Medication Reconciliation Research Articles

Impact of Cancer Diagnosis on Appropriate Use of Antithrombotic Medications in Individuals with Cardiovascular Diseases

Introduction: Cancer and Cardiovascular disease (CVD) often coexist and CVD is the leading cause of non-cancer mortality in people with cancer. Antithrombotic medications used to manage CVD are associated with increased bleeding risk, particularly in people with cancer. Appropriate management of CVD is therefore essential in individuals with cancer, both to decrease recurrent CVD as well as to prevent bleeding. In this study, we assessed utilization patterns of antithrombotic medications for CVD following a new diagnosis of cancer. Methods: Among people receiving primary care at the University of Vermont Medical Center from 2010 to 2019, we identified a cohort of 4,010 subjects with baseline CVD, identified from problem lists or billing codes within the first year of follow-up. Exclusion criteria included baseline cancer diagnosis (cancer known at the time of inclusion in the cohort or within the first year of follow-up) or a known history of venous thrombosis. Incident cancer was defined as new diagnosis of cancer after the first year of follow-up and did not include people with non-melanomatous skin cancers. We used the National Cancer Institute list of ICD-9 and ICD-10 codes for different cancer diagnoses. Patient's use of antithrombotics, prescribed or non-prescribed, were captured using computable phenotypes developed from the electronic outpatient medication reconciliation record and validated using chart review. People with baseline CVD who were diagnosed with cancer after the first year of follow up were matched 1:1 by sex and age with people with CVD and no cancer. We used logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) of persistent guideline-directed use of antithrombotic medications for 6 months after a new cancer diagnosis versus a matched time-period in those without incident cancer (use of antiplatelets in those with a history of atherosclerotic CVD and use of anticoagulation in those with a history of atrial fibrillation). Results: We identified 4,010 individuals with baseline CVD, 841 of whom (20%) developed incident cancer during follow-up. Distribution of CVD and antithrombotic use in the age- and sex-matched population are presented in Table 1. 2/3 of the population had coronary artery disease and about 30% had atrial fibrillation or flutter. About 65% of individuals were on any antiplatelet therapy and 18% were on anticoagulation for CVD. 41% of people with baseline CVD, and incident cancer diagnosis were still on antiplatelet therapy 6 months after their cancer diagnosis as opposed to 38 % in the matched population without a cancer diagnosis. 33% of individuals with incident cancer were still on anticoagulation for atrial fibrillation or flutter as opposed to 28% of the matched population without cancer. Both of these differences were statistically significant with OR=1.55 (95% CI, 1.15-2.1) for antiplatelets, and OR=1.56 (95% CI, 1.05,2.31) for anticoagulants, compared to those with no cancer diagnosis (Table 2). Conclusion: Surprisingly, our study found that incident cancer in individuals with baseline CVD was associated with increased adherence to antithrombotic therapy. We had hypothesized that incident cancer would be associated with lower use of antithrombotic therapy. This result could be related to increased interaction with medical specialists following a cancer diagnosis. The impact of increased adherence to antithrombotics on bleeding however, will need to be further investigated.

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project

Effective Care Transitions: Reducing Readmissions to Improve Patient Care and Outcomes.

Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services. A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization. An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model. Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up.

Addressing medial student knowledge deficits in 'hospital-to-home' transitions of care using a constructivism theory-based workshop intervention.

Effective teaching and learning initiatives on transitions of patient care, especially from hospital to home, are frequently lacking within medical school curricula. We trialled an integrated test-enhanced active learning strategy to prepare students for the safe management of these patient transitions. This randomised, prospective, single blinded, interventional study assessed medical students' knowledge, regarding patients' hospital-to-home transition. The intervention was a purpose-designed transitions of care workshop, the assessment tool was a multiple-choice assessment based on prior studies. Students were randomly allocated to the application of the assessment both pre- and post-workshop or to assessment solely post-workshop to determine the potential for the assessment to prime student learning. Sixteen students enrolled for the workshops. Significant knowledge gaps were identified. No student identified that medication errors were the most common source of post-discharge adverse events. Only 42% of participants knew that age >65 contributes to medication non-adherence, with 50% knowing that the medical reconciliation process should include discontinued medications. The workshop increased student knowledge, addressing identified knowledge gaps (74% pre-workshop versus 87% post-workshop, p < 0.005). Students self-perceived level of competency after completing the workshop intervention was increased (5.5 pre-workshop versus 15 post-workshop, p < 0.001). All aspects of student self-assessed competency increased significantly from the pre-workshop scores. There was no priming effect of the pre-workshop assessment on student knowledge scores or perceived competency. Important gaps in student knowledge skills and attitudes exist regarding the hospital to home transition. Our active learning strategy addressed these gaps, enhancing student understanding and confidence around transitions of patient care.

