Stephanie K. Mueller

Hospital-Based Medication Reconciliation Practices: A Systematic Review

BACKGROUND Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk. OBJECTIVES To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices. DATA SOURCES MEDLINE (1966 through February 2012) and a manual search of article bibliographies. STUDY SELECTION Twenty-six controlled studies. DATA EXTRACTION Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results. DATA SYNTHESIS Studies were grouped by type of medication reconciliation intervention-pharmacist related, information technology (IT), or other-and were assigned quality ratings using US Preventive Services Task Force criteria. RESULTS Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population. CONCLUSIONS Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

Novel Branching Membrane Translocational Peptide as Gene Delivery Vector

A fragment of HIV-tat protein, RKKRRQRRR, has been shown to have membrane penetration and nuclear localization properties, which are critical attributes of gene therapy agents. In this study, we designed a series of arborizing tat peptides, containing 1-8 tat moieties, and evaluated them as transfection enhancers in a variety of cell lines. We found that all compounds complexed with plasmid DNA, but only the molecule containing 8 tat-peptide chains shows significant transfection capabilities. Using rhodamine labeled plasmid and eight tat-peptide complex, we were also able to demonstrate intracellular delivery of the complex by fluorescence microscopy.

Impact of Hospital Teaching Intensity on Quality of Care and Patient Outcomes

Background: Proposed changes to financing of teaching hospitals and new quality-based performance incentives may differentially impact the financial health of teaching and safety-net institutions. Few data have examined the potential impact of these financial changes on teaching institutions. Objectives: To determine the association of hospital teaching intensity with processes and outcomes of care for the most common inpatient diagnoses in the United States. Research Design: Cross-sectional analysis of the 2008 Hospital Quality Alliance and 2007 American Hospital Association databases, adjusted for hospital characteristics. Subjects: A total of 2418 hospitals distributed across the country with available data on teaching intensity (resident-to-bed ratio), quality-of-care process measures, and risk-adjusted readmission and mortality rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Measures: Hospital-level quality-of-care process indicators and 30-day risk-adjusted readmission and mortality rates for AMI, CHF, and pneumonia. Results: Multivariable analysis demonstrates that all hospitals perform uniformly well on quality-of-care process measures for AMI, CHF, and pneumonia. However, when compared with nonteaching hospitals, increasing hospital teaching intensity is significantly associated with improved risk-adjusted mortality for AMI and CHF, but higher risk-adjusted readmission rates for all 3 conditions. Among high teaching intensity hospitals, those with larger Medicaid populations (safety-net institutions) had particularly high readmission rates for AMI and CHF. Conclusions: In this nationally representative evaluation, we found significant variation in performance on risk-adjusted mortality and readmission rates, and differences in readmission rates based on safety-net status. Our findings suggest that high teaching intensity and safety-net institutions may be disproportionately affected by upcoming changes in hospital payment models.

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

BackgroundUnresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.MethodsSix U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.DiscussionAt baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.Trial registrationClinicaltrials.gov identifier NCT01337063

Impact of Resident Workload and Handoff Training on Patient Outcomes

Impact of Resident Workload and Handoff Training on Patient Outcomes Stephanie K. Mueller, MD, Stephanie A. Call, MD, MSPH, Furman S. McDonald, MD, MPH, Andrew J. Halvorsen, MS, Jeffrey L. Schnipper, MD, MPH, LeRoi S. Hicks, MD, MPH Brigham and Women’s-Faulkner Hospital Academic Hospitalist Service, Boston, Mass; Division of General Internal edicine, Brigham and Women’s Hospital, Boston, Mass; Division of General Internal Medicine, Virginia Commonwealth University, Richmond; Divisions of General and Hospital Internal Medicine and Office of Educational Innovations, Internal Medicine Residency, Mayo Clinic, Rochester, Minn; Division of Hospital Medicine, UMass Memorial Healthcare, Worcester; Department of Quantitative Sciences, University of Massachusetts Medical School, Worcester.

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services

BACKGROUND Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs). OBJECTIVE To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs. DESIGN Pre-post cohort analysis. SETTING A 700-bed academic medical center. PATIENTS General medicine patients on any of the participating nursing units before and after implementation of regionalized care. INTERVENTION Regionalizing 3 general medical physician teams to 3 corresponding nursing units. MEASUREMENTS Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs. RESULTS Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other providers name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69). CONCLUSIONS We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016;11:620-627.

Rates, predictors and variability of interhospital transfers: A national evaluation

IMPORTANCE: Interhospital transfer (IHT) remains a largely unstudied process of care. OBJECTIVE: To determine the nationwide frequency of, patient and hospital‐level predictors of, and hospital variability in IHT. DESIGN: Cross‐sectional study. SETTING: Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. PATIENTS: Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013. EXPOSURES: Patient and hospital characteristics of transferred and nontransferred patients. MEASUREMENTS: Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates. RESULTS: Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74‐85 years (odds ratio [OR], 2.38 compared with 65‐74 years; 95% confidence intervals [CI], 2.33‐2.43); nonblack race (OR, 1.17; 95% CI, 1.13‐1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36‐1.37); lower diagnosis‐related group‐weight (OR, 2.02; 95% CI, 1.95‐2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79‐1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27‐1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30‐0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01). CONCLUSIONS: In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital‐level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT.

Physician Perspectives on Interhospital Transfers.

Objective The transfer of patients between acute care hospitals (interhospital transfer [IHT]) is a common but nonstandardized process leading to variable quality and safety. The goal of this study was to survey accepting physicians regarding problems encountered in the transfer process. Methods A cross-sectional survey of residents and inpatient attendings from internal medicine, neurology, and surgery services at a large tertiary care referral hospital was undertaken to identify problematic aspects of the IHT process as perceived by accepting frontline providers. The frequency that specific scenarios were encountered in caring for transferred patients and whether these processes impacted patient safety were determined using 5- and 3-point Likert scales, respectively. The frequency of responses to each question were measured using proportions. Results Approximately 51% of the 284 physicians surveyed responded. Pertinent findings included the following: physician subject surveys found that transferred patients sometimes, frequently, or always arrived without requiring specialized care in 56% of responses, arrived with unrealistic expectations of care in 77.2% of responses, arrived more than 24 hours after accepted for transfer in 80.1% of responses, and arrived without necessary transfer records in 86.9% of responses. Most respondents felt that lack of availability of transfer records and the time of day of arrival frequently posed a risk to transferred patients (57.2% and 53.1%, respectively). Response variation was noted between resident and attending physician respondents. Conclusions Expectations of care, delays and timing of transfer, and information exchange at time of transfer were identified as all too common problems in IHT, which creates a risk for patient safety. These areas are important targets for investigation and the development of interventions to improve patient safety.

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study

Background Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging. Methods We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression. Results Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR. Conclusions Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study. Trial registration number NCT01337063.

Inter-hospital transfer and patient outcomes: a retrospective cohort study

Background Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. Objective To evaluate the association between IHT and healthcare utilisation and clinical outcomes. Design Retrospective cohort. Setting CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. Participants Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories. Main outcome measures Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients. Results The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). Conclusions In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients’ disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.