Transcript Document

Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Executive Management: Examples
of Data and Indicators
Rita Shane, Pharm.D., FASHP, FCSHP
Chief Pharmacy Officer
Cedars-Sinai Medical Center
Assistant Dean, Clinical Pharmacy Services, at the University of
California, San Francisco, School of Pharmacy
Pharmacy Core Functions:
Safe, Effective, Efficient Medication Use
Patient Care and Risk
Reduction
Medication
Management
and Regulatory
Compliance
Resource
Management
Transitions of Care
Drug Expenditures
FY 09
FY 10
Inpatient Drug Expenditures
FY 11
FY 12
Outpatient Drug Expenditures
Drug Expense Variance FY11 Year to Date
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
-
Total Variance
$6,915,000
Drug Cost Summary – 2011 Price Increases
Drug
Price↑
Primary Use
Factor VII
Photodynamic therapy of tumors; Barrett’s
esophagus
33% Cardiac surgery, liver pts, factor deficiency
Alteplase
11% Stroke
Infliximab
21% Rheumatoid Arthritis, Crohn’s, Ulcerative Colitis
Basiliximab
66% Kidney transplant induction
Transplant desensitization/rejection, multiple
53%
myeloma
38% Renal Cell Carcinoma, Metastatic Melanoma
Porfimer sodium
Bortezomib
Aldesleukin
Nesiritide
Filgrastim
624%
78% Acute decompensated heart failure
13% Chemo-induced neutropenia
Heart, lung, kidney transplant
Mycophenolate IV 1560%
immunosuppression
Inpatient Drug Expenditures and
Transplant Volumes
Heart Transplant ↑ 230%, Allogenic BMT ↑ 81% from FY09 to FY12
500
450
400
350
300
250
200
150
100
50
0
$50,000,000
$45,000,000
$40,000,000
$35,000,000
$30,000,000
$25,000,000
$20,000,000
$15,000,000
$10,000,000
$5,000,000
$0
FY09
Total BMT
FY10
Total Solid
FY11
FY12
Inpatient Drug Expenditures
Epoetin (000)
$1,200
$1,000
$998
$800
Pharmacy
Protocol to
limit dose to
10,000 units
$731
$600
Pharmacy Protocol to
start medication on day
#8 and reduce standard
dose to 50 units/Kg
three times/week
$534
$389
$400
$200
$0
FY11
FY12
FY13
FY14
Hepatitis B Immune Globulin
(both inpatient and outpatient)
(000)
$400
$350
$337,000
$300
$250
6.2
Doses/Pt
Based on
UHC data,
reduced #
doses/pt.
$200
$150
$95,000
$100
2.2
Doses/Pt
$50
$0
FY13
FY14
Value Examples
Medication
Opportunity Identified and Pharmacist Intervention
CMV-IVIG
Pt with CMV viremia who had response to change in
antiviral from ganciclovir to foscarnet.
Intervention: Discontinued CMV-IVIG
Pt with methotrexate toxicity.
Intervention: Dose rounding
Pt without lab confirmation of acute intermittent
porphyria.
Intervention: Hold therapy pending lab results. Labs
returned negative.
Pt with HIV, hepatitis C, ITP; received 3 doses of IVIG as
outpatient. Admitted with bruising and headache, platelet
count of 9000/µL. MD ordered 2 more doses, however
platelets were increasing.
Intervention: Discontinue IVIG order
Pt with VP shunt malfunction repair. Receives idursulfase
weekly as an outpatient.
Intervention: Contacted patient’s medical geneticist to
administer dose post-discharge.