A Novel Home-Based Medication Management Program and Its Influence on Hospitalization Rates among Home Health Care Recipients

Patients do not take their medicine as prescribed 50% of the time, and of medication-related hospital admissions in the United States, 33% to 69% are due to poor medication adherence, at a cost of approximately $100 billion a year. Continue CareRx (CCRx) is a novel home-based medication management program that includes adherence packaging alongside medication reconciliation, review, and education by clinicians. We hypothesized that home health patients receiving the CCRx service may have a lower hospitalization rate than control home health patients. Between May 1, 2021, and March 31, 2023, 113 home health patients whose insurance covered the program were enrolled in CCRx. Home health patients not eligible for the program due to a noncovered pharmacy insurance benefit made up the control group (n = 21,304), which was matched with the CCRx group on age range (45-99 years old) and gender (67% women). Hospitalization rate was calculated in both groups and compared using generalized estimating equations analysis. The control group had a total of 7015 hospitalizations during the study period during 2,128,738 total managed days, whereas the CCRx group had 21 hospitalizations during 23,622 total managed days. These translated into rates of 1203 hospitalizations per 1000 per year for the control group, and 324 hospitalizations per 1000 per year for the CCRx group. The results showed that there was a significant main effect of group in predicting individual annual hospitalization rate (Wald χ2 = 56.415, P < .01). Specifically, being in the control group was associated with a 43.42-fold increase in the likelihood of a higher hospitalization rate (95% Wald CI for odds ratios: 7.24-230.44). Home health recipients enrolled in CCRx experienced a 73.1% lower hospitalization rate than controls. Making the program more widely available to patients receiving home health care may present a significant opportunity to reduce hospitalizations in this group.

Effect of educational intervention on medication reconciliation practice of hospital pharmacists in a developing country – A non-randomised controlled trial

BackgroundMedication reconciliation is an evidence-based practice that reduces medication-related harm to patients. This study evaluated the effect of educational intervention on medication reconciliation practice of pharmacists among ambulatory diabetes and hypertensive patients.MethodsA non-randomized clinical trial on medication reconciliation practice was carried out among 85 and 61 pharmacists at the intervention site and control site, respectively. Medication reconciliation was carried out among 334 (intervention-183; control-151) diabetes and/or hypertensive patients by the principal investigator to indirectly evaluate pharmacists’ baseline medication reconciliation practice at both sites. A general educational intervention was carried out among intervention pharmacists. Medication reconciliation was carried out by the principal investigator among another cohort of 96 (intervention-46; control-50) and 90 (intervention-44; control-46) patients at three and six months postintervention, respectively, to indirectly assess pharmacists’ postintervention medication reconciliation practice. Thereafter, a focused educational intervention was carried out among 15 of the intervention pharmacists. Three experts in clinical pharmacy analysed the medication reconciliation form filled by the 15 pharmacists after carrying out medication reconciliation on another cohort of 140 patients, after the focused intervention. Data was summarized with descriptive (frequency, percentage, mean ± standard deviation) and inferential (Pearson product-moment correlations analysis, independent-samples t-test and one-way ANOVA) statistics with level of significance set at p<0.05.Key findingsBaseline medication reconciliation practice was poor at both sites. Post-general educational intervention, medication discrepancy was significantly reduced by 42.8% at the intervention site (p<0.001). At the intervention site, a significant increase of 54.3% was observed in patients bringing their medication packs for clinic appointments making medication reconciliation easier (p=0.003), at 6-months postintervention. Thirty-five, 66 and 48 drug therapy problems were detected by 31 (43.1%), 33 (66.0%) and 32 (71.1%) intervention pharmacists at 1-, 3- and 6-month post-general educational intervention, respectively. Post-focused educational intervention, out of a total of 695 medications prescribed, 75 (10.8%) medication discrepancies were detected and resolved among 42 (30%) patients by the 15 pharmacists.ConclusionsThe educational interventions improved pharmacists’ medication reconciliation practice at the intervention site. It is expected that this research would help create awareness on medication reconciliation among pharmacists in developing countries, with a view to reducing medication-related patient harm.

