ProvidersPharmacists’ role in preventing hospital admissions and readmissions
January 6, 2021
By Kristen Engelen, PharmD
Avoidable hospital admissions put increased pressure on already-strained healthcare resources, causing emotional and financial distress for patients and their families while taxing the health system itself.
This unnecessary use of finite resources — staff, beds and other assets necessary to provide patient support — can also result in delays in treatment for other patients with sometimes life-threatening acute conditions. The current pandemic’s effects on our healthcare system is a good example, with millions of other procedures delayed
The Healthcare Cost and Utilization Project (H∙CUP) reports that in 2017, $33.7 billion in hospital costs were associated with 3.5 million preventable adult inpatient stays, and $561.1 million in hospital costs were spent on 108,300 preventable pediatric inpatient stays.
Because of their pivotal role in helping discover and prevent adverse drug events and acting proactively, pharmacists — delivering services in and out of the hospital, including convenient telehealth options — can help reduce this unnecessary use of resources, and aid patients and their providers in being proactive in discovering and treating medical issues before a trip to the hospital even becomes necessary.
The U.S. Agency for Healthcare Research and Quality (AHRQ) has identified Prevention Quality Indicators (PQI) which are measures of potentially avoidable hospitalizations for ambulatory care-sensitive conditions (ACSCs). Many PQI are chronic conditions that present in a comorbid fashion in geriatric patients with multiple prescribed drug therapies, increasing the potential for hospitalization from medication-related factors.
Similarly, potentially avoidable hospital readmissions are associated with unfavorable patient outcomes and high, unnecessary costs to the healthcare system. According to a review of 34 studies published between 1966 and 2010, 24% — so virtually a quarter — of all hospital readmissions were considered avoidable. Readmissions are a measured indicator of quality of care, and can result in financial penalties for hospitals.
Hawaii’s Pharm2Pharm three-year initiative program assessed that 26% of 401 hospital readmissions were medication-related and potentially preventable. Data shows the importance of pharmacist expertise and the collaboration between hospital and community settings to reduce medication-causative readmissions.
Helping prevent or reduce hospital admissions
The Centers for Disease Control and Prevention (CDC) reports there are more than 1 million U.S. hospital Emergency Department visits attributed to adverse drug events (ADEs). These ED visits result in hospitalization for over 25% of those patients. Many of those visits also were identified as preventable.
In addition, note that adults 65 years or older are three times more likely to need ED care for ADEs than younger patients. Shortages of primary care physicians have left 56 million Americans without adequate access to primary healthcare, revealing a market-driven pressure for pharmacists to participate in primary care to reduce avoidable hospital admissions.
Prescribing, monitoring and managing medications is a significant component of delivering primary care. It’s been shown time and again that creating preventive care programs incorporating pharmacists in the primary care setting increases detection and resolution of medication-related problems before those issues escalate to hospitalization.
Incorporating clinical pharmacist practitioners into primary/ambulatory care settings for collaborative drug therapy management has had positive effects on patient health outcomes, saves time for practitioners, exhibits institutional cost avoidance, and yields higher patient satisfaction. For example, Kaiser Permanente Colorado has expanded pharmacist roles in primary care and chronic disease management, documenting a reduction in avoidable hospitalizations, an increase in life-saving interventions, and a decrease in healthcare costs.
Creating programs within hospitals that include pharmacists as an integral part of the care team in the ED and for outpatient surgery cases has also been shown to help reduce medication-related incidents that result in admissions.
The Veterans Affairs San Diego Healthcare System implemented a 24-hour ED pharmacy service that resulted in a projected almost $1.7 million in annual cost savings attributed to serious patient harm prevented by pharmacist interventions. Also, The American Journal of Health-System Pharmacy published a study that pharmacist involvement in surgical antibiotic prophylaxis reduced postoperative infections by 34.3%, compared with hospitals which didn’t involve pharmacists in antibiotic stewardship.
RxLive patients see fewer admissions
Specifically, with a cohort of 3,000 patients who completed a consult with an RxLive pharmacist, we saw a statistically significant decline in admissions rate for opted-in versus opted-out providers. Shown in the chart below, this further emphasizes the value pharmacist interaction can bring.
Helping prevent/reduce hospital readmissions
A multidiscipline team that includes pharmacists has been proven to be an effective strategy for hospitals to reduce readmission rates. Potential for readmission can be reduced by pharmacist-led:
- Medication reconciliation upon admission
- Inpatient monitoring
- Participation in hospital rounds
- Review of medication list with patients or caregivers
- Collaboration at discharge with patients’ physicians and community pharmacists
- Patient follow-up after discharge
This pharmacist involvement creates an optimal setting for enhanced quality of inpatient care and the promotion of patients’ successful self-management of long-term conditions and medication therapy, resulting in decreased readmission rates.
Several health organizations have launched initiatives utilizing pharmacists for medication review and recommendations, resulting in positive health outcomes, reduced hospital readmissions and significant cost savings.
Transitions of care — Multiple studies have shown that transitions of care — from inpatient shift to shift, hospital to skilled nursing or home — is where it’s easiest to have miscommunications that can cause avoidable errors. The Pharm2Pharm initiative emphasized using pharmacists in transitions of care to reduce hospital readmission rates through collaborative relationships between hospital and community pharmacists to implement patient-specific medication therapy management plans. Study findings published in the Journal of the American Geriatrics Society estimated a 36% reduction in medication-related readmissions and cost savings of approximately $6.6 million annually.
Similar results were found with the REACH and STAAR initiatives. In both initiatives, pharmacists — as a component of multidisciplinary teams — performed medication reconciliation, patient education at discharge, and follow-up calls post-discharge. Findings showed hospital readmission rates fell 50% and 30% respectively.
As a part of a multidisciplinary healthcare team, pharmacists are central figures in promoting positive health outcomes and decreasing health expenditures. Pharmacists across a variety of specialties — community, hospital, clinical pharmacist practitioners, long-term care consulting and more — provide a deep and broad range of expertise. They provide support across the primary care, inpatient, outpatient and home arenas, ultimately reducing avoidable hospital admissions and readmissions while improving clinical, financial and patient-satisfaction outcomes and quality of life.
Access Denied: A Look at America’s Medically Disenfranchised. Robert Gram Center; George Washington University.
Clinical and Economic Outcomes of Pharmacist-managed Antimicrobial Prophylaxis in Surgical Patients. American Journal of Health-System Pharmacy (AJHP)
Implementing a Comprehensive, 24-hour Emergency Department Pharmacy Program. American Journal of Health-System Pharmacy (AJHP)
Pharm2Pharm, A Formal Hospital Pharmacist to Community Pharmacist Collaboration. Primary Care Collaborative
Medication Safety Program. Centers for Disease Control and Prevention (CDC)
Potentially Preventable Medication-related Hospitalizations: A Clinical Pharmacist Approach to Assessment, Categorization, and Quality Improvement. Journal of the American Pharmacists Association (JAPhA)
Prescribing Pharmacists in the Ambulatory Care Setting: Experience at the University of North Carolina Medical Center. American Journal of Health-System Pharmacy (AJHP)
Proportion of Hospital Readmissions Deemed Avoidable: A Systematic Review. Canadian Medical Association Journal (CMAJ)
The Medication REACH Program. Einstein Medical Center
Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacist: A Quasi-Experimental Study. Journal of the American Geriatrics Society (JAGS)
The Role and Impact of the Pharmacist in Long-term Care Settings: A Systematic Review. Journal of the American Pharmacists Association (JAPhA)
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.