Medication reconciliation in specialty patients poses more challenge

How effective is medication reconciliation in your institution?

That's a question that many pharmacists may not be able to answer. But answers are beginning to emerge at two institutions, Parkview Hospital in Fort Wayne, Ind., and Children's Healthcare of Atlanta (CHOA), Ga. Both institutions are studying medication reconciliation in specialty populations.

In Atlanta, CHOA is taking an interventional approach. Children's transplant services pharmacy specialist Rochelle Schmidt is running the numbers on a pilot clinic designed to smooth the transition from pediatric care to adult care for kidney transplant patients.

"What we know is that adolescents have the worst five-year graft survival rate, similar to patients over the age of 65," Schmidt said. "As they move from pediatric providers to adult providers, there seems to be a gap in care." Results from the first six months of the clinic should be released later this year, Schmidt said.

Both pharmacists noted that medication reconciliation is trickier when it comes to patients with less common medical problems and medications. Thorne noted two potential problems for patients who are admitted with a rare disease or who are taking unfamiliar medications. One is a communication gap. The person in charge of medication reconciliation may not recognize the disease or the drug. The patient may not recognize the unusual nature of the disease or the drugs needed to treat it.

"If you don't recognize a drug the patient is on at admission, or don't recognize the disease and know to ask about specific drugs, it's easy to forget to check whether it needs to be continued on an inpatient basis," Thorne said.

The other problem is structural. Drugs that target rare diseases such as MS are frequently not on inpatient formularies. Writing nonformulary orders, especially for expensive agents such as any of the interferons, is a barrier to care. "Products that are on formulary are much more likely to be continued," Thorne said. "It's not that we want to discontinue therapy the patient is on, it's that we don't have the agent available."

The problems are different for adolescent transplant patients. There can be a physical transition of care from pediatric to adult providers, as from CHOA across the street to Emory University Hospital, Schmidt said. But other transitions are just as important.

Many children lose insurance coverage when they turn 18 and drop off their parents' policies, she noted. That creates financial barriers to continuing care and increases the risk of graft loss. The social and emotional changes of adolescence also translate into increased risk for graft loss.

Adolescents tend to be less adherent to drug regimens, lab work, and clinic visits. They may feel peer pressure against prescription drug regimens as well as perceived side effects such as acne and weight gain. "The transition from pediatric care to the adult setting has been studied in diabetes and cystic fibrosis, but nobody knows what really happens with transplant patients," Schmidt said. "It's no different from the transition from inpatient to outpatient care; it just takes a few years longer."