Evaluation of patient care interventions and recommendations by a transitional care pharmacist

Figures & data

Table 1 Classification, definition and example of pharmacist interventions

Intervention topic	Definition	Example
Add/change/delete medication
Duplicate therapy	Discontinue one of two or more medications that have similar effects	Patient taking both niacin and lovastatin. Discontinue niacin – patient with good lipid control.
Guideline adherence	Recommend lab tests consistent with current international guidelines	Check lipid panel for patient with history of acute myocardial infarction.
Indication without a medication	Patient has a diagnosis for which a medication is known to be appropriate	Heart failure patient needs beta-blocker therapy.
Medication selection	Change medication to one with fewer side effects, greater chance of patient compliance, or substitute for two other medications.	Change glyburide to glipizide for patient with renal insufficiency who has experienced early morning hypoglycemic events.
Medication without indication	Discontinue a medication because a patient no longer has symptoms, or lab values obviate the need	Discontinue oral pantoprazole in patient no longer at risk for gastric stress ulcers.
Notable adverse drug reaction	Recommend discontinuing or changing a medication due to a moderate-severe reaction	Discontinue bedtime temazepam & as-needed lorazepam for patient who is over-sedated.
Potential drug/food/disease interaction	Discontinue drug which has propensity to worsen a patient co-morbidity, eg, likelihood of fall	Discontinue diazepam in 93 year-old female who has recently experienced falls and a head contusion. Use trazodone for sleep.
Allergies
Allergy information updated/deleted	Change allergy record to reflect current status of allergies, including updates from patient	Remove meclizine allergy – patient takes at home without problem.
Existing allergy reaction	Identify the exact type of reaction to a known allergy	Sulfa causes hives and shortness of breath.
New allergy identified	Patient exhibits an allergy that has not been documented elsewhere	Penicillin causes rash.
Patient allergic to original medication ordered	Change an ordered medication when documentation shows an existing patient allergy.	Patient allergic (rash) to ciprofloxacin that was ordered for enterbacter cloacae in the urine. Change to ceftriaxone.
Cost
Nonformulary/insurance issue	Change a medication to the formulary agent covered by a patient’s insurance.	Change pantoprazole back to over-the-counter omeprazole at discharge.
Patient cannot afford original medication	Change to a less expensive medication	Change pantoprazole to over-the-counter omeprazole.
Dosing
Appropriate dosing	Change medication dose based on patient age, comorbidities, or other medications	Change ophthalmic drops, Xalatan, from both eyes to right eye only.
Dose adjustment for drug interaction	Increase or decrease medication dose in consideration of other medications	Decrease weekly warfarin dose in response to added amiodarone therapy.
Renal/hepatic dosing	Change medication dose based on renal function	Decrease dose of allopurinol to 150 mg/d (from 300 mg/d) for estimated creatine clearance of 20 ml/min.
Sub-therapeutic dosing	Increase medication dose in order to achieve benefit, or resume previous levels at discharge to what the patient had prior to admission.	Atenolol dose reduced from 100 mg/d to 50 mg/d upon admit. Now BP to 171/99. Recommend resume home dose of 100 mg.
Supra-therapeutic dosing	Decrease medication dose in patient when warranted by lab results or patient side-effects	Decrease dose of glyburide 3 mg bid to daily for blood glucose of 38 this am.
Other
Patient counseling	Explain to patient or family the importance of a medication, reasons for changes, or how to take a medication	Counsel patient on inhaler technique and provided a visual aid for appropriate inhaler technique steps at discharge.
Route change	Any change in the medication’s route of administration based on the patient’s clinical status	Change IV to oral ciprofl oxacin – patient able to take oral medications.
Vaccines missing	Order a guideline-indicated vaccine and there is no recent documentation	Pneumovax.

