does pharmacist led medication review improve health outcomes

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  1. 1. Does Pharmacist-Led Medication Review Improve Health Outcomes? Evaluation of a Quality Improvement Project February 19, 2015 Quality Forum Corinne M Hohl MD FRCP MHSc Attending Physician, Dept of Emergency Medicine, VGH Associate Professor, Dept of Emergency Medicine, University of British Columbia Scientist, Centre for Clinical Epidemiology and Evaluation CIHR New Investigator
  2. 2. ADE: unintended and harmful effects of medications. Most common cause of preventable iatrogenic morbidity. Patients with ADEs commonly present to EDs: 12% of ED visits amounting to 20,000 visits per year to VCHA 35-40% of are not attributed to medication use by MDs 50% greater odds of spending additional days in hospital/month. Leading cause of unplanned admissions.
  3. 3. Co-funded by BC HSPO & VCHA in 2011 Aim: To evaluate the effect of pharmacist-led medication review in high-risk ED patients on health outcomes compared to usual care (medication reconciliation). Innovation: A new model of delivering pharmacy care to ensure that patients receive optimal medication therapy from when they arrive.
  4. 4. Design: Prospective comparator study, non-blinded that was nested within a continuous quality improvement project at 3 sites. Population: High-risk adults presenting to a participating ED at a time an ADE pharmacist was present (including evenings and weekends)
  5. 5. Intervention: Medication Review by Clinical Pharmacists Best-possible medication history & initiated med reconciliation Review of medications critically to identify ADEs, and medication-related problems Communication with emergency MD/GP/geriatric triage nurse if discharged or emergency/admitting MD if admitted. Control: Med reconciliation by admitting/consultant services & medication review on the ward among admitted.
  6. 6. Reconciliation an accurate medication history from a variety of sources based on which medications are re- prescribed. Aim: to avoid medication errors at care transitions. Review an accurate medication history followed by a structured, critical examination of a patients medications Aim: to reach agreement on the goals of therapy, minimize errors, optimize medication effectiveness, identify medication-related problems and ADEs.
  7. 7. Outcomes: 1 o Proportion of days spent in hospital within 30 days of the index ED visit (encompasses index admission and days readmitted) 2 o Proportion admitted Unplanned ED visits within 7d Mortality (all-cause)
  8. 8. ED visits (VGH, LGH, RH) (n=135,323) Excluded (n=124,516) Low-risk or unknown (n=95,837 ) Age < 19yrs (n=882) Pharmacist not available (n=22,675) CTAS=1 unknown (n=236) Multisystem Trauma (n=302) Scheduled re-visit (n=1,643) Sexual assaults (n=4) Post-operative complications (n=224) Social problems (n=317) Pregnancy-related complication (n=18) Death on arrival/in ED (n=406) Repeat visits (n=1,964) Unresolved linkage (n=1) Left Against Medical Advice/Missing data (n=9) High-Risk eligible (n=10,805) Med Rev (n=6,416) Control (n=4,389) Systematic Allocation Patient Flow
  9. 9. Med Rev (n=6,416) Control (n=4,389) Median age, yrs 71 69 Female, % 56.4 55.1 Mean No. Meds 8.1 7.7 Lowest SES quintile, % 11.7 11.2 Ambulance Arrival, % 37.1 32.9 Daytime Arrival, % 61.2 61.3 Weekend Arrival, % 13.2 12.4 Baseline Characteristics Overall
  10. 10. Med Rev (n=6,416) Control (n=4,389) Median age, yrs 71 69 Female, % 56.4 55.1 Mean No. Meds 8.1 7.7 Lowest SES quintile, % 11.7 11.2 Ambulance Arrival, % 37.1 32.9 Daytime Arrival, % 61.2 61.3 Weekend Arrival, % 13.2 12.4 Baseline Characteristics Overall
  11. 11. Median No. Hospital Days over 30 Days of Follow-Up Difference in Days ( 95% CI) p-value All Sites -0.48 days (-0.96 to 0.0) 0.058

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