The Daniel K. Inouye College of Pharmacy Scripts

Abstract

The purpose of this project was to utilize pharmacists and pharmacy students to perform comprehensive medication reconciliation by telephone prior to a patient's office visit with their primary care physician, to address any medication issues. The project's aims were to decrease polypharmacy, improve the accuracy of medication reconciliation, and to allow more time for the physician to meet with the patient. Patients were called prior to appointment and a thorough medication reconciliation was conducted including verification of current prescription medications, over-the-counter medications, and herbal supplements. A total of 21 patients were enrolled in the study, and in 36% of patients, the number of medications decreased after the intervention. However, overall, the average number of medications used by patients increased from an average of 8.9 to 9.5 medications (P = .39). All patients included in the study had at least one medication change in the electronic medical record system. Most of the changes were to add medications that were not on the medication list or to remove medications on the list that the patient was no longer taking. This study demonstrated improved accuracy with pharmacist/pharmacy student involvement in the medication reconciliation process.

Introduction

Approximately 41% of patients have at least one medication discrepancy in their medical record.¹ One of the Joint Commission's National Patient Safety Goals for both ambulatory care and hospital settings is providing medication reconciliation.² Pharmacist-guided medication reconciliation averts medication discrepancies and prevents adverse drug reactions.^1,3 Although medication reconciliation is important, it can be time consuming, especially with patients with several comorbid conditions and multiple medications.

The Physician Center at Mililani, a John A. Burns School of Medicine family practice medical residency staffed clinic, services those with low or fixed income. Physicians typically have 15- to 30-minute appointments with patients and within this window, the medical assistant takes the patient's vitals and performs a medication reconciliation prior to the physician performing the physical exam and office visit. This short encounter may not be the most opportune time to perform a comprehensive medication reconciliation.

The purpose of this project was to utilize pharmacists and pharmacy students to perform comprehensive medication reconciliation by telephone prior to a patient's office visit with their primary care physician. During these encounters, pharmacists/pharmacy students would address any medication refill requests and any medication issues prior to the appointment. The project's aims were to decrease polypharmacy, improve the accuracy of medication reconciliation, and to allow more time for the physician to meet with the patient. The project was created based on previous studies that showed pharmacists medication reconciliation improved accuracy and, from previous experience of the primary author, provided diabetes management over the phone.^1,3 The idea was that if diabetes management could be done over the phone, then so could medication reconciliation.

The study was initially intended as a prospective, randomized control trial as a quality improvement project to decrease polypharmacy. However, due to poor enrollment our project became a proof of concept that showed that having a pharmacist/pharmacy student performing medication reconciliation prior to a patient's appointment with a physician improves accuracy of medication lists and can help improve physician and patient satisfaction.

Methods

This project included adults 18 years or older who were prescribed four or more medications with a scheduled office visit appointment and gave consent. Patients were randomly selected based on availability of pharmacist or pharmacy student on the day of appointment. Forty patients per group were calculated to meet a power of 80%, P < .05, to show a reduction in the number of medications in 40% of patients in the treatment group versus 15% in the control group. The University of Hawai‘i institutional review board approved the study.

Description of intervention (Figure 1): Pharmacist/pharmacy students performed chart reviews using the electronic medical records system (EPIC) and randomly selected patients who met the inclusion criteria. Patients were called prior to appointment and provided verbal consent for study participation. A thorough medication reconciliation was conducted including verification of current prescription medications, over-the-counter medications, and herbal supplements. In addition, patients were asked if they had any questions or problems with their medications, and if they needed any refills. After the telephone encounter the pharmacist/pharmacy student performed a medication review which included assessing the appropriateness of medications (eg, drug-drug interactions, therapeutic appropriateness, duration of drug treatment). A telephone encounter note was documented in the electronic medical record which was forwarded to the physician. Completion of additional medication reconciliation and completion of written consent was done at the patient's appointment. Discrepancies, recommendations for medication changes, and refill requests were addressed on day of visit with physician, prior to the patient's appointment. Following the appointment, the patient and physician completed post-visit surveys.

Figure 1.

Diagram of Workflow

Results

After a two-year recruitment period, only 21 patients with an average age of 62, consented to participate in the study and came in for their scheduled appointment (Figure 2). It was decided to end the study prior to meeting the 40 patients needed due to lack on enrollment. A control group was not pursued since the study did not meet the number of participants required. Female patients accounted for 53% of the study group, 86% of patients had hypertension, and 33% had diabetes mellitus. Table 1 includes the baseline characteristics of the patients.

