Dataset Information

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital.

ABSTRACT:

Study objective

This study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention.

Setting

The study took place in an outpatient anticoagulation clinic within a small community hospital.

Participants

Patients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included.

Design

This is a quality improvement initiative.

Interventions

Utilizing the electronic medical record and patient interview, use and indication for daily aspirin therapy was confirmed. Prospectively collected patient demographics and past medical history were used to determine appropriateness of aspirin therapy. For patients identified as receiving inappropriate aspirin therapy, a fax was sent to the referring provider recommending aspirin discontinuation.

Main outcome measures

To assess the effectiveness of the intervention, outcomes were retrospectively measured. The primary outcome was the percentage of "accepted" recommendations. Secondary outcomes included the prevalence, dosing, and indications for aspirin therapy.

Results

Eighty (33 %) of 242 patients were on aspirin. Fifty-two patients with atrial fibrillation and/or venous thromboembolism were assessed and aspirin was deemed inappropriate in 22 patients. The provider agreed with deprescribing aspirin therapy in 45 %. The most common dose and indication of aspirin therapy was 81 mg (98 %) and primary prevention (40 %) respectively.

Conclusions

In our small practice, pharmacist-led interventions were an effective means to recommend aspirin discontinuation in our identified patients. Further studies are needed to optimize a pharmacist's role and address the long-term effects of deprescription.

SUBMITTER: Domaleczny BJ

PROVIDER: S-EPMC10978311 | biostudies-literature | 2022 May

REPOSITORIES: biostudies-literature

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Publications

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital.

Domaleczny Brooke J BJ Lewis Susan J SJ Richardson Jennifer L JL Eid Heather R HR

American heart journal plus : cardiology research and practice 20220501

<h4>Study objective</h4>This study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention.<h4>Setting</h4>The study took place in an outpatient anticoagulation clinic within a small community hospital.<h4>Participants</h4>Patients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included.<h4>Desig ...[more]

PMID: 38559886

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Project description:BackgroundPharmacists working within interprofessional teams in the outpatient setting are well placed to address medication-related problems before and after hospital admission. Therefore, exploration of these roles is warranted.ObjectivesTo explore pharmacists' and other health professionals' perspectives of the impact of pharmacists working within interprofessional teams in outpatient clinics. Furthermore, we endeavoured to identify both the challenges and contributors to success with the introduction of pharmacists into these settings.MethodsThis qualitative study involved semi-structured interviews with both hospital outpatient clinic pharmacists and other clinic health professionals to gain an in-depth understanding of how the introduction of pharmacists into clinics impacted clinic processes, patient care, and relationships with other health professionals. Participants were recruited from the outpatient clinics who had recently added a pharmacist to their service. Participants involved in setting up the roles were invited to participate in a voluntary interview, the transcripts from which were analysed into themes and sub-themes using an inductive and deductive approach.ResultsA total of 34 staff were interviewed of which 68% were female and 74% were aged between 31 and 50 years. The cohort included 16 outpatient pharmacists, nine pharmacist team leaders, five clinic nurses and four clinic doctors (specialist consultant or registrar). Three overall themes were identified: the benefits, the contributors, and the challenges of introducing clinical pharmacy services to outpatient clinics. When establishing a clinic role, pharmacists' awareness, adaptability, and strong communication were shown to be key traits to building rapport and trustworthiness with the established clinic team.ConclusionsWhen pharmacists are integrated into multidisciplinary outpatient clinics they and their colleagues believe that they provide benefits to the patients and the clinics. Decision makers need to be cognizant of factors that contribute to, as well as those that impede, the successful implementation of outpatient pharmacist roles.

Project description:PurposeNearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC.MethodsA total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping.FindingsFour essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication.ImplicationsDeprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.

