DJ Clark, Clara Mikhaeil, and Karen White
Health & Services The purpose of this project is to improve clinical outcomes in patients transitioning from inpatient to outpatient care by optimizing the process that primary care pharmacists use to perform comprehensive medication reviews.
• Transitions of care from the inpatient to outpatient setting is an area of great opportunity for improving patient outcomes. • One prospective cohort study found that 20% of patients discharged from the hospital to home experienced an adverse event within 3 weeks of discharge. Of these adverse events, 66% were medication related.1 • Another observational study found that 14% of patients had medication discrepancies at discharge, and that readmission rates were significantly higher in these cases.2,3 • Currently, patients receiving care at our medical group are reviewed by a clinical pharmacist following hospital discharge if the reason for hospitalization is, or medications were changed for treatment of: • Congestive Heart failure • Osteoporosis/fragility fracture • Diabetes on insulin • Anticoagulation • Patient confusion with medications or difficulty taking/obtaining them • Anecdotally our group has reported many resolved medication issues and avoided medication adverse events since this system was implemented, although these interventions have not been formally quantified. • There is not currently a standardized process clinical pharmacists use to review medications upon hospital discharge.
• Results from a retrospective chart review and a clinical pharmacist satisfaction survey were utilized to standardize and optimize our transitions of care review process. Inclusion Criteria: • All transitions of care consults completed by clinical pharmacists Exclusion Criteria: • None Primary Endpoint: • The number of interventions/recommendations provided by clinical pharmacists to primary care providers per transitions of care consult Secondary Endpoints: • The time taken by clinical pharmacists to complete transitions of care consults • Proportion of clinical pharmacist recommendations that are implemented • 30-day re-hospitalization rates.
• Results of the initial review (August and September 2021) and survey were utilized to make improvements to transitions of care review process. • Interventions implemented thus far include: • Development of EPIC smart phrases to standardize pharmacist review process. • Meeting with the Clinical Support Coordinator team to review strategies to optimize referrals to clinical pharmacy. • A second retrospective chart review was completed 1 month after the updated EPIC smart phrases were implemented (April 2021) to determine the impact on recommended interventions and time spent per pharmacist consult.
These results suggest that a standardized review process conducted via EPIC smart phrases increases interventions provided via clinical pharmacy review during transitions of care. Several important confounding factors such as seasonal/staffing variation and the unblinded nature of this study must be considered when interpreting study results.
ult. Additional Data Collection: • One more month of data will be added to the evidence summarized here to allow 2 months of pre and post data. • 30-day readmission rates post-intervention will be evaluated when 30 days have passed from the data collection period. This will allow for determination of increased interventions or readmission rates. Continued Process Improvement Possibilities: • Adjusting criteria for PharmD review • Leverage clinical pharmacy team to continue modifying and improving recently created EPIC smart phrases • Continued collaboration with Clinical Support Coordinator team to ensure appropriate referrals for pharmacist review.
Erica Dominguez, Ben Rosati, and Trevor Laursen
To evaluate the efficacy of provider education on adherence to guideline directed therapy in outpatient chronic obstructive pulmonary disease (COPD) management in South Oregon PMG clinics.
