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Acceptance of Recommendations by Inpatient Pharmacy Case Managers: Unintended Consequences of Hospitalist and Specialist Care

Authors

  • Sammuel V. Anderegg Pharm.D.,

    1. Department of Pharmacy, University of Kansas Medical Center, Kansas City, Kansas
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  • David E. DeMik Pharm.D.,

    1. Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
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  • Barry L. Carter Pharm.D., FCCP, FAHA, FASH,

    Corresponding author
    1. Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
    2. Department of Family Medicine, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa
    3. Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, The Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
    • Department of Pharmacy, University of Kansas Medical Center, Kansas City, Kansas
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  • Jeffrey D. Dawson Sc.D.,

    1. Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
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  • Karen Farris Ph.D.,

    1. Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
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  • Constance Shelsky M.S.N.,

    1. Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
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  • Peter Kaboli M.D.

    1. Department of Internal Medicine, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa
    2. Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, The Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
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  • The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

  • This study was supported in part by a National Heart, Lung, and Blood Institute grant (1RO1 HL082711). Drs. Carter and Kaboli were also supported by the Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) (Department of Veterans Affairs, Health Services Research and Development grant REA 09-220).

For questions or comments, contact Barry L. Carter, Pharm.D., FCCP, FAHA, FASH, Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, IA 52242; e-mail: barry.carter@uiowa.edu.

Abstract

Study Objective

To determine whether recommendations made by pharmacists and accepted by hospital physicians resulted in fewer postdischarge readmissions and urgent care visits compared with recommendations that were not implemented.

Design

Prospective substudy of pharmacist recommendations.

Setting

Tertiary care academic medical center and private community-based physician practices and community pharmacies.

Patients

A total of 192 patients aged 18 years or older who were a subsample of a randomized, prospective study, who were admitted with a previous diagnosis of one of nine cardiovascular or pulmonary diseases or diabetes mellitus or had received oral anticoagulation therapy and who were discharged to community-based care provided by private physicians and community pharmacists.

Measurements and Main Results

Pharmacy case managers performed evaluations for patients and made recommendations to inpatient physicians. Patients received drug therapy counseling, a drug therapy list, and a wallet card at discharge. Data were collected from patients and private physicians for 90 days after discharge. Pharmacy case managers made 546 recommendations to inpatient physicians for 187 patients (97%). Overall, 260 (48%) of the 546 recommendations were accepted. The acceptance rate was lower for patients who had an urgent care visit compared with the other patients (33.6% vs 52.2%, p=0.033). High acceptance rates were noted for updating the record after medication reconciliation (36 patients [78%]) and when there was an actual allergy (2 [100%] of 2 patients) or medication error (2 [100%] of 2 patients). Physicians were less likely to accept recommendations related to drug indications (p<0.001), drug efficacy (p=0.041), and therapeutic drug and disease state monitoring (p=0.011). Recommendations made for patients with a relatively greater number of drugs were also less likely to be accepted (p=0.003).

Conclusion

Recommendations to reconcile medications or address actual drug allergies or medication errors were frequently accepted. However, only 48% of all recommendations were accepted by inpatient physicians, and there was no impact on health care use 90 days after discharge. This study suggests that recommendations by pharmacy case managers were underused, and the low acceptance rate may have reduced the potential to avoid readmissions.

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