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The American Journal of Accountable Care June 2018
Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model
Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
Lessons Learned in Implementing Behavioral Screening and Intervention
Richard L. Brown, MD, MPH
The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care
Taylor Justice, MBA, President of Unite Us
Case Study: Encouraging Patients to Schedule Annual Physicals
Nicholas Ma
Effects of an Integrated Medication Therapy Management Program in a Pioneer ACO
William R. Doucette, PhD; Yiran Zhang, PhD, BSPharm; Jane F. Pendergast, PhD; and John Witt, BS
Are Medical Offices Ready for Value-Based Reimbursement? Staff Perceptions of a Workplace Climate for Value and Efficiency
Rodney K. McCurdy, PhD, and William E. Encinosa, PhD
Utilizing Community Resources, New Payment Models, Technology to Deliver Accountable Care
Laura Joszt, MA
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Cost-Effectiveness of Pharmacist Postdischarge Follow-Up to Prevent Medication-Related Admissions
Brennan Spiegel, MD, MSHS; Rita Shane, PharmD; Katherine Palmer, PharmD; and Duong Donna Luong, PharmD

Cost-Effectiveness of Pharmacist Postdischarge Follow-Up to Prevent Medication-Related Admissions

Brennan Spiegel, MD, MSHS; Rita Shane, PharmD; Katherine Palmer, PharmD; and Duong Donna Luong, PharmD
A multivariable sensitivity analysis conducted on a pharmacy follow-up program of high-risk patients demonstrated cost savings to hospitals in 98.3% of head-to-head trials across 1000 hypothetical hospitals.

Objectives: To measure the cost-effectiveness and direct budget impact of a pharmacist follow-up program in high-risk patients versus usual care.

Study Design: Cost-effectiveness analysis of a quality improvement initiative comparing a postdischarge pharmacist program versus usual care.

Methods: Pharmacists at Cedars-Sinai Medical Center, a large, community-­based, academic medical center, contacted patients within 72 hours of discharge. Patient and prescriber drug-related problems (DRPs) were identified and resolved. Eligible patients met 1 or more of the following criteria: (1) receiving more than 10 medications, (2) having a diagnosis of pneumonia or congestive heart failure, and (3) receiving anticoagulants. The study measured annualized incremental direct hospital cost per 30-day readmission prevented.

Results: Of 185 patients identified, 90% were contacted within 72 hours of discharge; of this group, 86.4% had 1 or more DRPs. The 30-day intention-to-treat readmission rates for the program versus usual care were 16.2% and 21.6%, respectively, and the average costs per patient were $3433 and $4015, respectively (difference, $582; Monte Carlo 95% CI, $528-$635). In multivariable sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, the intervention remained cost-saving in 98.3% of head-to-head trials.

Conclusions: The previously documented efficacy of pharmacist postdischarge care remains effective in a real-world application. The program is cost-saving to hospitals operating in a population health model or capitated model.

The American Journal of Accountable Care. 2018;6(2):e1-e8
There are more than 3 million hospital readmissions per year in the United States, costing over $41 billion in direct healthcare expenditures.1 One in 5 acute hospitalizations results from complications of treatment itself, of which half are medication related; it is possible that many of these hospitalizations can be prevented.2 The rising incidence of medication-related hospitalizations is a consequence of polypharmacy among patients with multiple comorbidities, poor health literacy, and decreased medication adherence.3-5 Further, patients with chronic conditions often receive uncoordinated care from disconnected physicians, leading to complex regimens and difficulty in ensuring that medication lists are accurate during vulnerable care transitions.

Up to 86% of patients have errors in their medication list upon admission, with an average of 3.3 errors per patient overall6,7 and 7.4 errors per high-risk patient.8 Nearly 40% of these drug-related problems (DRPs) have the potential to cause harm.6 Half of DRPs occur from unintentional prescribing errors because of incomplete or inaccurate information about what is prescribed.9,10 Furthermore, medication errors occur in up to 75% of patients during hospitalization, with many of these mistakes propagated after discharge11; between 14% and 80% of patients have at least 1 medication list discrepancy upon leaving the hospital. Postdischarge adverse drug events occur in up to 19% of patients, and one-third of these events are preventable.12-16 In short, DRPs are pervasive and expensive before, during, and after acute hospitalization.
Findings of previous efficacy trials reveal that when pharmacists perform intensive medication reconciliation and patient education during and after discharge, there are fewer adverse drug events, emergency department visits, and readmissions, particularly in patients at high risk for DRPs.14,17-20 However, despite clear evidence that integrated pharmacist postdischarge programs are highly efficacious, it is unclear whether they are cost-effective when subjected to everyday care within a population health model. Given the large expense of hospital readmissions, we hypothesized that cost savings from a pharmacist-led postdischarge program would offset the costs of establishing and maintaining the program.

In this study, we measured the real-world budget impact of instituting a pharmacist follow-up program. We then performed sensitivity analysis to create a return on investment (ROI) lookup table for hospitals of varying size and staffing costs that are considering implementation of a similar pharmacist postdischarge follow-up program.


Study Overview

We conducted this study at Cedars-Sinai Medical Center (CSMC), a large, urban, academic hospital in Los Angeles, California. We instituted a quality improvement project in which postgraduate residency-trained pharmacists conducted telephone postdischarge follow-up for high-risk patients. We compared 30-day readmission rates between consecutive patients managed in the pilot program and a control population that did not receive the pharmacist intervention. We then calculated the incremental cost per readmission avoided and the budget impact of the pharmacist program on direct hospital outlays. Finally, we performed sensitivity analyses to estimate the program’s health economic performance in other healthcare systems, recognizing that our local results may not generalize to other settings. In the sections below, we describe the health economic analyses, competing management strategies, cost accounting, clinical probability estimates, and sensitivity analyses. 

Health Economic Model

We used decision analysis software (TreeAge Pro, version 2014; TreeAge Software, Inc; Williamstown, Massachusetts) to compare directly measured costs of 2 patient cohorts hospitalized at CSMC. The Figure displays the truncated decision model. We populated the model with data obtained from a quality improvement project at CSMC comparing a standardized pharmacist postdischarge follow-up program versus usual care, described below. We then followed the cohort over the course of a 30-day time horizon and compared 30-day readmissions between strategies. 

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