Figure 2.

Analytic Sample at Enrollment

Table 1.

Characteristics of the Patient Population

Demographics (N=21)
Average Age	62 y.o (range 36–39)
Patients ≥ 65 y.o	33%
Female	53%
Comorbidities
Diabetes Mellitus (DM)	33%
Patients ≥ 65 y.o +DM	14%
Medications
Average # medications prior to phone call	8.9
Average # medications after clinic visit	9.5 (P = .39)
Patients with ≥ 8 medications	52%

The primary goal of this study was to decrease polypharmacy and in 36% of patients, the number of medications decreased after the intervention. However, overall, the average number of medications used by patients increased from an average of 8.9 to 9.5 medications (P = .39). All patients included in the study had at least one medication change in the electronic medical record system. Most of the changes were to add medications that were not on the medication list or to remove medications on the list that the patient was no longer taking. In some instances, the medication dose had to be changed. There was a total of four medications that were discontinued after discussion with the physician after the pharmacist/pharmacy student medication reconciliation and review. Examples of medications discontinued were memantine in an elderly patient because of increased risk of fall and dizziness and lack of efficacy, and oxycodone in a patient who was not achieving pain relief with the medication and was experiencing side effects. Figure 3 includes the details of all medication changes made per patient.

Figure 3.

Number of Medication Changes per Patient

Five physicians were included in the study. Of the five physicians, three completed the survey and all three agreed that they felt they had more time with patients because of the intervention, but one of the three physicians was not able to see their patient on time because of the intervention.

The patient survey was completed by 44% of the patients and 100% of the respondents felt the intervention was helpful (Table 2). Furthermore, 86% of the patients felt they had more time with the physician because of the intervention.

Table 2.

Analysis of Outcomes

Primary Outcomes
Reduction in # of medications	36%
Patients with medication changes: dose reduction, discontinuation, and/or addition of medications to reduce long-term complications	100%
Secondary Outcomes
Potentially harmful medications eliminated, #	4
Patients perceived more time with physician at office visit following phone call	94%

Commentary on the Project

The objective of this project was to conduct a prospective, randomized control trial as a quality improvement project to decrease polypharmacy. Due to limited enrollment after 2 years, it was decided to stop the research portion and instead continue the project as quality improvement project and proof of concept. This project showed that having a pharmacist/pharmacy student performing medication reconciliation prior to a patient's appointment with a physician improves accuracy of medication lists.

This project had problems with recruitment for several reasons and was therefore unable to meet power for the study. Many patients were willing to have the pharmacist/pharmacy student perform a medication reconciliation over the phone but did not consent to inclusion in the study and thus their data were not included. Patients seemed very reluctant to be part of a research study, even with assurances that we would conceal their identity. Other challenges for recruitment were that patients were not at home when the pharmacist called or they consented to the medication reconciliation but did not show up for their scheduled appointment. Performing the medication reconciliation by phone for all patients consistently and educating patients that the pharmacist would be calling prior to their appointment may have increased participation.

The data from patients that were included in the study indicates that thorough medication reconciliation performed by a pharmacist or pharmacy student prior to office visits can help improve accuracy of medication lists. All patients in the intervention group had a change to their medications to accurately reflect current medication profiles.

Performing the medication reconciliation by phone prior to the appointment with the physician helped improve patient satisfaction based on increased perceived time with the physician during clinic visits. It also helped to improve physician satisfaction as the majority of physicians felt intervention helped increase the time spent with patient.

This intervention would work well in clinics that have at least three physicians and are able to partner with a full-time pharmacist or pharmacy students. Medication reconciliation by phone would work best on high-risk patients, such as those recently discharged from the hospital who are at high-risk for readmission or on four or more medications. Other patients who might benefit from this intervention are those who have been recently discharged from a hospital to decrease the number of visits to the clinic, which is helpful to patients with transportation issues or who are disabled.

Although this study demonstrated improved accuracy with pharmacist/pharmacy student involvement in the medication reconciliation process, contacting patients by telephone prior to their appointment is not a current workflow in this clinic. The limited time the pharmacist/pharmacy student are in clinic makes it challenging to offer this service to all doctors and all appropriate patients. Instead, the pharmacist/pharmacy student is available to do same-day medication reconciliation during times they do not have scheduled patients. Physicians and medical residents may also ask patients to schedule an appointment with the pharmacist/pharmacy student to do medication therapy management reviews. This workflow allows the service to focus on those who are high risk and also allows more efficient use of the pharmacist/pharmacy student's and patient's time.