Abstract
OBJECTIVE
To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital.
METHODS
This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service.
RESULTS
A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761).
CONCLUSIONS
Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.
Keywords: medication; medication counseling, pediatrics, pharmacist
Background
Pharmacist-led discharge counseling programs have improved the quality of patient care by reducing medication errors and improving medication adherence for adult patients.1–4 In 2014, Anderegg and colleagues1 reported outcomes from implementation of a bundle of pharmacy interventions that included pharmacist-provided discharge education for high-risk adult internal medicine patients. While the overall study group did not experience a reduction in 30-day readmissions, the high-risk subgroup who received pharmacist discharge counseling experienced a significant reduction, 17.8% to 12.3% (p = 0.0423).1 Similarly, Jack et al3 published the results of a discharge improvement bundle that included a pharmacist phone call after discharge to provide medication teaching, which decreased hospital utilization after discharge. A study by Bell et al,4 reviewing pharmacist counseling for patients with acute coronary syndrome, saw an improvement in unplanned health care utilization for patients with low health literacy.
Medication counseling is particularly important for pediatric patients because children are more likely to experience medication errors and are more vulnerable to serious harm when errors occur than adults.5–7 Factors that make pediatric patients more susceptible to medication errors include the need for caregivers to learn appropriate administration technique, potential low health literacy of caregivers, and the lack of commercially available dosage forms.5,8–10 A study by Schillie et al6 estimated that 5691 pediatric patients visited the emergency room in a single year because of medication errors, with the most common error being administration of the incorrect dose by a caregiver. Similarly, Rodriguez et al11 showed that 13% of pediatric hospital readmissions within 3 days were related to medication-related problems. Bailey et al12 found that 28% of subjects misunderstood dosage instructions for oral liquid medications prescribed for children, and the common causes for misunderstanding included problems with dosage measurement and frequency of administration. Multiple medication counseling strategies have demonstrated the ability to decrease errors in the pediatric outpatient setting: use of pictograms, milliliter-exclusive labeling system, provision of oral syringes, use of the teach-back method, device teaching, and written action plans.13–17
Few studies have evaluated the effect of pharmacist discharge counseling in pediatric patients. Mallory et al18 found that implementing a discharge medication delivery program with pharmacist counseling increased accuracy of caregiver medication understanding and satisfaction during a postdischarge phone call. Nguyen et al19 reported the outcomes from a pharmacist discharge counseling program targeting pediatric patients with complex medical conditions, which showed an estimated cost savings associated with pharmacist intervention at the time of discharge counseling. The intervention reported in the current study aimed to improve hospital discharge medication counseling and decrease readmissions due to medication errors after hospital discharge. This study measures the effect of the pharmacist-led service on caregiver satisfaction with discharge education, caregiver-reported medication compliance, and 90-day medication-related readmission rates in pediatric patients.
Methods
This was a prospective observational cohort study comparing caregiver satisfaction, reported compliance, and reported understanding of medications for patients discharged before and after implementation of a pharmacist-led medication discharge counseling service. Caregivers were included if the patient was younger than 12 years, discharged from the pediatric intensive care unit or the general pediatrics inpatient unit, and met 1 or more of the following criteria at discharge: taking high-risk medications, polypharmacy defined as 4 or more medications, or required medication device teaching. High-risk medications were defined as anticoagulants, cardiovascular agents, antiepileptics, or immunomodulators. Device teaching included but was not limited to injectable medications, epinephrine auto-injection, inhalers, intranasal midazolam, or rectal diazepam. Caregivers were excluded if the patient was discharged from the neonatal intensive care unit, was discharged to a long-term care facility or an outside hospital, or if the caregiver's primary language was not English. For the purpose of consistency within this study, caregivers of patients older than 12 years were excluded because adolescent patients demonstrate varying levels of independence with medication use at home. Each unique patient had a caregiver included in the study only one time regardless of the number of readmissions during the study period. Patients in the pre-implementation group were not eligible for the post-implementation group.
Education was provided to the medical teams about the new service, which targeted high-risk patients. This service was activated by providers through an electronic consult order in the medical record. The electronic consult was visible to all members of the medical team. The consult order contained information regarding the reason for the consult, expected discharge time for the patient, and contact information for the provider. Pharmacists provided evidence-based teaching including provision of medication schedules, provision of oral syringes, medication device teaching, and use of the teach-back method. There was no discharge counseling standard prior to the implementation of the pharmacist service. Historically, patients received discharge medication education from a physician, nurse, pharmacist, or combination without a standard approach. Demographic and readmission data were obtained from each patient's electronic medical record.
