Medication Reconciliation: The Inpatient Hospitalist Perspective

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Medication ReconciliationThe Inpatient
Hospitalist Perspective

• Peter Kaboli, MD, MS
• Iowa City VAMC
• CRIISP (Center for Research in the Implementation
  of Innovative Strategies in Practice)
• University of Iowa, Iowa City, IA
• AHRQ-Washington, D.C.
• September 27, 2007

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JCAHO Definition of Med Reconciliation

• The process of comparing a patient's medication
  orders to all of the medications that the patient
  has been taking.
• This reconciliation is done to avoid medication
  errors such as omissions, duplications, dosing
  errors, or drug interactions.
• It should be done at every transition of care in
  which new medications are ordered or existing
  orders are rewritten.
• Transitions in care include changes in setting,
  service, practitioner or level of care.

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Is Med Reconciliation New?

• Absolutely not.
• JCAHO IOM put it into the spotlight.
• Transitions of care have always been a problem.
• EMRs help, but dont fix problem (VA).
• Fragmented care is the norm, even as far back as
  1872.

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Beethoven's Doctor Accidentally Poisoned Him,
Pathologist Claims
Wednesday, August 29, 2007            
VIENNA, AUSTRIA   DID SOMEONE KILL BEETHOVEN? A
VIENNESE PATHOLOGIST CLAIMS THE COMPOSER'S
PHYSICIAN DID INADVERTENTLY OVERDOSING HIM WITH
LEAD IN A CASE OF A CURE THAT WENT WRONG. OTHER
RESEARCHERS ARE NOT CONVINCED, BUT THERE IS NO
CONTROVERSY ABOUT ONE FACT THE MASTER HAD BEEN A
VERY SICK MAN YEARS BEFORE HIS DEATH IN 1827.
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Are Computerized Med Lists Accurate?

• 493 older veterans on gt5 medications
• Pharmacist brown bag interview
• Mean of 12.4 regularly scheduled meds
• range 5-49
• 8.0 Rx, 2.9 OTC, 1.5 vitamins/herbals
• Kaboli, et al. Assessing the Accuracy of
  Computerized Medication Histories, AJMC.
  200410872-877

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Agreement Definitions

• of Patients with Perfect Agreement between the
  interview and computer
• Omissions meds not on computer profile, but
  being taken by the patient
• Commissions meds on the computer profile, but
  not being taken by the patient

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Findings

• Only 5.3 of patients had perfect agreement
• Omissions
• 1.3 medications per patient
• 25 of all medications omitted
• Commissions
• 1.3 medications per patient
• 12.6 of all medications not being taken
• 23 of Allergies and 64 of ADEs missing
• Impossible to have 100 accuracy all the time

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Top 5 Omissions
34 of omissions were prescription drugs
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Top 5 Commissions
66 of commissions were prescription drugs
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Other findings from our VA outpatient clinical
pharmacist/physician intervention

• Health literacy was associated with medication
  knowledge, but NOT with taking meds correctly or
  ADEs at 6 and 12 months.
• Outpatient pharmacist/physician evaluation can
  improve medication appropriateness, but hard to
  show improved clinical outcomes (ADEs).
• Patients are just as likely to NOT be taking a
  recommended medication as they are to be taken
  extra medications (polypharmacy).

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Implementing Med Reconciliation Kaboli, et al.
Clinical Pharmacists and Inpatient Medical Care
A Systematic Review. Arch Int Med, 166, May 8,
2006

• Clinical Pharmacists
• 11 RCTs of Admission and/or Discharge Med
  Reconciliation
• ? Preventable ADEs
• ? Time to input allergy information
• ? Readmission
• ? Medication knowledge
• ? Medication appropriateness
• ? Compliance
• Why wouldnt a clinical pharmacist help?
• Unfortunately not cheap or available 24-7

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Clinical Pharmacist InterventionSchnipper, et
al. Role of Pharmacist Counseling in Preventing
ADEs After Hospitalization. Arch Int Med, 166,
Mar 13, 2006.

• Discharge counseling with 3-5 day follow-up phone
  call (N178).
• 30 day Preventable ADE rate 11 vs. 1, but not
  all ADES
• Half of patients had discrepancies from pre-admit
  to discharge
• Did not improve medication adherence or
  ED/hospital re-admission

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Inpatient Clinical Pharmacists Roles

• Careful review of med lists, including contacting
  local pharmacy if necessary
• Rounding with team, especially in ICU
• Make recommendations to inpatient team at admit
  and/or discharge
• Ensure patients get medications
• 3-5 day follow-up phone calls
• Are they better than physicians or nurses?

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What works for you?

• Clinical pharmacists
• Hospitalists
• Residents
• Nurses
• Pharmacy students
• Pharmacy techs

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Summary Keys for Success

• Pharmacist and Physician champions
• Electronic or paper format
• Team accountability
• Involvement of patient/family
• Health literacy and social support
• Discharge counseling
• Communication to primary care or SNF and
  outpatient pharmacy
• Follow-up phone call