Connecting the disconnected: Leveraging an in-home team member for video visits for older adults.

Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes. This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change. Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password. Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

Development and feasibility of an educational module on medication reconciliation for hospital pharmacists in the United Arab Emirates: a pilot study

Abstract Background The practice of medication reconciliation by pharmacists is minimal in United Arab Emirates hospitals. Objectives To design an educational module for pharmacists on medication reconciliation and assess its feasibility. Methods The study consisted of three parts: A pre-educational module survey using a validated knowledge, perception, practice, and barriers questionnaire (Cronbach’s α = 0.78), delivery of the educational module, and participants’ feedback. An educational module (general introduction to medication reconciliation, what is medication reconciliation, how to do medication reconciliation, and practicing medication reconciliation) was developed based on Miller’s pyramid and validated by three experts and pilot-tested. The knowledge and perceptions of pharmacists were evaluated by comparing pre-post educational module survey results. Results The module influenced the participants’ knowledge and perception of medication reconciliation. All of the participants gave ‘positive’ feedback on the intervention and the methodology applied, and they agreed on the need for training and workshops related to medication reconciliation. In addition, all ‘agreed’ that a lack of knowledge about medication reconciliation is the biggest barrier to medication reconciliation practices. The results further illustrated that all pharmacists had a ‘positive’ experience and ‘agreed strongly’ on understanding the majority of the content. Conclusion This study was successful in answering the research question by enrolling suitable participants, managing the timeline, and possessing resources for completing the study and hence considered feasible. This module can be utilized in continuous professional development programs to improve pharmacists’ knowledge, perceptions, and practice toward the medication reconciliation process aiming to reduce drug therapy-related problems in hospital settings.

Impact of Medication Reconciliation in Oncology Early Phase Studies: A Drug-Drug Interaction Retrospective Study.

This study aims to investigate the impact of medication reconciliation (MR) conducted by pharmacists before patient enrollment and the initiation of investigational treatments. By implementing MR, the primary objective is to evaluate the extent to which the inclusion of patients with prohibited or not recommended concomitant medications in clinical trials can be significantly reduced. The study included all patients who participated in clinical trials and underwent MR between September 1, 2015, and September 1, 2020. To identify prohibited or monitored drugs, protocols and investigator's brochures provided by the sponsor were meticulously reviewed and taken into consideration. MR was performed for 501 patients, uncovering 35% of the medications they were currently taking. Through the pharmaceutical analysis, a total of 346 drug-drug interactions (DDIs) were identified, of which 188 required monitoring and 158 were strictly prohibited. More than half of the prohibited medications were herbal drugs. A significant portion of these prohibited drugs were discontinued, with only 6% being replaced by suitable alternatives. The implementation of MR played a crucial role in the identification of 51% of the prohibited or monitored drugs that were initially overlooked by oncologists. MR is a highly effective measure aimed at reducing the risk of DDIs with investigational drugs, thereby minimizing protocol deviations and enhancing patient care. Sponsors of clinical trials value its implementation and recognize the substantial benefits it brings to the entire trial process. Consequently, many sponsors willingly provide funding to investigational sites that adopt MR as part of their standard practice, acknowledging its critical role in ensuring patient safety and maintaining data integrity throughout the course of clinical research studies.

