Can a transitional R.Ph. ensure continuity of care?

Can a hospital reduce patients' risks and cut costs by hiring a pharmacist to focus on potential errors during transitions from ambulatory to inpatient care and back again? Two-thirds of postdischarge errors are medication mistakes, according to a study in Annals of Internal Medicine last year. In light of that and similar findings, Providence Health System is running a randomized trial at its Portland Medical Center to examine the worth of a transitional pharmacist.

The study, which is being done with Medicare managed care beneficiaries, assigns a pharmacist to reconcile medication information at admission, consult with physicians on inpatient medications, provide patient education, transfer information from acute to primacy care, and follow up with the patient after discharge. The researchers will compare outcomes for those patients who get the transitional pharmacist's care with outcomes for similar patients who get only the usual care.

One outcome measure will actually look at whether the patient is readmitted to any facility or emergency room, for any reason, within 30 days of discharge. That's a pretty intense judgment for any medication management program, admitted K. Bruce Bayley, Ph.D., a director of research for Providence. But, he said, preventing those extra costs for readmissions would be key to making the business case for such a program. And it is only with a strong business rationale that the strategy will spread to other facilities.

The study's secondary measures will include risk reduction related to poor information, improved patient satisfaction, improved treatment guidelines compliance, and overall costs of care. The study comes in the wake of research with Providence and other health systems that found computerization helped but did not solve all the information-exchange problems across the care continuum. Done in conjunction with Research Triangle Institute (RTI) International research organization of North Carolina, both studies are funded by the federal Agency for Healthcare Research & Quality and were highlighted at the agency's September patient safety conference, held in Arlington, Va.

Bayley admitted that much of what Providence's dedicated pharmacist does is what R.Ph.s have done in hospitals for years. The transitional pharmacist, whose name has been blinded for the study, recommends medications to physicians when she sees a diagnosis without an appropriate medication. She calls attention to existing allergies and potential interactions. She works with appropriate doses. And she makes the cost substitutions that the hospital likes to do.

She does those tasks because the study team feels that to do the transition work well, the pharmacist must track what goes on during the stay: why medications are held and why they are started. And in that process she has an added opportunity for consultancy with the hospitalist, Bayley said.

But with her specific transition focus, the pharmacist also gathers all the information on drugs from admitted patients and from electronic and other sources. She may need to archive drugs the patient is no longer using. When the patient leaves the hospital, she communicates a care plan, with an up-to-date list of medications, to the primary care provider. Then she follows up with the patient three days after discharge.

Bayley indicated that, in light of all the pharmacist's various interventions, it may be through some of the study's secondary measures that the researchers can relate her work to the transitional points: was there better adherence to guidelines, was there risk reduction due to better information, and was there a complete discharge list of medications rather than a physician's scribble of "resume as at home?"

Bayley said the researchers also considered the fact that by adding another person, they're increasing complexity and another point at which things could go wrong. That's one reason, he said, that in the extensive run-up to the study, the transitional R.Ph. was carefully linked to the nurses and the hospitalist.