Lee A. Lindquist

Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission

BackgroundThis study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.MethodsStudy pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients’ number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness.ResultsOver one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient’s age ≥65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09–4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14–1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.ConclusionOver one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.

Teaching Medication Reconciliation Through Simulation: A Patient Safety Initiative for Second Year Medical Students

Errors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care. To design and implement an interactive learning exercise to teach second year medical students about medication reconciliation Northwestern University Feinberg School of Medicine, Chicago, IL The Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history. At the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class. The Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.IntroductionErrors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care.AimTo design and implement an interactive learning exercise to teach second year medical students about medication reconciliationSettingNorthwestern University Feinberg School of Medicine, Chicago, ILProgram DescriptionThe Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history.Program EvaluationAt the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class.DiscussionThe Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.

Sedentary Behavior as a Risk Factor for Physical Frailty Independent of Moderate Activity: Results From the Osteoarthritis Initiative

OBJECTIVES This prospective longitudinal study investigated the association between baseline objectively measured sedentary time and 2-year onset of physical frailty. METHODS We studied 1333 Osteoarthritis Initiative participants 55 to 83 years of age who were at risk for physical frailty, as assessed via low gait speed (< 0.6 m per second) or inability to perform a single chair stand. Baseline sedentary time was assessed through accelerometer monitoring. Hazard ratios (HRs) for physical frailty onset were estimated with discrete survival methods that controlled for moderate physical activity, sociodemographic characteristics, baseline gait and chair stand functioning, and health factors. RESULTS The incidence of physical frailty in this high-risk group was 20.7 per 1000 person-years. Greater baseline sedentary time (adjusted HR = 1.36 per sedentary hour; 95% confidence interval [CI] = 1.02, 1.79) was significantly related to incident physical frailty after control for time spent in moderate-intensity activities and other covariates. CONCLUSIONS Our prospective data demonstrated a strong relationship between daily sedentary time and development of physical frailty distinct from insufficient moderate activity. Interventions that promote reductions in sedentary behaviors in addition to increases in physical activity may help decrease physical frailty onset.

Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model

Older adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2–6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6–20.9%); 34.6% (95% CI = 30.1–39.3%) received social work consultation, 43.9% (95% CI = 39.1–48.7) received pharmacy consultation, and more than 90% received telephone follow‐up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1–49.7), compared with 60.0% (95% CI = 58.8–61.2) non‐GEDI. ED nurses undergoing a 3‐month training program can develop geriatric‐specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults.

Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs

ABSTRACTWith its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care “receivers” and tailoring home care to meet patient needs, (3) building “recovery plans” into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.

Understanding preventable hospital readmissions: masqueraders, markers, and true causal factors.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.i Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing post-discharge home visits or phoning patients.ii,iii Although beneficial, these strategies are costly and require additional, highly-trained personnel. Consequently, they have been difficult to sustain financially in a fee-for-service environment and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.iv However, all hospital systems will still want to do this in the most efficient manner possible. One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition-specific models such as heart failure. Two studies in this issue work to better identify high-risk patients. Mudge and colleagues prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss. These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.v What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate risk patients, they were able to reduce readmissions significantly.vi In the studies by Mudge and Allaudeen, the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.vii Using a defined set of diagnostic categories to classify readmissions (e.g., ambulatory care sensitive conditions) may misclassify many cases.viii Determining preventable hospitalizations through detailed chart review is expensive and may have limited inter-observer reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field. Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication non-adherence and worsening illness.ix–x Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous post-discharge follow-up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living. Similarly, Allaudeen found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does belonging to Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions. Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure). FIGURE 1 INTERFACES OF TRANSITIONAL CARE With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed the below table as a framework to consider when moving forward in creating and implementing interventions. Table 1 Possible Causal and Modifiable Factors Associated with Readmission To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen, it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all-cause readmission and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (e.g., access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

Older Adults and Unanticipated Hospital Admission within 30 Days of Ambulatory Surgery: An Analysis of 53,667 Ambulatory Surgical Procedures

To evaluate whether age is independently associated with greater rate of unanticipated hospital admission within 30 days of ambulatory surgery.

Developing multilingual prescription instructions for patients with limited English proficiency

This article describes the development of a set of patient-centered prescription medication instructions and their translation into Chinese, Korean, Russian, Spanish, and Vietnamese. Challenges and lessons learned from this process are reported to inform future efforts to develop easy-to-understand, multilingual materials for use in health care settings.

The association between health literacy and indicators of cognitive impairment in a diverse sample of primary care patients

OBJECTIVES To confirm the association of health literacy scores as measured by Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT) with cognitive ability and education. To determine whether this association differs by cognitive task. METHODS Cognitive impairment was measured using the Mini-Cog, which combines a delayed word recall task (WRT) and a clock drawing task (CDT) to yield an overall classification of normal versus cognitively impaired. Participants were recruited from primary care clinics that provide care to underserved patients. RESULTS Participants (n=574) were predominantly non-Hispanic black (67%) with a mean age of 46 years, 50% did not have health insurance, 56% had a high school education or less and 21% screened positive for cognitive impairment. Overall cognitive ability and education were significantly associated with health literacy after adjusting for other variables, including race/ethnicity and physical health. We observed a stronger association between the CDT and health literacy than between the WRT and health literacy. CONCLUSION By confirming hypothesized associations, this study provides additional support of the validity of Health LiTT. PRACTICE IMPLICATIONS Health LiTT is a reliable and valid tool that researchers and clinicians can use to identify individuals who might have difficulty understanding health information.

Cruise ship care: a proposed alternative to assisted living facilities.

Options for elderly patients who can no longer remain independent are limited. Most choices involve assisted living facilities, 24‐hour caregivers, or nursing homes. State and federal assistance for payment for individual care is limited, and seniors usually pay for most costs out of pocket. For those patients who have the means to afford assisted living centers or nursing homes, “cruise ship care” is proposed. Traveling alongside traditional tourists, groups of seniors would live on cruise ships for extended periods of time. Cruise ships are similar to assisted living centers in the amenities provided, costs per month, and many other areas. This article begins with an examination of the needs of seniors in assisted living facilities and then explores the feasibility of cruise ship care in answering those needs. Similarities between cruise ship travel and assisted living care, as well as the monetary costs of both options, are defined. A decision tree with selections for nonindependent care for seniors was created including cruise ship care as an alternative. Using a Markov model over 20 years, a representative cost‐effectiveness analysis was performed that showed that cruises were priced similarly to assisted living centers and were more efficacious. Proposed ways that cruise ship companies could further accommodate the needs of seniors interested in this option are also suggested. Implementation for cruise ship care on the individual basis is also presented. Ultimately, it is wished to introduce a feasible and possibly more desirable option to seniors who can no longer remain independent.