Transitions of care from the womb to the world: Implementation of inpatient neonatal med rec

BackgroundMedication use during pregnancy is common. Safety of fetal medication exposures is an important consideration for pregnancy and for pharmacologic management and care of newborns. ObjectivesThe objective of this study was to describe the impact of implementing a neonatal medication reconciliation service at an acute-care hospital. Practice descriptionA neonatal medication reconciliation process was implemented at the University of New Mexico Hospital, a level 4 maternity center in a 500-bed academic medical center. Pharmacy personnel identified inpatient pregnant and postpartum patients who required medication reconciliation. In addition to performing maternal medication reconciliation, clinically significant medication exposures that occurred during pregnancy were recorded for neonates. Practice innovationOur neonatal medication reconciliation process evaluated prenatal “medication use” via a maternal medication history. We considered our medication reconciliation to be occurring during a “transition” from in utero to being born, which, to the best of our knowledge, has not been commonly reported as a transition of care in which pharmacists may play a role. Evaluation methodsWe conducted a retrospective descriptive chart review of patients who had both maternal and neonatal medication reconciliation services performed. We collected demographics, comorbidities, medications, and clinically significant exposures from the medication reconciliation note. ResultsA total of 384 charts were included in the final analysis. Of these, 167 medication reconciliations (43.5%) identified at least one medication history problem and 97 medication histories (25.3%) identified at least one potentially clinically significant neonatal medication exposure. Practice implicationsAlthough several limitations exist, a neonatal medication reconciliation process can be implemented in any inpatient setting with pharmacy staff available to perform and record reconciliation. ConclusionOpportunities for pharmacist involvement in pregnancy, postpartum, and neonatal care are expected to increase. Further research is warranted to more clearly determine the maternal and neonatal benefits of this medication reconciliation process and to link fetal exposures to outcomes.

Abstract 12011: A Case of Emphysematous Pyelonephritis With Use of Empagliflozin

Background: SGLT2i improve cardiovascular (CV) outcome in patients with HFrEF with or without diabetes (DM). Although recent trials and metanalysis have showed improve renal outcomes with SGLT-2i, one should be aware of the potential serious adverse effects with this group of medications including life threatening UTI. Case: 50-year-old female with history of type 2 DM presented with septic shock due to bilateral (B/L) pyelonephritis, with no associated renal calculi. CT of the abdomen also revealed emphysematous pyelonephritis of the left kidney. Few days later, patient went into PEA requiring intubation with return of spontaneous circulation within 4 minutes of advanced cardiac life support. Patient was extubated subsequently later on during her hospitalization. Work up for PEA revealed depressed left ventricular systolic function with an EF of 25-29% with no wall motion abnormality. Patient also developed decompensated HFrEF with development of b/l pleural effusion and generalized anasarca. Cardiology was consulted for management of her cardiomyopathy. She was recommended coronary angiography but she declined. Therefore, Patient was started on guideline direct medical therapy for HF with metoprolol succinate, lisinopril and spironolactone. Due to recent evidence of SGLT-2i improving CV outcomes in patients with HFrEF, it was also recommended to start SGLT-2i. Discussion: On further reviewing regarding use of SGLT-2i and association with UTI, we found a case report causing emphysematous pyelonephritis with use of canagliflozin. Medication reconciliation done at the time of discharge revealed that patient was recently initiated on empagliflozin three months prior to her admission. Therefore, it was speculated that her emphysematous pyelonephritis could be one of the rare complications of SGLT-2i since no other etiologies was noted per urological workup and we decided not to continue SGLT-2i. A search of FAERS from March 2013 through October 2014 identified 19 cases of urosepsis reported with the SGLT2 inhibitors (canagliflozin [n=10] and dapagliflozin [n=9]). All cases resulted in hospitalization. No deaths were reported. Clinicians should be aware of potential life-threatening UTI which may occur with SGLT-2i use.