Table 2 Description of study population

Descriptor	Percentage or value
Average age	78.9
Age range	60 to 94
Age > 85	31%
Male	33%
Avg. number of medications
Currently taking	9.8
3+ prior inpatient admissions in prior year	38%
Cardiac DRG	11%
Neuromusculoskeletal DRG	19%
Medical-GI DRG	20%
Medical-respiratory DRG	19%
Discharge to SNF or foster care	33%

Table 3 Time estimates for transitional care pharmacist tasks

TCPTask	Estimated time required (minutes)
	Range	Avg	Percent
Admission
Collect historical data	30–60	45	13%
print/read H&Ps
print/reconcile EHR
draft care plan
review/document pertinent labs
Medication history by patient	30–45	37.5	11%
interview
patient interview
review paper chart data
In-hospital
Daily Rounding	60–90	75	22%
update new labs/culture
information
assess current progress
ascertain discharge plan
follow-up on interventions made
Discharge
Type discharge medication list	15–30	22.5	7%
Counsel patient	20–40	30	9%
Write follow-up care plan	60–90	75	22%
write care plan
update EHR flowsheet
update EHR medication list
update EHR allergies
route final document to PCP
Other
Identify patients from daily printouts	30–45	37.5	11%
Enter data on all	10–15	12.5	4%
recommendations made
Total time per patient (min)	255–415	335	100%
Total time per patient (hr)	4.3–6.9	5.6
Patients per 40 hour week	9.4–5.8	7.2

Table 4 Timing of interventions

	Phase of care
Intervention	Admission	In-hospital	Discharge	Follow-up	Total
Add/change/delete medication
Duplicate therapy	4	19	9	2	34
Guideline adherence	4	23	1	0	28
Indication without a medication	33	103	147	9	292
Medication selection	3	23	11	2	39
Medication without indication	6	27	11	0	44
Notable adverse drug reaction	3	9	0	0	12
Potential drug/food/disease interaction	9	17	11	1	38
Allergy
Allergy Information updated/deleted	27	1	0	0	28
Existing allergy reaction	120	4	0	0	124
New allergy identified	49	4	1	1	55
Patient allergic to ordered medication	0	1	0	0	1
Cost
Nonformulary/insurance issue	0	0	6	0	6
Patient can’t afford original medication	0	6	10	0	16
Dosing
Appropriate dosing	5	20	31	3	59
Dose adjustment for drug interaction	1	1	1	0	3
Renal/hepatic dosing	0	17	3	1	21
Sub-therapeutic dosing	5	20	9	0	34
Supra-therapeutic dosing	1	11	2	1	15
Other
Patient counseling	6	23	9	3	41
Route change	0	15	1	0	16
Vaccines missing	9	10	2	0	21
Total	285	354	265	23	927
Percentage by phase of care	31%	38%	29%	2%	100%

Table 5 Expected temporal impact of interventions

Expected temporal impact	Number	Percentage
Short-term	190	20.5%
Long-term	151	16.3%
Both short-term and long-term	583	62.9%
Not rated (inadvertently)	3	0.3%
Total	927	100%

Table 6 Importance of interventions as rated by pharmacist

Rating	Importance	Number	Percentage	Examples
1	Prevented Mortality	0	0.0%	Avoided administration of a medication listed as an allergy with an anaphylactic reaction in medical record.
2	Prevented Serious Morbidity	273	29.2%	Held a medication in response to supratherapeutic drug levels, ie, digoxin, theophylline, warfarin, etc.
3	Prevented Potential ADE or Standard of Practice	626	67.7%	Lowered warfarin dose empirically in response to addition of amiodarone.Added ACEI therapy to patient with both diabetes and hypertension.
4	Cost or Product Selection	27	2.9%	Switch PPI therapy from esomeprazole to pantoprazole per approved therapeutic interchange. Adherence to an established outpatient medication formulary.
	Not Rated	1	0.1%	(Inadvertently not rated)
Total		927	100.0%

Table 7 Interventions with an impact on decreasing morbidity

Intervention	Number of recommendations estimated to decrease morbidity	% of all morbidity reducing recommendations
Indication w/o a medication	85	31%
Existing allergy, reaction	22	8%
Vaccines missing	21	8%
Med w/o indication	15	5%
Potential drug/food/disease interaction	15	5%
Patient counseling	15	5%
Medication selection	15	5%
Appropriate dosing	13	5%
Duplicate therapy	13	5%
Subtherapeutic dosing	11	4%
Supratherapeutic dosing	10	4%
Renal/hepatic dosing	10	4%
Guideline only	9	3%
Notable adverse drug reaction	8	3%
New alergy identified	4	1%
Dose adjustment for drug interaction	2	1%
Route change	2	1%
Allergy Information updated/deleted	1	0%
Patient allergic to original med	1	0%
Patient cannot afford original med	1	0%
Nonformulary/insurance issue	0	0%
Total	273	100%