In the pre-implementation cohort, caregivers were identified at the time of pharmacist admission medication reconciliation. Caregivers were identified on the basis of the patient's incoming medications and were asked to consent to participate in the postdischarge survey. It was accepted that patients in the pre-implementation phase would receive discharge medication counseling from a pharmacist, nurse, or physician during usual care. After implementation of the service, consent was obtained at the time of pharmacist discharge medication counseling.
Survey Tool. A 7-question survey was developed by the study investigators, and data were collected with REDCap online software (Vanderbilt University, Nashville, TN). Caregivers in the pre- and post-implementation groups were asked the same 7 question survey (Table 1). The survey asked caregivers to rate their satisfaction of the discharge process, their understanding of the medication regimen, medication device technique, and patient medication compliance, using a 5-point Likert scale. The surveys were conducted via telephone within 2 weeks of the patients' discharge date. Caregivers were given 3 attempts to respond to the survey via telephone. If caregivers did not respond after the first phone call, a text message was sent to them from the study email, using their phone number @ vtext.com, a free service; and the primary investigators made 2 more phone call attempts within 14 days of the date of discharge.
Table 1.
Description of Telephone Survey
| Question | Result |
|---|---|
| 1. How satisfied are you with the discharge experience at Rush University Children’s Hospital? |
|
| 2. How satisfied are you with how your questions and concerns regarding your child’s medications were addressed by a health care provider during discharge medication teaching? |
|
| 3. How much do you agree with the following statement: The written information provided to me about my child’s medications was easy to understand. |
|
| 4. How much do you agree with the following statement: I understand what each of the medications prescribed for my child is being used for. |
|
| 5. How much do you agree with the following statement: I am confident in my ability to accurately measure medications, using an oral syringe.* |
|
| 6. How much do you agree with the following statement: I am confident in my ability to use medication devices prescribed to my child; for example, Epipen, Diastat, or inhaler.* |
|
| 7. How many medication doses has your child missed in the past week? |
|
* For patients who answered “not applicable,” these were not included in the total score.
Data Collection and Analysis. The primary outcome of this study was to evaluate the effect of a pharmacist-led discharge medication counseling program on telephone survey score, expressed as a percentage of total points, on the 7-question telephone survey. Each of the telephone survey questions was graded on a 5-point Likert scale (Table 1). Questions answered as not applicable were not included in total score. Secondary outcomes were to evaluate the effect of the service on occurrence of readmissions within 90 days of hospitalization due to a medication-related issue; and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response regarding discharge medications (Question 25), which was asked during the telephone survey. This question reads, “When I left the hospital, I clearly understood the purpose for taking each of my medications” with the answers: I was not given any medication when I left the hospital (0 points), strongly disagree (1 point), disagree (2 points), agree (3 points), strongly agree (4 points).
Categorical variables were analyzed with a Fisher exact test. Continuous variables were described as means or medians as appropriate and analyzed with a Student t test or Mann-Whitney U test. A sample size of at least 30 participants per group was targeted to ensure normality. Assuming a 25% dropout rate, 40 participants were enrolled per group.
Results
Between January and March 2020, a total of 40 pediatric patient caregivers consented to the pre-implementation phase; 8 caregivers were excluded because they did not respond after 3 telephone attempts, resulting in a final sample size of 32. Recruitment for the post-implementation phase started in May 2020. Owing to staffing restrictions and high patient acuity as a result of the COVID-19 pandemic, recruitment of patients in the post-implementation cohort took significantly longer, ending in January 2021. In the 9-months after implementation of the service, pharmacists performed 171 medication consults; 70 (41%) patients were older than 12 years and thus their caregivers did not meet inclusion criteria. A total of 40 caregivers consented to the post-implementation phase; 8 caregivers were excluded because they did not respond after 3 attempts of contact to complete the survey, resulting in a final sample size of 32.
Demographics, except for age and reason for inclusion, were similar between groups (Table 2). The average age in the pre-implementation group was 7 years compared with 3 years in the post-implementation group (p = 0.004). Most patients were White (37.5% and 40.6%), and of non-Hispanic ethnicity (62.5% and 68.7%), in the pre- and post-implementation groups, respectively. Patients were taking an average of 7.7 medications in the pre-implementation group compared with 5.5 in the post-implementation group (p = 0.105). The most common reason for inclusion was presence of a high-risk medication (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. Twenty-three (72%) in the pre- and 13 (40%) in the post-implementation group were included for more than 1 reason (p = 0.0105).
Table 2.