Teleconsultation compared with face-to-face consultation in the context of pre-anesthesia evaluation: TELANESTH, a randomized controlled single-blind non-inferiority study

Study objectiveDuring the COVID crisis, pre-anesthesia teleconsultations were widely used leading to savings in time and money. However, the non-inferiority of this system has not yet been evaluated. DesignProspective, randomized, controlled, single-blind non-inferiority study. SettingUniversity hospital. PatientsPatients scheduled for surgery requiring a single pre-anesthesia consultation (PAC). InterventionPre-anesthesia teleconsultation (PATC) from patient's home. MeasurementsPrimary outcome: concordance between the pre-anesthesia visit (PAV), performed on the day of surgery, and PAC or PATC on:•ASA score (split into two groups: 1–2 and 3–4)•Mouth opening (separated into ≤35 mm or > 35 mm).•Pre-anesthesia medication reconciliation (expected therapeutic adjustments in anticoagulants, antiplatelet drugs, antihypertensives and antidiabetics).Secondary outcomes: cancellation rate, immediate perioperative complications, patient satisfaction, organization, and economic and ecological costs. Main resultsOut of 172 patients included, 149 were analyzed. PATC was no less effective than PAC in terms of the primary outcome or each of its components: the difference between groups was: - 0.044[90% CI: −0.135; 0.047] (p = 0.0002). There was no difference in cancellation rates (PAC 1.99% vs. PATC 1.27%, p = 0.6) or in immediate perioperative complications (none). Satisfaction was 9.48 (±1.45) in the PAC group and 8.96 (±1.68) in the PATC group (p = 0.0006). In the PATC group, the mean savings per patient were 30 km (± 29), 36 min (± 27), and 18 (± 18) euros, respectively. ConclusionsAccording to our criteria, PATC was not inferior to PAC for preoperative patient evaluation and may be an interesting economical, ecological alternative.

Improving Parkinson's Medicine Administration in Hospitals: The Impact of an Out-of-Hours Drug Box.

Background Parkinson'sdisease (PD) is a progressive neurodegenerative condition characterised by the loss of dopaminergic neurons and the presence of Lewy bodies. PD medications, notably Levodopa, are critical in controlling patients' symptoms and improving their quality of life. These medications are time-critical, and a delay in administration can have a negative impact on a patient's mobility, quality of life and symptoms. Objective The objective of this quality improvement project (QIP) was to (1) determine the occurrence and underlying factors contributing to delays in PD medication administration at Huddersfield Royal Infirmary and (2) evaluate the impact of subsequent interventions in improving the administration of time-critical PD medications. Methods A total of 20 patients were recruited from Ward 5, a care of the elderly ward, at Huddersfield Royal Infirmary for the entire duration of this QIP; 10 in the pre-intervention phase and 10 for the post-intervention phase one month following the implementation of three interventions: 'Parkinson's Drug Box', ward-based teaching and a hospital-wide screensaver reminder. Datawascollected from the electronic patient record (EPR) to determine and compare the following measures before and after the interventions: the percentage of PD medications administered within the 30-minuterecommendedwindow, the admission-to-medication reconciliation time, scheduled-to-actual dose administration time, and factors causing delays. Results Following the implementation of three interventions, the percentage of patients receiving PD medications within the recommended 30-minute window doubled, increasing from 10% to 20%. Moreover, the average delay in patients receiving their initial PD medication dose decreased from 7.8 hours to 3.7 hours. The percentage of patients experiencing medication delays due to stock shortages also dropped from 50% to 10%. Conclusions Earlier medicines reconciliation and the availability of time-critical drugs out of hours are both key factors in helping to ensure PD medication is administered on time in hospitals. Staff education and a 'Parkinson's Drug Box' are two relatively simple measures that have resulted in improved outcomes for Parkinson's inpatients.

Perception survey on the value of the hospital pharmacist at the emergency department

ObjectiveTo determine the perception and evaluation of the Emergency pharmacist by the medical and nursing staff at the Emergency department. MethodsA multicenter study based on a survey sent to the Spanish Society of Hospital Pharmacists (SEFH) for Emergency pharmacists (EPh) to distribute among the Emergency staff. Descriptive statistics were used, with a 95% confidence interval. Results102 (12%) questionnaires were completed by 73 Emergency Physicians (71.6%) and 29 Emergency Nurses (28.4%), out of 835 surveys sent. The most common pharmaceutical activities, and perceived as more relevant for patient safety, were: consultation solution, prescription validation, and medication reconciliation. 63% of respondents supported the prospective review of high-risk medications, while 89% believed that the Pharmacist improves the quality of care. EPh are considered useful for training healthcare staff and patients, and 77% of respondents considered them as an integral member of the team. They would resort more to Pharmacists if they were present at the hospital department. ConclusionsThe results show the acceptance of Hospital Pharmacists in the Emergency Department; their functions are known and valued. They are considered an integral member of the team, who will provide safety and improve patient care.Medication reconciliation and prescription validation are highlighted because of their relevance in terms of safety. Further studies are needed to assess health outcomes and their economic impact.

