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American Society of Health-System Pharmacists Summer 2013

The Pharmacological Intervention in Late Life (PILL) Service: Enhancing Medication Safety After Hospital Discharge

The PILL Service is a care transition program designed to support older adults with cognitive impairment and help them maintain independent function. This program, which has resulted in improved clinical and economic outcomes, is characterized by a team effort focusing on proactive medication review and patient-centered medication reconciliation.
Age-related cognitive decline becomes more prevalent with advancing decades. Five percent of people in the seventh decade of life suffer from age-related cognitive decline. That number climbs to almost a quarter of patients by the eighth decade, and 35% of patients by the ninth decade of life. As the population ages, and a large population of elderly patients enter later decades of life, the number of cases of cognitive decline is projected to double by 2050.

Because individuals with cognitive deficits are at risk for nonadherence and medication safety issues, the Pharmacological Intervention in Late Life (PILL) Service was developed at the VA Boston Healthcare System.

In a presentation focused on the PILL service, James L. Rudolph, MD, Tia Kostas, MD, and Allison M. Paquin, PharmD, of the VA Boston Healthcare System presented methods for enhancing medication safety after hospital discharge using a program that helps elderly patients adhere to prescribed therapy. The presenters identified some of the factors related to cognitive impairment that increase the risk of problems with transitions between hospital and home care, as well as some methods associated with a pharmacist-led intervention that audience members might transfer to other practice settings.

Cognition includes much more than just memory; also included are attention, executive function, language skill, and psychomotor function, all of which can impact basic daily functions such as bathing, using a toilet, eating, grooming, and use of medications. This was a key point in the presentation, highlighting the need for additional care and attention to older patients with complex drug regimens.

Tia Kostas, MD, examined issues related to medication management after discharge. Starting with a patient case, Kostas highlighted the importance of recognizing adherence challenges before the challenges become medical problems. Recognizing problems caused by medications that adversely affect cognition and helping caregivers overcome challenges associated with adherence may reduce some of the difficulties in managing medications after discharge.

The risks associated with age-related decline include a decline in kidney function, liver function, and albumin levels in plasma. Other changes to the body, including an increase in body fat percentage, a decrease in muscle mass, and greater permeability of the blood-brain barrier, contribute to changes in the disposition of medications. Even without the challenge of adherence, the effect of medications may change with age.

Kostas mentioned that polypharmacy affects many elderly patients. Elderly patients may have multiple comorbid conditions, leading to visits to several different physicians and specialists. These visits may lead to prescriptions for multiple medications. In 3 “golden rules,” Kostas summarized the challenges of deciding whether to prescribe a new medication for a geriatric patient. First, Kostas emphasized that the administration of any medication involves a trade-off of risks and benefits. Second, when a patient presents with a new symptom, that symptom should be considered a side effect of medication until proved otherwise. Third, limiting regimen complexity is desirable. Regimen complexity varies with the number of medications. Patient difficulties with swallowing tablets and special instructions for dosage and administration may limit the effectiveness of treatment if patients fail to follow instructions properly.

Remedies for the difficulties in managing medication use among the elderly include strategies that promote medication reconciliation. Because transitions of care often lead to mismatches in treatment regimens (poor communication has been linked with 50% of all hospital-related medication errors and 20% of all adverse drug events), pharmacists can serve as medication therapy reviewers. In this role, pharmacists can identify potential medication discrepancies and evaluate medication appropriateness, safety, and efficacy for a given individual. Kostas presented evidence supporting the use of medication reconciliation through a summary of over 26 studies that demonstrated a reduction in medication discrepancies, adverse events, and healthcare use with appropriate reconciliation.

Allison M. Paquin, PharmD, then provided an overview of the PILL service, which joins other care transition initiatives such as Project RED (Re-Engineered Discharge), Better Outcomes by Optimizing Safe Transitions (BOOST), the Guided Care Model, Hospital to Home (H2H), and others. Paquin described how in 2006 the quality improvement program started with veterans in a Veterans Administration hospital located in Boston. This large academic medical center includes 3 campuses and encompasses 4 community clinics. Experience from the program revealed that medication errors often begin with prior hospital stays and may be reduced by collaboration among physicians and the pharmacy staff. A redesign in 2010 helped patients manage care from the home setting and helped prevent readmissions to the hospital.

In the PILL clinic experience, patients at high risk for cognitive dysfunction, including patients with congestive heart failure, received calls for medication review and follow-up after discharge to home care. The phone calls were conducted by a pharmacist who reviewed the medication list and proactively discussed the patient’s experience with medications. After receiving care through PILL clinic visits at home, the investigators evaluated how well patients followed the regimen.

Home visits involved a face-to-face interaction with a team of a pharmacist and a physician to provide a review of the patient’s supply of medicine at home versus the prescribed medication regimen. To develop an assessment and plan, the clinical team used a list of contraindications, made an assessment of drugs used for nonapproved indications, and considered the Beers criteria. The team identified medications that were ineffective, duplications of therapy, and use of anticholinergic drugs for possible replacement or discontinuation of treatment. The team also provided renewals of prescriptions, and reviewed the dose, frequency, and directions for use of each medication in the regimen.

Paquin emphasized that pharmacist time spent in telephone consults led to improved outcomes and reduced medication discrepancies. PILL home calls led to a significantly reduced risk of death within 60 days of hospitalization (4% vs 12%; P =.01). An average of 2.2 medications were discontinued with PILL visits.

The annual cost savings to the healthcare system with PILL home visits included an estimated $222,332 saved in salary, and $311,911 saved in avoided costs of care. Compared with the costs of implementing the program, the net cost savings reached almost $90,000 per year. These findings show that the PILL clinic is not only economically feasible, but that it led to cost savings. In addition to the reduced risk of death after hospitalization, there is the potential for benefits to patients and benefits to the financial position of healthcare systems.

 
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