Description of Patient Demographics
| Pre-implementation (N = 32) | Post-implementation (N = 32) | p value | |
|---|---|---|---|
| Age, median (IQR), yr | 7 (3–10) | 3 (1.25–10) | 0.004 |
| Race, n (%) | 0.8 | ||
| White | 12 (37.5) | 13 (40.6) | |
| African American | 9 (28) | 11 (34.4) | |
| Other | 11 (34.5) | 8 (25) | |
| Ethnicity (Hispanic), n (%) | 12 (37.5) | 10 (31.3) | 0.559 |
| Male, n (%) | 16 (50) | 20 (62.5) | 0.313 |
| Length of stay, median (IQR), days | 2 (1–3.75) | 2 (1–4.75) | 0.862 |
| Medications at discharge, median (IQR), No. | 7.7 (4–11) | 5.5 (4–7) | 0.105 |
| Reason for inclusion, n (%)* | |||
| High-risk medications | 27 (84.4) | 18 (56.3) | 0.014 |
| Polypharmacy | 23 (71.9) | 7 (21.9) | <0.001 |
| Device teaching | 6 (18.8) | 20 (62.5) | <0.001 |
* Patients may have been included for ≥2 reasons.
The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038) (Table 3). No individual questions had significantly different scores. Eight patients (25%) in the pre-implementation group and 32 (100%) in the post-implementation group were counseled by a pharmacist. A post hoc analysis was performed, eliminating the 8 patients who received pharmacist counseling from the pre-implementation group. After eliminating those patients who received pharmacist counseling, the average survey score was 31 ± 3.7 in the pre-implementation group compared with 32.5 ± 2.26 in the post-implementation group (p = 0.06).
Table 3.
Survey Scores
| Question | Score, mean ± SD | p value | |
|---|---|---|---|
|
|
|
||
| Pre-implementation (N = 32) | Post-implementation (N = 32) | ||
| 1 | 4.47 ± 0.77 | 4.54 ± 0.72 | 0.586 |
| 2 | 4.63 ± 0.68 | 4.63 ± 0.50 | 0.814 |
| 3 | 4.59 ± 0.6 | 4.71 ± 0.46 | 0.135 |
| 4 | 4.84 ± 0.36 | 4.77 ± 0.43 | 0.49 |
| 5 | 4.82 ± 0.48 | 4.82 ± 0.39 | 1 |
| 6 | 4.71 ± 0.65 | 4.62 ± 0.62 | 0.607 |
| 7 | 4.94 ± 0.35 | 4.91 ± 0.30 | 0.703 |
| Average survey score (%)* | 30.94 ± 3.50 | 32.5 ± 2.26 | 0.038 |
* Score is percentage of total points, considering all survey questions not marked “not applicable” by the respondent.
The score on HCAHPS Question 25 was 3.81 ± 0.40 in the pre-implementation group and 3.78 ± 0.42 in the post-implementation group (p = 0.761). Thirteen (41%) patients in the pre-implementation group were readmitted within 90 days: 0 (0%) readmissions were due to medication-related reasons, 3 (9%) were scheduled readmissions, and 10 (31%) were unrelated to the first admission. Nine (28%) patients in the post-implementation group were readmitted within 90 days: 0 (0%) readmissions were due to medication-related reasons, 2 (6%) were scheduled readmissions, and 7 (22%) were unrelated to the first admission.
Discussion
This study demonstrated an improvement in the average composite score on a postdischarge telephone survey after implementation of a pharmacist discharge counseling service. The magnitude of the change in the score between groups was small, increasing from 30.94 in the pre-implementation group to 32.5 in the post-implementation group. When caregivers who received pharmacist counseling in the pre-implementation group were excluded, the overall survey score was similar: 30.94 vs 31 points; however, the comparison to the post-implementation group lost significance owing to the reduction in overall sample size. This suggests that pharmacist counseling in the pre-intervention group as part of regular care did not skew the results. It is important to note that the composite score in the pre-implementation group was high at baseline, 30.94 of 35 possible points (88.4%), leaving minimal room to demonstrate improvement with implementation of the service.