• COPD is the third most common cause of death in the US • The CDC reports costs attributable to COPD in 2010 were $32.1 billion projected to have increased to $49 billion by 2020 • Direct healthcare costs include detection, prevention, physician office visits, hospitalizations, home care, and medications hospitalizations accounting for about 45 50% of these direct costs • Clinical burden of uncontrolled COPD has been shown to impact quality of life, health status, daily activities, physical activity, sleep, comorbid anxiety and depression, and disease progression • Data indicates a direct relationship between severity of COPD and overall cost of care. Studies have also shown that adherence to guideline directed therapy for COPD decreases trends in cough and shortness of breath, exacerbations, emergency department visits, and hospitalizations • PMG Clinical Pharmacists have shown positive outcomes in collaborative management of chronic disease states such as diabetes, hypertension, and cardiovascular risk reduction, making pharmacists well positioned to provide education on guideline adherence
Methodology • Primary Outcome • Change in provider adherence to guideline directed therapy in COPD management after provider education as determined by pre and post surveys • Secondary Outcome • Change in percentage of patients where a CAT/ mMRC score was reported before and after survey intervention • Baseline reporting of pulmonary function tests ( • Change in percent appropriateness of inhaler therapy between February 2021 and March 2021 pre and post provider education as determined by guideline recommended therapy
Interventions: • Comparison of pre and post survey responses following provider education sessions for the primary objective • Chart review of January 2021 and March 2021 for secondary objectives Inclusion Criteria: • Providers: • PMG primary care providers in Southern Oregon clinics • Providers who choose to complete pre and post surveys • Patients: • •≥18 years with confirmed diagnosis of COPD Exclusion Criteria: • Providers: • Pulmonologists • Patients: • Asthma/COPD and asthma diagnoses • Elevated IgE levels (>0.35 kIU /L) if obtained
Primary Outcome: • There was statistically significant improvement seen after provider education for classification and initial treatment of COPD management as determined by pre and post surveys. • Other findings from provider surveys include: • Cost of inhalers was reported to be a barrier in COPD management 75 90% of the time. • Other overarching barriers identified include patient adherence, smoking cessation, formulary changes, and time and availability with the patient. Limitations: • Reduced post survey responses submitted after each provider education session. Pre survey and post survey answers were unable to be matched for analysis. Secondary Outcome: • All CAT/mMRC score reporting were conducted by pulmonology specialty and no change in reporting was seen in primary care clinics. • There was a change in baseline reporting of PFTs between January 2021 and March 2021 in primary care clinics. Two baseline PFTs were obtained in February 2021 post provider education. Limitations: • Chart review only captured patients who presented to clinic for COPD in the months of January 2021 and March 2021. Potential to have missed other patients with baseline PFT and/or mMRC/CAT score reporting. • Percent appropriateness of inhaler therapy depended on CAT/mMRC score reporting.
• Pharmacist led provider education positively impacted COPD management as determined by pre and post surveys • Barriers identified for optimized COPD therapy fall under the scope for management by clinical pharmacy • Further workflows to improve obtaining baseline PFTs and symptom reporting in primary care settings is needed
Adam Olesen, Kelsie Fiss, and Judy Wong
• Depression affects almost 10 of Americans over 18 years old 1 • Per the Centers for Disease and Control Prevention, the 2020 COVID 19 pandemic has led to an increase in adults struggling with mental health 1 • There is currently a shortage of mental health prescribers, with over half of all counties within the United States not having a single psychiatrist 2 • Southern Oregon also has a shortage of mental health prescribers, resulting in longer wait times for care • Evidence demonstrates that depression managed by pharmacists in the primary care setting led to increased follow up frequency, increased medication adherence, improved PHQ 9 scores, and patient satisfaction 3
The purpose of this study is to quantify, characterize, assess, and identify the management trends of clinical pharmacy specialists ( that are managing depression of patients at Providence Medical Group (PMG)
• A retrospective chart review was performed on patients who were managed by a clinical pharmacist for depression from January 2019 through December 2020 This information was gathered via the intervention tracking tool within the electronic medical record ( The endpoints below were gathered for evaluation of management trends by the pharmacists • A presentation was provided to the PMG clinics in Southern Oregon, reviewing the depression collaborative practice agreement ( Patients referred after this presentation were followed up to four months and included in data analysis • In order to meet a power of 80 the calculated sample size is 32
