique the admitting physician’s patient history and physical combination utilizing the pharmacist during medica- and medication counseling provided by the physician tion reconciliation, discharge, and with 3 follow-up or nursing staff at discharge. Patients were not inter- phone call interactions postdischarge. Our study was viewed face-to-face on admission and did not receive designed to evaluate the impact of intensive pharma- discharge counseling by a pharmacy team member. cist involvement during the acute care admission as Patients were assessed daily by the pharmacist for well as for a 30-day time period postdischarge on evaluation of the pharmacotherapy plans and presence both ADEs and readmissions. of MEs or safety-related concerns. The control group received 1 postdischarge phone call from a pharmacist METHODS at day 30 to assess for study endpoints of ADEs, All patients were admitted to hospitalist-based inter- MEs, ED visit, and readmission only. The endpoints nal medicine units at Northwestern Memorial Hospi- of ADEs and MEs were determined by professional tal, an 894-bed academic medical center located in judgment by the clinical pharmacist based on an algo- Chicago, Illinois. Patients were randomized by study rithm similar to National Coordinating Council for investigators using a random number generator to Medication Error Reporting and Prevention, although either the usual care or intervention arms and then a specific tool was not utilized. evaluated each day for eligibility to participate in the The study group received face-to-face medication study. Patients remained blinded throughout the reconciliation on admission by a pharmacist or a study. Patients met inclusion criteria if they were dis- pharmacy student. Prior to discharge, a personalized charged to home and either discharged on greater medication plan was created by the pharmacist and than 3 scheduled prescription medications or dis- discussed with the physician. Medication discrepancies charged with at least 1 high-risk medication. High- were addressed prior to the discharge instructions risk medications were classified as anticoagulants, being given and discussed with the patient. Medica- antiplatelets (eg, aspirin and clopidogrel), hypoglyce- tion counseling was performed at discharge by the mic agents (eg, insulin), immunosuppressants, or anti- pharmacist or pharmacy student. Patients received 3 infectives. Patients also needed to participate in a min- phone calls at 3, 14, and 30 days postdischarge. The imum of 1 postdischarge
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