Appraising the Role of Pharmacists in Medication Reconciliation at Hospital Discharge: A Field-Based Study

Objective: To measure the effect of the pharmacist-led medication reconciliation service before hospital discharge on preventing potential medication errors. Methods: This behavioral interventional study took place in a public teaching hospital in Iraq between December 2022 and January 2023. It included inpatients who were taking four or more medications upon discharge from the internal medicine ward and the cardiac care unit. The researcher provided the patients with a medication reconciliation form and reconciliation form (including medication regimen and pharmacist instructions) before discharging them home. Any discrepancies between the patients’ understanding and the actual medication recommendations prescribed by the physician were identified and solved. Results: Fifty inpatients received a pharmacist-led medication reconciliation review before hospital discharge. Out of 50 patients, 44% had a clear understanding of their medications before the intervention. In contrast, 56% of the patients had at least one potential medication error before the reconciliation, which was addressed by the pharmacist's intervention. Approximately two-thirds (89.4%) of the potential medication errors were clinically significant, and 5.3% of these errors were serious. The most frequent potential error that prevented this was duplication (31.5%) (the patient was about to duplicate the same medication from different manufacturers or different medications from the same pharmacological class). Conclusion: Lack of medication reconciliation can cause significant medication errors, which might be serious and cause harm to patients. This study has the potential to shape policies and practices that prioritize medication safety and optimize patient outcomes during transitions of care.

Barriers to engagement of patients in medication reconciliation.

362 Background: Medication reconciliation (MedRec) is a process where a detailed medication list is compiled and reviewed with an appropriate health care professional for completeness and drug-drug interactions, then communicated across all of the patient’s healthcare teams. While effective MedRec can minimize the risk of adverse events, uptake in outpatient oncology can be poor. Engagement of patients and caregivers in collection of medication lists through patient portals has been suggested as a potential change idea to improve uptake. To understand barriers and facilitators of patient engagement in the MedRec process through an electronic patient portal we undertook semi structured interviews in a comprehensive cancer center in Ontario, Canada. Methods: Patients in outpatient oncology clinics and chemo-daycare waiting areas were approached to participate in interviews; as we wished to understand barriers both users and non-users of the medication list feature of the patient portal were eligible to participate. Participant recruitment continued until saturation of data was reached. Interviews were carried out virtually following a semi-structured guide between 08/2022 and 12/2022. Interviews were recorded and transcribed verbatim; thematic coding was completed in NVIVO by two members of the study team. Results: A total of 10 patients participated in interviews; participants ranged in age between 30 to 89 years, and all completed post-secondary education. Patients’ emphasized issues with provider/care team communication expressing it was unclear why they were asked to enter medications and did not know if anyone was reviewing the medications entered. Additionally, patients had a fear of inputting erroneous medications resulting in their overall avoidance to use the portal. Portal features such as the use of generic vs trade name medications created lack of clarity for patients when entering medications into the system. Presently, the language is limited to English which may reduce the number of users. Accessibility issues such as font size and overall layout, especially on mobile devices were noteworthy during interviews. Patients recommended the addition of the following features: refill information including requests, medication reminder features via text/email and linkable medication information. Conclusions: Our findings indicate that although patients are using the portal to upload their medication lists, there are technical and systemic improvements that can be made to increase patient usage. In addition to updates to the patient portal to create added value to patients, and improve comprehension and accessibility, patient education is needed to raise awareness of the importance of MedRec and their role in the process and improve buy in.