Project description:Few studies have analyzed community hospital-based parenteral anti-infective therapy (CohPAT). We aimed to assess the clinical impact of a pharmacist-led implementation of a clinical practice guideline (CPG) for CohPAT, and to determine the pharmacist's role in CohPAT medication management. The prospective-period patients (post-implementation group) were compared with the historical control-period patients (pre-implementation group) for receiving a continuous antimicrobial parenteral injection. A CPG was used for laboratory testing for efficacy and safety, the monitoring of adverse drug events during admission, microbiology results coordination, and dosage adjustment. For any antimicrobial drug-related problems, the pharmacist consulted with the clinicians. Over 14 months, 50 participants were included in each group. In the pre-implementation period, 7 (14%) and 4 (8%) out of 50 patients received an inappropriate dosage and nonlaboratory monitoring for dose adjustment, respectively. The patients received the proper dosage of antimicrobial agents, which increased significantly from 78% pre- to 100% post-implementation (p = 0.000). The pharmacist's interventions during the prospective-period were completely accepted by the clinicians, and significantly greater laboratory monitoring complying with CPG was given to the postimplementation group than the pre-implementation group (100% vs. 60%; p = 0.000). Significantly less patients with unfavorable outcomes (failure or in-hospital mortality) were observed in the post-implementation than in the pre-implementation (6% vs. 26%; p = 0.006) group. For the logistic regression analysis, lower respiratory infection (adjusted OR, aOR 3.68; 95%CI 1.13-12.06) and the post-implementation period (aOR 0.21; 95%CI 0.06-0.83) were significant risk factors that were associated with unfavorable outcomes. Given the better clinical outcomes and the improved quality of septic patient care observed after implementation, pharmacist-led implementation should be adopted in healthcare settings.

Project description:BackgroundPalivizumab provides passive immunity for respiratory syncytial virus (RSV), but poor adherence compromises protection. A hospital initiative promoted administration of first palivizumab doses at an outpatient clinic immediately after discharge. The objectives of this study were to evaluate the impact of the initiative on location and timing of first palivizumab dose, patient adherence, reimbursement, acquisition cost and RSV-positive hospital readmissions.MethodsThis retrospective cohort study included pediatric patients who received palivizumab from 2012 to 2016. Three groups were compared: "before initiative," "transition" and "after initiative." Patients who did not qualify for palivizumab or who were eligible for palivizumab in previous RSV seasons were excluded. Multivariable logistic and linear regressions adjusted for patients' characteristics were used in outcome analysis.ResultsAfter adjusting for patients' characteristics, there was a 13.5-fold (95% confidence interval: 5.9-30.5, P < 0.0001) increase in odds that patients would receive outpatient administration of palivizumab and 2.7-fold (95% confidence interval: 1.3-5.7, P = 0.0103) increase in odds of receiving the second dose within 35 days after initiative implementation compared with before. Although there was no significant difference in reimbursement percentage after initiative implementation (32% ± 30% after initiative and 31% ± 22% before), calculated palivizumab acquisition costs were 20.8% lower. RSV readmissions were not significantly different.ConclusionsImplementation of an initiative with defined workflow, multidisciplinary collaboration, and early case management efforts to obtain insurance authorization increased outpatient administration of first palivizumab doses. Patient adherence improved as demonstrated by more timely receipt of the second palivizumab dose. There was no difference in reimbursement; however, acquisition cost decreased which is valuable considering low reimbursement rates. RSV-positive readmissions did not change significantly.

Project description:BackgroundMany older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications.ObjectivesWe sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults.MethodsWe conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded.ResultsWe screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement.ConclusionsWe identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.

Project description:ImportanceFor some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes.ObjectiveTo assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin.Design, setting, and participantsThis pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021.InterventionPrimary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician.Main outcomes and measuresOutcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time.ResultsA total of 6738 patients treated with warfarin (3160 men [46.9%]; mean [SD] age, 62.8 [16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P < .001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P = .001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P = .03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P = .34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P = .02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P = .001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P = .04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P = .36 for change in slope before and after 24 months before the intervention).Conclusions and relevanceThis quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic-based aspirin deimplementation intervention can improve guideline-concordant aspirin use.

Dataset Information

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital.

Study objective

Setting

Participants

Design

Interventions

Main outcome measures

Results

Conclusions

Publications

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital.

Similar Datasets

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