Transitions of Care in Heart Failure: Identifying Patients for Intervention

Meredith Miles, PharmD1; Karen Gunning, PharmD, BCPS1,2; Vanessa Stevens, PhD1,3; Brandon T. Jennings, PharmD, BCACP1,2 1University of Utah College of Pharmacy, Salt Lake City, Utah; 2University of Utah Hospitals and Clinics, Salt Lake City, Utah; 3University of Utah Pharmacotherapy Outcomes Research Center, Salt Lake City, Utah

Introduction / Background

Conclusions

•  Transitions of Care is an issue for many different disease states •  Contributing factors:

•  Complexity of medication regiments, lack of awareness of medication changes by patients, care givers, and physicians, lengthy follow up periods, and a multitude of patient comorbidities1,2

•  Heart failure readmissions are a CMS initiative as of 2007 due to cost burden3

•  Transitions of care is commonly an inpatient focus, but could be beneficial for outpatient health care providers to become more involved with in the transition to home4

•  Heart failure is not currently being targeted by pharmacists at the University of Utah Health Care community clinics for medication management

•  Identified common comorbidities for HF exacerbation to be: hypertension hyperlipidemia, coronary artery disease, atrial fibrillation, and diabetes

•  Omission of HF therapy (39%) was the most common medication related problem at discharge from hospitalization

•  Follow Up (37%) /Titration (30%) of HF therapy are the most common medication related problem s at PCP Follow Up Visit

•  Further Direction/Analysis: Identify areas of benefit for pharmacist intervention via literature analysis and formulate models to predict higher risk patient profiles for pharmacist intervention in the outpatient setting.

Correspondence Please address inquiries to: Meredith Miles, PharmD

PGY1 Community Practice Resident University of Utah College of Pharmacy/Bowman’s Pharmacy

Meredith.Miles@pharm.utah.edu All authors have no relevant conflicts of interest to declare

Limitations •  Retrospective chart analysis •  Limited scope of understanding beyond what is documented to make

decisions about drug related problems

Objectives •  Define what drug related problems occur during care transitions •  Categorize patient characteristics to identify patients with heart failure drug

related problems •  Analyze hospital readmission as a secondary outcome

Results: Secondary

               

92.08%

References 1.  Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and

information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297(8):831–841. [PubMed:17327525]

2.  Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, LaPointe NM, Burkhardt CD, Schilli K, Seaton T, Trujillo J, Wiggins B.Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012 Nov;32(11):e326-37. doi: 10.1002/phar.1215. Epub 2012 Oct 26.

3.  Centers for Medicare & Medicaid Services. Hospital Quality Initiative Outcome. 7500 Security Boulevard, Baltimore, MD 21244. August 18, 2013.

4.  Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Annals of Internal Medicine. 2011; 155(8):520–528.[PubMed: 22007045]

Results: Primary

Methods / Process •  Descriptive analyses of heart failure hospital admission drug related

problems •  Inclusion: Patients 18+ years with 1 hospital admission from January 1,

2010 – February 1,2014 and followed by a PCP at an outpatient clinic •  Heart failure ICD-9 code for admitting diagnosis

•  Exclusion: Discharge to SNF or hospice •  Analyze a patient chart at hospital discharge and primary care physician

follow up for medication related problems based on: •  Laboratory values, physician charting, and medication reconciliation

reports and current guideline reference

               

Medication Related Problems At Hospital Discharge

Medication Related Problem

Occurrences n %

Subtherapeutic dose 12 30% Supratherapeutic dose 4 10% Omission of HF therapy 26 65% Inappropriate choice of

HF therapy 6 15%

Follow Up Issue (ADE, Medication

Reconciliation error, or Drug-Disease/Drug

Interaction)

19 47.5%

Medication Related Problems at Primary Care Physician Follow Up Medication Related

Problem Occurrences

n % Subtherapeutic dose 21 52.5%

Supratherapeutic dose 3 7.5% Omission of HF therapy 18 45% Inappropriate choice of

HF therapy 3 7.5%

Follow Up Issue (ADE, Medication

Reconciliation error, or Drug-Disease/Drug

Interaction)

26 65%

Primary HF Admission Demographics (n=40)

n Mean/Percent Age (mean) 40 64.5 years

Weight 40 99.9 kg Male 26 65%

Female 14 35% White 28 70%

Unspecified 8 20% Hispanic 2 5%

Black 1 2.5 %

Pacific Islander 1 2.5%

Hospital Stay 40 5.5 days Time to PCP F/U 33 9.67 days

29.5 %

24.4 %

15.3% 11.5 %

19.2%

CAD (n=9)

HTN (n=15)

DM (n=23)

AFIB (n=19))

HLD (n=12)

24.3% 0 2 4 6 8

10 12 14 16 18

No Readmissions

Readmission(s)

Readmission Vs. No Readmission: PCP Follow Up Length (Days)

45.5%

54.5%

29.4%

15.3% 11.5%

19.2%

HLD: Hyperlipidemia and lipidemia disorders; CAD: coronary artery disease and other non-ischemic disease; HTN:

hypertensive disorders; DM: diabetes; AFIB: arrhythmias and atrial fibrillation

Distribution of Common Comorbidities for HF Exacerbation

0 5

10 15 20 25 30

No Readmissions

Readmission(s)

Readmission Rates Post Hospital Discharge (1/1/10-1/15/14)

62.5%

37.5%

Day

s

Pat

ient

s