Transitions of Care
Joey Sweeney, PharmD, BCPS
Transitions of care are fraught with risk for patients. This issue has gained the attention of many stakeholders, and in 2012, CMS began to focus on holding health systems accountable for unwanted readmissions. Some systems have used pharmacists to help drive these numbers down. However, no attempt had been made to quantify a collaboration between inpatient and ambulatory pharmacists until a recent study, published in the Journal of Managed Care and Specialty Pharmacy, investigated the impact of including pharmacists in the transitions-of-care framework.
Evaluating transitions of care
McFarland and colleagues designed a pharmacist-to-pharmacist transitions-of-care model in which an inpatient pharmacist would identify a patient for intervention and then coordinate outpatient follow-up with an ambulatory pharmacist.
The quasi-experimental, matched interrupted time series design study was conducted at a multisite Veterans Affairs health care system. Patients admitted to the hospital for diabetes, hypertension, COPD, and heart failure were included if they were seen after discharge by an ambulatory pharmacist in a clinic.
Patients were excluded if they were discharged from the hospital to hospice, skilled nursing facilities, long-term-care facilities, or home-based primary care (care provided in the patient’s home). Curiously, patients were also excluded if they were scheduled to be seen in a specialty clinic (hypertension clinic, endocrine clinic, pulmonary clinic, and/or heart failure clinic).
Patients with end-stage renal disease, cirrhotic, decompensated liver disease, and stage C or D valvular heart disease were also excluded because these patients were already following up in other specialty clinics.
If a patient with one of the above diagnoses was admitted to the hospital, the inpatient pharmacist would coordinate whether the patient should follow up with an ambulatory pharmacist within 10 days of discharge while adhering to the exclusion criteria.
Near the day of discharge, the inpatient pharmacist would provide education related to medications pertinent to the patients’ diagnoses. Within 10 days of discharge, the ambulatory pharmacist would meet with the patient face to face in the clinic and evaluate all of the patient’s medications and conditions.
The study’s primary endpoint was the composite 30-day, all-cause readmission rate (including emergency department visits or hospital readmission). The researchers compared patients in the experimental group with historical patients with similar diagnoses who were discharged before the transitions-of-care program was implemented.
Secondary endpoints included the composite index 30-day readmission rate (readmission or emergency department visit for a condition for which the patient was recently discharged), individual all-cause and index 90-day acute care utilization rates, and outcome analysis for the individual disease states.
Study results
A total of 484 patients, with 242 in each group (366 with heart failure, 66 with COPD, 10 with hypertension, and 42 with diabetes), were included in the analysis. Surprisingly, for the primary endpoint of composite 30-day, all-cause acute care utilization rates, no statistically significant difference was identified, with 26.9% of patients in the intervention group and 28.9% in the historical group readmitted or seen in the emergency department within 30 days of discharge. The secondary endpoint of a composite 90-day, all-cause acute care utilization was lower in the intervention group (62.4%) than in the comparator group (74.4%).
While it is disappointing that the primary endpoint showed no difference between groups, pharmacist-to-pharmacist transitions-of-care interventions are likely beneficial, as evidenced by the positive secondary endpoint differences. One significant limitation of this study that may have impacted the primary endpoint was the exclusion criteria. It seems as though the sickest patients, who could have benefited from the pharmacist-to-pharmacist intervention, were excluded because they were already following up with their specialist’s group.
Additional studies with fewer exclusion criteria may be useful to determine if the addition of patients with more advanced illnesses would see greater benefit to a pharmacist-to-pharmacist transitions-of-care model.