The Impact of Implementing a Pharmacist-led Deprescribing Program on Medication Adherence among Hemodialysis Patients

Background: One way to target polypharmacy and inappropriate medication in hemodialysis (HD) patients is with medication deprescribing. Objective: To assess the impact of implementing a pharmacist-led deprescribing program on medication adherence among HD patients. Method: A prospective interventional, one-group pretest-posttest-only design study was conducted at a hemodialysis center in Wasit Governorate, Iraq. Medication reconciliation followed by medication review based on the deprescribing program was done for all eligible patients, and the patients were monitored for three months for any possible complications. Results: Two hundred and seventy patients were screened for eligibility. Only one hundred and eighteen were enrolled in the deprescribing program. The median age was 51.5 years, 56.8% were males, and hypertension was the most common etiology for their chronic kidney disease (CKD); 78% had comorbidities. After deprescription, there was a significant reduction in the number of medications from 6.0 to 4.0 and a reduction in the number of pills from 7.0 to 5.0. Medication adherence accessed using the Arabic version of Morisky, Green, and Levine’s (MGL) adherence scale also had a significant reduction from 2.0 to 1.0. Conclusion: A pharmacist-led deprescribing program is a successful strategy for decreasing the number of medications and daily pills prescribed while simultaneously improving hemodialysis patients' adherence to their regimens without compromising the patient’s safety.

Medication Reconciliation in Veterans Receiving Dialysis at Edward Hines VA Hospital: A Quality Improvement Initiative

Medication Reconciliation in Veterans Receiving Dialysis at Edward Hines VA Hospital: A Quality Improvement Initiative

Impact of an embedded oncology clinical pharmacist in an outpatient oncology center.

424 Background: Oncology pharmacists are uniquely positioned to improve the quality of care provided to patients with cancer within the team-based setting. Some benefits include providing information that supports safe and cost-effective use of medications relative to supportive care management, drug-drug interaction evaluation, patient counseling, answering drug information questions, and reducing physician workload. The primary objective of this study is to evaluate the benefit of a full-time clinical pharmacist in the ambulatory oncology setting through documenting pharmacist-driven clinical interventions, correspondence of those interventions with cost avoidance, and perceived benefit from provider and patient satisfaction surveys. Methods: Pharmacists were in clinic Monday through Thursday, covering three medical oncologists each day. Interventions were documented through EPIC i-Vents. The categories included: adverse events, drug interactions, lab monitoring, medication reconciliation, order clarification, patient education/counseling, drug information, and supportive care. Pharmacist interventions correlated with cost avoidance benefits based on values from prior publications. Weekly surveys were sent to the providers to assess satisfaction of the program and to improve workflow. Results: The data from this pilot program reflects the study period starting January 9, 2023 through June 1, 2023. The financial impact, as calculated from the pharmacist interventions, cost avoidance values and time spent resulted in the estimated cost avoidance of $169,321.10 based on a total of 839 interventions. Other interventions were made that were not given a cost value. Thus, the estimated cost savings is likely an under-estimation of the true cost savings provided from this service during this five-month study period. Extended providers (n = 5) and medical oncologists (n = 3) surveys indicated an overall strong agreement to the benefits of an oncology pharmacist’s involvement in clinic. The pilot program is currently working on a method to gather patient surveys to assess patient satisfaction. Conclusions: This study demonstrates the clinical and financial benefit of an embedded oncology pharmacist in the outpatient oncology clinic. As we move into an era with increasing approvals of oncology medications, coupled with increasing complexity of care, this service may help address some of the unmet gaps to improve collaborative and comprehensive patient-centered care.

A systems approach to the safety and efficiency of prescribing at the primary–secondary care interface

The interface between primary and secondary care represents a highly complex and heterogeneous system that continues to pose risks to the safety and quality of care. Many issues relate to prescribing activities, and suboptimal information sharing between stakeholders can lead to avoidable harm events and system inefficiencies that increase workload. The framework of a systems approach is used to structure four key interface issues: medicines reconciliation, prescribing at secondary care outpatient appointments, shared records, and quality of communication. We outline opportunities for improved safety and efficiency, and identify key barriers that need to be addressed. Significant further development is required for the measures discussed. We recommend the use of a systems approach to methodologically support this process, particularly due to the inherent system-wide understanding of problems that it generates. We argue such understanding is essential to ensure that risks and workload are not shifted around a system, without overall gain.