Glucarpidase
Panhemitin
IVIG
Idursulfase
Cost
Savings
$75,000
$24,805
$24,984
$15,074
$10,500
Pharmacist’s Role in Evaluating Medications
Patient
Characteristics
Medications
Age
Prior to Admit
Medication List
-Pediatrics
As well as new orders
Drug
Indication
Dose
-Geriatrics
Gender
Height/Weight
Allergies
Route
Kidney/Liver
Function
Frequency
Current labs
Dosage form
Previous
Duration
admissions
Current Medication List
Drug-drug interactions
Drug-disease interactions
Drug-food interactions
Duplicate therapy
Contraindications
Medications needed but
not prescribed
Monitoring requirements
Special
Considerations
High risk patients or
therapies such as:
Chemotherapy
Blood thinners
Antibiotics
Drugs with narrow
therapeutic index
ICU
Prescribing Errors Intercepted
September ‘11 – June ’13
3500
CPOE Implementation
3000
May ‘12-June’13 Average/Month:
2431
(116/1,000 pt days)
49% Increase
Sept - Feb Average/Month:
1633
2500
(76.6/1,000 pt days)
2000
1500
Prescribing Errors Intercepted/1,000 Orders
1000
IOM: 2.87
CSMC: 10.4 (pre-CPOE)
500
0
Prescribing Errors Intercepted/1,000 Orders
IOM: 2.87
CSMC: 15.6 (post-CPOE)
Methodology
Life Threatening
Low Capacity for Harm
Serious/Significant
Prescribing Errors Intercepted by Pharmacists
ORDER RECEIVED
ACTION TAKEN
OUTCOME AVOIDED
SEVERITY
RATING
HYDROmorphone PCA
dose 2.4mg q8 minutes.
Current dose= 0.2mg
Recommended 0.3mg
Narcotic overdose, leading
to respiratory failure and
possible death.
Life
Threatening
MD note included plan to
start antibiotics for R/O
meningitis. No antibiotics
ordered.
Recommended to start
antibiotics at
meningitis dosing.
Potential undertreatment
of meningitis
Life
Threatening
Methotrexate 10mg daily
Recommended
and patient on weekly dose continuing weekly
for RA.
dose.
Potential antineoplastic
overdose and possible
death.
Life
Threatening
Fentanyl patch ordered
Recommended
upon admission. Per SNF,
discontinuing.
patient was not on fentanyl
patch
Potential narcotic
overdose, leading to
respiratory failure and
possible death.
Life
Threatening
Medication Reconciliation Across
Transitions of Care
Changing clinical conditions require continually evaluating the
medication lists at each transition
Resolution of Drug-Related Problems (DRPs) in
High-Risk Hospitalized Patients
7.4 Drug-Related Problems Identified Per Patient
Based on Medication History
21% of inpatient orders were changed due to DRPs identified
40% of resolved DRPs were
classified as life-threatening or
serious/significant
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PTA Drug-Related Problems (DRPs)
Medication on
PTA List
DRP Type
Capacity for
Harm
PTA List: Med not listed on PTA med list
Finding: Pt reports taking flecainide 50
mg BID
Omission of
Medication
Life-Threatening
PTA List: Med not listed on PTA med list
Finding: Pt reports taking Plavix 75 mg
daily
Omission of
Medication
Serious/Significant
PTA List: Prednisone 20 mg daily
Finding: Pt reports it was d/ced by MD 6
months ago
Extraneous
Medication
Serious/Significant
PTA List: Furosemide 40 mg BID
Finding: Pt reports taking 60 mg BID
(CHF pt)
Wrong Dose
Serious/Significant
Mycophenolate
PTA List: Mycophenolate 360 mg BID
Finding: Pt reports taking 720 mg BID
Wrong Dose
Serious/Significant
Midodrine
PTA List: Midodrine 100 mg TID
Finding: Pt reports taking 30 mg TID
Wrong Dose
Life-Threatening
Flecainide
Plavix
Prednisone
Furosemide
Drug-Related Problem
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Hospitalist-Pharmacist
Transitions of Care Collaboration
Evaluation of Medication List Accuracy,
Adherence, and Literacy
Validate
Medication
History
∙∙∙∙
Identify HighRisk Patients
Assess
Adherence
and Literacy
∙∙∙∙
Educate
Patient
Notify MD
Regarding
DRPs
Identified
along with
Recommendations
PostDischarge
Follow-Up
within 72 Hrs:
-Med Rec
-Adherence &
Literacy
Reinforcement
-Education
Additional
Calls up to 30
Days Based
on Risk
Assessment
Criteria to Determine Need for Post-Discharge
Follow-Up Medication Adherence and Literacy
Literacy
High literacy
Intermediate
literacy
Low literacy
No post-DC f/u
needed
Educate pt.
No post-DC f/u
needed
Post-DC f/u needed
Adherence
High adherence
Intermediate
adherence
Educate pt.
No post-DC f/u
needed
Educate pt. No postDC f/u needed?
vs.
Post-DC f/u needed?
