Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center

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1 Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center at the Maritime Institute

2 Reducing Hospital Readmissions Related to Medication Use Stacy Carson, PharmD ISMP Safe Medication Management Fellow Institute for Safe Medication Practices November 3 rd, 2011

3 Objectives Define the length of time utilized for hospital readmission statistics according to CMS Describe medications commonly associated with readmissions

4 Readmissions Definition: Any admission to the same hospital occurring within 7, 15, or 30 days after discharge 1 Centers for Medicare & Medicaid Services (CMS) utilizes 30 days for readmission statistics Sometimes considered a marker for poor quality care, wasted revenue, and inefficient use of resources 2 Mortality and readmission rates are public knowledge

5 Why Readmissions Matter Statistics from the 2007 Medicare Payment Advisory Commission (MedPAC) report: 17.6% of all admissions results in readmissions within 30 days of discharge Two-thirds of all readmissions were considered avoidable Medicare is spending an additional $15 billion a year on readmissions (about $7,200 per readmission)

6 Why Readmissions Matter Statistics from the 2007 MedPAC report: ~12.5% of Medicare heart failure admissions were followed by a readmission within 15 days Accounting for more than 90,000 admissions at a cost of $590 million All-cause 30-day readmission rates per thousand patients discharged with heart failure increased by 11% between 1992 and

7 Readmissions MedPAC found no improvement in potentially preventable 30-day readmission rates from In 2010, CMS reported the 30-day readmission rates at: 2010 CMS 30-day Readmission Rates Pneumonia 18% Acute myocardial infarction 20% Heart failure 24% MedPAC March 2011 Report.

8 Maryland Readmission Statistics Comparison of Maryland hospitals (n=45) 30-day readmission rates to the US National Rate* Better than National Rate % (n) No different than National Rate % (n) Worse than National Rate % (n) Too small to determine rate % (n) Average Rate for Maryland Hospitals % Pneumonia 0% (0) 84% (38) 16% (7) 0% (0) 20% [ ] Acute myocardial infarction 0% (0) 82% (37) 4% (2) 13% (6) 21% Heart failure 2% (1) 76% (34) 22% (10) 0% (0) 26% [ ] *Data from: Data last updated Aug 20, Accessed Oct 6, 2011.

9 Focus on Performance For Medicare inpatients, CMS will be implementing reimbursement withholding related to: Readmissions (FFY 2013) Value-based purchasing (FFY 2015) Core measures Patient satisfaction Hospital-acquired conditions (FFY 2015) *FFY = Federal Fiscal Year Patient Protection and Affordable Care Act,

10 Medications Medications commonly associated with adverse drug reactions (ADRs) after discharge Antibiotics (38%) Corticosteroids (16%) Cardiovascular drugs (14%) Analgesics (including opiates) (10%) Anticoagulants (8%) Forster AJ. Ann Intern Med. 2003;138:

11 Medications Medications commonly associated with readmissions Analgesics/Opioids Anticancer drugs Oral anticoagulants Antiplatelets Digoxin Diuretics/Antihypertensives Glucocorticoids Ruiz B et al. Eur J Clin Pharmacol. 2008;64: Teymoorian SS et al. J Am Geriatr Soc. 2011;59:948-9

12 Reasons Related to Medication Readmissions Incomplete medication reconciliation Admission into hospital Transfers during admission Discharge home Poor discharge planning/patient education Low patient/caregiver health literacy Medication non-compliance Patient s inability to pay for their prescriptions post discharge No follow-up with physician post-discharge

13 ISMP Self-Assessment: Comparison of 2010 and 2011 Maryland Data 2011 # Self-Assessment Items Key Element IX Year Patients are provided with up-to-date, written information at an 8 th grade reading level (or lower) in their primary language about drugs that are prescribed at discharge, or a trained translator or language line is utilized to provide important oral and/or written information about drugs prescribed at discharge. Criteria have been established (e.g., selected high-alert drugs, high-risk patient populations) to trigger an automatic consultation with a pharmacist for patient education. None (A+B) Partial (C+D) 2010 n/a Full (E) % 31% 60% % 33% 20% % 31% 14% 203 Pharmacists or prescribers design drug administration schedules that consider the patient s lifestyle and minimize the number of times per day that medications must be taken for patients at high-risk for nonadherence with medications prescribed at discharge. % Change +7% -2% -6% % 44% 39% % 33% 31% % Change +19% -11% -8%

14 ISMP Self-Assessment: Comparison of 2010 and 2011 Maryland Data 2011 # Self-Assessment Items Key Element IX Year Patients are informed about the potential for error with drugs that have been known to be problematic (e.g., methotrexate prescribed weekly for arthritis, frequently changing warfarin doses) and are provided with strategies to help prevent such an occurrence after discharge. Patients are instructed on when and whom to call for concerns or questions about their drug therapy after discharge. None (A+B) Partial (C+D) Full (E) % 44% 51% % 45% 43% % Change +7% +1% -8% % 10% 90% % 15% 81% % Change +4% +5% -9%

15 Transitional Care Model - Study Prospective, matched-control study of 239 patients Conducted at 6 Philadelphia hospitals Targeted: elders hospitalized with heart failure 3 advanced practice nurses (APNs) 3-month APN-directed discharge planning and home follow-up protocol Provided safety net designed to prevent medication and other medical errors After 52 weeks, the intervention group had: Longer time interval to first readmission or death (P =.026) Fewer readmissions (104 vs 162; P =.047) Lower mean total costs ($7,636 vs $12,481; P =.002) Naylor MD et al. J Am Geriatr Soc. 2004;52:

16 Pharmacist Interventions Study Randomized controlled trial of 178 patients Conducted in a large teaching hospital Targeted: patients admitted to general medicine floor who could be contacted via phone 30 days after discharge 3 pharmacists Medication reconciliation and counseling prior to discharge Follow-up phone calls 3-5 days post-discharge to discuss problems/adverse drug events (ADEs), changes in regimen, adherence, schedule follow-up 30 days post-discharge, the intervention group had: Preventable ADEs: 1% vs 11%; P =.01 Preventable, med related ED visits/readmissions 1% vs 8%; P =.03 Schnipper JL et al. Arch Intern Med. 2006;166:

17 Programs/Models/Resources Accountable Care Organizations Helps doctors, hospitals, and other providers better coordinate care for Medicare patients Transitional Care Model Program that provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults Medical Homes or Patient-Centered Medical Homes (PCMH) Program that coordinates primary care for all ages Established through National Committee for Quality Assurance (NCQA)

18 Programs/Models/Resources Partnership for Patients Brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly. Health Care Leader Action Guide to Reduce Avoidable Readmissions Manuals/2010/Jan/Health-Care-Leader-Action-Guide.aspx Guide that addresses avoidable readmissions Suggests strategies that hospitals could pursue at different stages of the care continuum to reduce avoidable readmissions.

19 Up Next: Projects Focusing on Medication-Related Readmissions Thank you for your time!