• Non pharmacologic measures were assessed at every patient visit, including addressing presence of support system, meeting with BHI, and exercise • Addressing adherence led to therapy changes based on patient specific needs such as switching antidepressant therapy to a longer acting agent due to lack of adherence • There were only three instances where regimens were augmented with an additional agent This potentially indicates pharmacists were attempting to identify the best primary medication before augmenting with an additional agent • At first visit, dose increase occurred for over 25 of the patients, demonstrating potential benefit of dose increases prior to referrals • The mean decrease in PHQ 9 scores shows a clinically significant improvement in depression severity for this subset of patients
• Based on the total number of depression referrals received, the depression CPA is currently underutilized • When a CPS is managing depression, there is consistent follow up to assess medication tolerance and response and more frequent follow up is available if needed • There was only one incidence where a medication was increased to a dose that only had anecdotal evidence, demonstrating a strong adherence to evidence based practice by the clinical pharmacists • These evidence based and meaningful interventions resulted in clinically significant improvements in depression severity
Assessing the effect of an electronic health record order entry guideline on duration of outpatientantimicrobial therapy prescribed for uncomplicated urinary tract infections
Kasey Rubin, Chelsea Houshour, and Christine Doran
• Fifty percent of antibiotics prescribed in the outpatient setting are unnecessary1. •Outside of unnecessary prescribing, the antibiotics chosen can be incorrect with an inappropriate duration of therapy1. •It has been estimated that resistant infections affect nearly 3 million Americans annually and are the cause of 35,000 deaths each year with added costs up to $33.2 billion dollars1. •The Centers for Disease Control (CDC) recommends that outpatient antimicrobial stewardship programs identify “high priority conditions.” •Examples of high priority conditions include acute respiratory infections, urinary tract infections (UTI)and skin and soft tissue infections (SSTI).2 •Antibiotics are not associated with a diagnosis code and no specific guidance provided on duration in EHR •Providence St. Joseph Health (PSJH) created an outpatient antimicrobial stewardship guideline to assist with prescribing practices of antimicrobials in the outpatient setting. This guideline will be integrated into the electronic health record (EHR) at order entry. •The PSJH guidelines are based on guideline directed therapy by Infectious Diseases Society of America (IDSA) and American Academy of Family Physicians (AAFP) among others.
• Study design •Retrospective/Prospective •Pre-intervention: November 2020 –January 2021 •Post-intervention: To be determined •Primary Outcome •Duration of therapy for uncomplicated UTIs measured in days •Secondary Outcome •Percentage of appropriate prescriptions based on guideline directed therapy •Inclusion criteria •>18 years old •Diagnosis code of N.39 within the designated time frame at PMG primary care clinics and urgent/immediate care clinics •All encounter types: office visit, telephone, virtual, MyChart, orders only •Exclusion criteria •Antibiotics prescribed within 30 days at the time of index date •Patients who were/are pregnant at the time antibiotic prescription •Patients with complicated UTIs, chronic UTIs or pyelonephritis
• Antimicrobials were over-prescribed on average by the following amountof days for uncomplicated UTIs: • Beta-lactams: 0.8 days • Nitrofurantoin: 1.4 days •Trimethoprim/Sulfamethoxazole (TMP/SMX): 2 days •Fluroquinolones (FQN): 2.3 days •Based on a sample size of 100 patients: •Fifty-two percent of patients had allergies that affected treatment decisions which may lead to antibiotic challenge workflow/protocols •The prevalence of guideline directed antibiotic choice was 85% based on a sample size of 100 patients •The duration of therapy was inappropriate 70% of the time based on a sample size of 100 patients •Based on results from selective sample size, guideline tool could provide a decrease in duration of therapy especially for TMP/SMX and FQNs
• The guideline has not been uploaded due to system delays with pandemic •The sample selected for evaluating secondary outcomes was not randomized. Instead, patients were selected if they were prescribed an antibiotic that is not first-line or for a longer duration than generally recommended •Selective sample size to identify trends in prescribing patterns which lead to more TMP/SMX and FQN prescriptions •Ex: FQNs prescribed for 7 days •Ex: TMP/SMX prescribed for 5-7 days •A future limitation of this study is providers choosing to not utilize the guideline resulting in no change in prescribing patterns
• Collect data once EHR guideline is implemented to determine post-intervention prescribing patterns •An opportunity exists for clinic pharmacists to educate providers on UTI prescribing practices •Analyze results utilizing ANOVA statistical testing •Associate prescribed antibiotics with appropriate and accurate diagnosis codes