Post-DC f/u needed
Use clinical judgment
Low adherence
Post-DC f/u needed
Post-DC f/u needed
Post-DC f/u needed
Post-Discharge Metrics
Post-DC f/u Call
Completed
Readmissions
Prevented*
# of Patients
207
16%
Average DRPs/Pt
2.9
Post-Discharge Findings
• 58% of pts had discrepancies between their discharge medication
list and what they were taking
• 33% of pts were taking more medications than were prescribed
(excludes vitamins, herbals, etc)
*Validated by MD Review
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Examples of Post-Discharge Follow-up
Reason for Admission
Drug-Related Problems Identified PostDischarge and Pharmacist Intervention
54 y/o w/ HTN & DVT admitted
for sickle cell crisis & left
parietal stroke
Issue discovered: Pt had self-d/ced warfarin,
amlodipine, and carvedilol
92 y/o w/ altered mental status
found to have a UTI & toxic
digoxin level, also w/
arrhythmias & low blood
pressure
Issue discovered: Pt had continued taking
medications that had been stopped, including
digoxin, metoprolol, and zolpidem
Adverse Outcome
Prevented
Avoided potential
occurrence of
thromboembolism,
Intervention: Contacted MD and confirmed that readmission, and/or
warfarin and anti-hypertensives should be redeath
started. Pharmacist contacted pt and
instructed to take all meds as was prescribed at
d/c; do not self-start, self-d/c, self-dose, or
adjust any med w/o speaking to MD first;
educated pt on the importance of compliance
to avoid complications
Intervention: Instructed patient to d/c these
medications
Avoided potential drug
toxicity, lifethreatening
arrhythmias, recurrence
of confusion, and/or
death
21
Enhanced Care Program for
Skilled Nursing Facilities (SNF)
SNF Post-Discharge Follow-Up
Identification of
Patients Discharged
to SNF
Medication
Reconciliation:
Discharge
Medication List vs
SNF MAR
Pharmacist Clinical
Evaluation
NP consults
Drug-Related Problems
Communicated to NP
for Follow Up
ECP Pharmacy Data Summary
Data Period: 1/22/13 -6/30/14
# of Patients
# of Serious/
Significant DrugRelated Problems
(DRPs) Identified
% of Patients
Requiring
Intervention
2013
1st Quarter
2014
2nd Quarter
2014
Total
708
241
223
1172
560
275
245
41%
(293/708)
56%
(134/241)
54%
(120/223)
1080
(14 were lifethreatening)
47%
(547/1172)
Examples of ECP Pharmacist Post-Discharge Follow-Up
Reason for Hospital
Admission
Drug-Related Problems Identified Post-Discharge and Adverse Outcome
Pharmacist Intervention
Prevented
98 y/o M from home w/
hip fracture and multiple
medical issues.
Issue discovered: Pt was a new start on fentanyl 25mcg in
house. Dose was increased to 50mcg 1 hour prior to
discharge.
Intervention: Called SNF to d/c fentanyl 50mcg order.
Informed SNF RN that the patch was already placed on
the pt. SNF RN was unaware.
79 y/o M w/ ESRD - HD on
TuThSat - with catheterrelated S. aureus
bacteremia.
Issue discovered: Per ID, vancomycin after dialysis to be
continued after d/c and was on discharge medication list.
There was an order at the SNF for vancomycin but not at
the dialysis center. Pt dialyzed on Sat after d/c but did
not receive vancomycin.
Avoided severe
respiratory
depression or death
due to potential
supra-therapeutic
dose of fentanyl.
Avoided progression
of bacteremia and
catheter re-infection
d/t missed doses of
antibiotics.
Intervention: Ensured vancomycin administration
occurred.
89 y/o F w/multiple
medical problems
including pulmonary
hypertension.
Issue discovered: Sildenafil 25mg PO TID was listed on
discharge medication list but not continued at the SNF.
Intervention: Pharmacist recommended re-initiation of
medication for the pt, who also required an oxygen mask
at the SNF.
Avoided worsening of
respiratory status and
potential progression
of condition and
organ damage.
25
Readmissions Dashboard
Interdisciplinary Team Results
SNF
Baseline
Jan 2013
Feb 2013
Mar 2013
20%
17%
21%
12%
21%
22%
18%
15%
30-day All-Cause
Readmissions
Rate
6SE Heart Failure
30-day All-Cause
Readmissions
Rate
26
QUESTIONS