Elizabeth A. Chester

Laboratory monitoring of drugs at initiation of therapy in ambulatory care.

BACKGROUND AND OBJECTIVES: Product labeling and published guidelines reflect the importance of monitoring laboratory parameters for drugs with a risk of organ system toxicity or electrolyte imbalance. Limited information exists about adherence to laboratory monitoring recommendations. The objective of this study was to describe laboratory monitoring among ambulatory patients dispensed medications for which laboratory testing is recommended at therapy initiation.DESIGN AND SUBJECTS: We conducted a retrospective cross-sectional analysis of patients in 10 geographically distributed health maintenance organizations who were newly prescribed medications with recommended laboratory test monitoring. The main outcome measure was the proportion of initial drug dispensing without recommended baseline laboratory monitoring for 35 newly initiated drugs or drug classes.RESULTS: One hundred seven thousand, seven hundred sixty-three of 279,354 (39%) initial drug dispensings occurred without recommended laboratory monitoring. Patients without monitoring were younger than patients who had monitoring (median 57 vs 61 years, P<.001). Thirty-two percent of dispensings where a serum creatinine was indicated did not have it evaluated (range across drugs, 12% to 61%); 39% did not have liver function testing (range 10% to 75%); 32% did not have hematologic monitoring (range 9% to 51%); and 34% did not have electrolyte monitoring (range 20% to 62%) (P<.001).CONCLUSIONS: Substantial opportunity exists to improve laboratory monitoring of drugs for which such monitoring is recommended. This study emphasizes the need for research to identify the clinical implications of not conducting recommended laboratory monitoring, existing barriers to monitoring, and methods to improve practice.

Clinical Outcomes of a Home-Based Medication Reconciliation Program After Discharge from a Skilled Nursing Facility

Study Objective. To assess the impact of a pilot pharmacist‐managed medication reconciliation program on mortality and use of health care services in patients discharged to home from a skilled nursing facility (SNF).

Collaborative Drug Therapy Management and Comprehensive Medication Management―2015

The American College of Clinical Pharmacy (ACCP) previously published position statements on collaborative drug therapy management (CDTM) in 1997 and 2003. Since 2003, significant federal and state legislation addressing CDTM has evolved and expanded throughout the United States. CDTM is well suited to facilitate the delivery of comprehensive medication management (CMM) by clinical pharmacists. CMM, defined by ACCP as a core component of the standards of practice for clinical pharmacists, is designed to optimize medication‐related outcomes in collaborative practice environments. New models of care delivery emphasize patient‐centered, team‐based care and increasingly link payment to the achievement of positive economic, clinical, and humanistic outcomes. Hence clinical pharmacists practicing under CDTM agreements or through other privileging processes are well positioned to provide CMM. The economic value of clinical pharmacists in team‐based settings is well documented. However, patient access to CMM remains limited due to lack of payer recognition of the value of clinical pharmacists in collaborative care settings and current health care payment policy. Therefore, the clinical pharmacy discipline must continue to establish and expand its use of CDTM agreements and other collaborative privileging mechanisms to provide CMM. Continued growth in the provision of CMM by appropriately qualified clinical pharmacists in collaborative practice settings will enhance recognition of their positive impact on medication‐related outcomes.

Randomized Trial to Improve Prescribing Safety During Pregnancy

OBJECTIVE This study sought to determine whether a computerized tool that alerted pharmacists when pregnant patients were prescribed U.S. Food and Drug Administration pregnancy risk category D or X medications was effective in decreasing dispensings of these medications. DESIGN Randomized trial. Pharmacy, diagnostic, and laboratory data were linked to identify pregnant patients prescribed targeted medications. Women (n = 11,100) were randomized to intervention or usual care. Physicians and pharmacists collaborated on the intervention. MEASUREMENTS The primary outcome was the proportion of pregnant women dispensed a category D or X medication. The secondary outcome was the total number of first dispensings of targeted medications. RESULTS A total of 2.9% of intervention (n = 177) and 5.5% of usual care (n = 276) patients were dispensed targeted medications (p < 0.001): 1.8% of intervention (n = 108) and 3.9% of usual care (n = 198) patients were dispensed only category D medication(s); 0.9% of intervention (n = 54) and 1.2% of usual care (n = 58) patients were dispensed only category X medication(s); 0.2% of intervention (n = 15) and 0.4% of usual care (n = 20) patients were dispensed both category D and X medications (p = 0.05). This resulted in intervention patients receiving 238 dispensings of unique targeted medications and usual care patients receiving 361 dispensings of unique targeted medications (p = 0.03). The study was stopped primarily due to 2 false-positive alert types: Misidentification of medications as contraindicated in pregnancy by the pharmacy information system and misidentification of pregnancy related to delayed transfer of diagnosis information. CONCLUSION Coupling data from information systems with knowledge and skills of physicians and pharmacists resulted in improved prescribing safety. Systems limitations contributed to project discontinuation. Linking ambulatory clinical, laboratory, and pharmacy information to provide safety alerts is not sufficient to ensure project success and sustainability.

Randomized trial to improve laboratory safety monitoring of ongoing drug therapy in ambulatory patients.

Study Objective. To determine whether an electronic tool effectively increases the percentage of patients receiving laboratory monitoring during ongoing drug therapy.

A Multidisciplinary Approach to Transition Care: A Patient Safety Innovation Study

INTRODUCTION Patients with complex medical care needs often embark on multiple care transitions over an extended period of time. As these patients or their caregivers often become the chief source of communication for complex medical situations, each transition can create an opportunity for health care errors. Combining the efforts of the established departments of Chronic Care Coordination (CCC), Clinical Pharmacy Call Center (CPCC), and Continuing Care, Kaiser Permanente Colorado created programs to further safe care transitions. METHODS Two key goals for safe care transitions were established: 1) reductions in medication errors and 2) increased follow-up with care plans. To achieve these goals, communication plans targeted at medication reconciliation, patient education, and coordination of outpatient recommendations were established. Expected outcomes included reductions in medication errors, decreased Emergency Department and hospital admissions, decreased readmissions, and increased outpatient follow-up and medication compliance. RESULTS A review of medication-reconciliation records for intervention patients indicated that >90% of all discharge summaries contained at least one potential drug-related problem including duplicative drugs, omitted therapy, and medication contraindications. After skilled nursing facility discharge, patients who were transitioned by CPCC clinical pharmacists were: 1) 78% less likely to die; 2) 29% less likely to need an Emergency Department visit; and 3) 17% more likely to follow up with primary physicians and clinicians than were patients in the usual care group. Health care cost savings for patients seen by the CCC program demonstrated, conservatively, an annualized per patient savings of

Improving Laboratory Monitoring at Initiation of Drug Therapy in Ambulatory Care: A Randomized Trial

5276. For 763 patients enrolled in 2003, this amounts to an estimated, annualized savings of

Monitoring of Drugs With a Narrow Therapeutic Range in Ambulatory Care

4,025,588. CONCLUSIONS Patients are becoming more informed and involved in their care, but they require ongoing education and coaching to become effective advocates for themselves. Identification of unintended medication discrepancies and potential drug-related problems and increased follow-up during care transitions can improve patient safety and quality of care while saving health care resources.