Important limitations exist in the study design. First and foremost, this survey measured caregiver-reported satisfaction and understanding as opposed to objective medication knowledge or demonstrated accuracy of administration technique. Caregivers may have been unwilling to admit not understanding instructions or missing doses, or may have overestimated their understanding. Studies that have demonstrated the value of evidence-based counseling strategies have used objective endpoints, such as improvement in observed accuracy of caregiver dosing.13–17 A satisfaction-based survey would not capture potentially meaningful differences in accuracy of medication use in the outpatient setting. Furthermore, caregiver's responses to the questions may have been influenced by overall experience during the hospital stay instead of targeted to their experience with the medication discharge process only. Their responses may have been biased by knowing the researcher calling on the phone to check in, thereby increasing their likelihood of a positive response. Non-English speaking caregivers were excluded from this study owing to time limitations in ability to translate the consent form. These patients and their caregivers represent an important section of the population at risk for potential barriers to education comprehension. Lastly, readmission information from other hospitals was not available, so some readmissions may not be captured in our data.
The prospective nature of the study meant all participants needed to sign informed consent to allow the study team to call them after discharge. This created an inherent difference between groups because they were identified based on different criteria. Patients newly starting high-risk medications or medication devices during the hospital stay would not have been identified for inclusion in the pre-implementation group. Patients in the pre-implementation group may have had less medication changes at the time of discharge than patients in the post-implementation group who were targeted for pharmacist counseling by providers. The pre- and post-implementation groups differed in the most common reason for inclusion. The most common reason for inclusion in the pre-implementation group was the presence of a high-risk medication on their incoming medication list compared with the need for device teaching in the post-implementation group. Patients in the pre-implementation group were more likely to have multiple reasons for inclusion, which may have made them higher risk than those in the post-implementation group. Furthermore, the need to obtain consent from patients changed usual care in the pre-implementation group by increasing contact with the pharmacist, which may have positively affected caregiver experience. Because each patient's caregiver was only included in the study once, patients with complex medical conditions who had polypharmacy issues and frequent admissions are likely more represented in the pre-implementation group.
Caregiver enrollment in the pre-implementation group occurred before the effect of the COVID-19 pandemic, whereas enrollment in the post-implementation group occurred during the pandemic. Enrollment during the pandemic was challenging because of periods where patient contact was limited and care was sometimes provided virtually. Because caregivers had to sign a hard copy of the consent form, some caregivers who received counseling were unable to be enrolled. Additionally, there were no readmissions due to medication-related issues, therefore we were unable to show any difference between the groups. This is not surprising because previous studies that reported an effect of discharge counseling programs on readmissions had included significantly larger sample sizes.1,3,4
The design of this study and intervention differed from previous pediatric counseling studies. The program implemented by Mallory et al18 differed in the design of the intervention: their study incorporated delivery of discharge medications to bedside, and caregivers were called after discharge as part of routine care. The study used the teach-back method to assess caregivers' understanding of medications objectively during follow-up, which is a strength compared with the present study. Interventions paired with medication delivery require patients to fill medication at the hospital pharmacy, thus missing patients who choose to fill medication at home pharmacies. Because the current study included all caregivers regardless of pharmacy preference, assessment of this intervention is more robust. The intervention by Nguyen et al19 was more similar to the present intervention in that caregivers were identified during the discharge process by other care providers. These authors tracked pharmacist interventions to predict cost savings instead of contacting patients directly to measure caregivers' understanding or satisfaction.19 The primary outcome of the present study is of interest because no previous study has looked at the effect of counseling on caregiver satisfaction. Furthermore, the intervention presented in the current study offered a significant change to pharmacist workflow by implementing a standardized process. This allowed the medical team to more readily communicate with pharmacy staff and pharmacists to track their workload. This increased communication may mean more patients are identified for the service and fewer patients are discharged before pharmacist counseling has been completed. Any effectt of the change in workflow on pharmacists' ability to capture patients who would benefit from pharmacy services is not captured in the present study design.
Future studies should measure the effect of pharmacist counseling in pediatric patients by using objective measures of caregiver understanding. Objective assessments of adherence such as fill history would also be useful. Because health literacy affects counseling outcomes, a formal assessment of health literacy prior to pharmacist counseling may affect the efficacy of the counseling. Effective methods to measure the effect of counseling on non-English speakers should also be investigated, because these patients are likely at high risk of poor educational outcomes.
Conclusion
Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and self-reported medication understanding as shown by a post-discharge telephone survey. The magnitude of the difference observed in the study was small. Further studies are needed that include objective outcomes and larger patient populations to assess the effect on medication-related readmission rates.
Acknowledgments
Preliminary results were presented at PPA Annual Meeting virtually on April 23, 2021.
ABBREVIATIONS
- HCAHPS
Hospital Consumer Assessment of Healthcare Providers and Systems
Footnotes
Disclosures. The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Ethical Approval and Informed Consent. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national guidelines on human experimentation and have been approved by the Institutional Review Board at Rush University Medical Center, Chicago, IL. Informed consent was not required.
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