The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients

BACKGROUND: Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department. METHODS/DESIGN: An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle. DISCUSSION: This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety. TRIAL REGISTRATION: Dutch trial register: NTR151

The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients

Abstract Background Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department. Methods/Design An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient. The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers. The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists. Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle. Discussion This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety. Trial registration Dutch trial register: NTR1519</p

Completeness of patient records in community pharmacies post-discharge after in-patient medication reconciliation : a before-after study

BACKGROUND: Transfer of discharge medication related information to community pharmacies could improve continuity of care. This requires for community pharmacies to accurately update their patient records when new information is transferred. An instruction manual that specifies how to document information regarding medication changes and clinical information (i.e. allergies/contraindications) could support community pharmacies. OBJECTIVE: To explore the effect of instruction manuals sent to community pharmacies on completeness of their patient records. SETTING: A before-after study was performed (July 2009-August 2010) in the St Lucas Andreas Hospital, a general teaching hospital in Amsterdam, The Netherlands. METHODS: Patients discharged from the cardiology and respiratory ward were included consecutively. The intervention consisted of a training session for community pharmacies regarding documentation problems and faxing an instruction manual to community pharmacies specifying how to document discharge information in their information system. Usual care consisted of faxing a discharge medication overview to community pharmacies without additional instructions. Two weeks after discharge the medication records of community pharmacies were collected by fax. These were compared with the initial discharge overviews regarding completeness of medication changes (i.e. explicit explanation that medication had been changed) and clinical information documentation. MAIN OUTCOME MEASURE OUTCOMES: were the number and percentage of completely documented medication changes (either needing to be dispensed or not) and clinical information items. The sample size was calculated at 107 patients per measurement period. Multivariable logistic regression was used for analysis. RESULTS: Two hundred and eighteen patients (112 before-106 after) were included. Completeness of medication changes documentation increased marginally after the intervention (46.6 vs 56.3 %, adjusted Odds Ratio 1.4 [95 % confidence interval 1.07-1.83]). Documentation increased when medication was actually dispensed by the community pharmacy. No significant improvements were seen for allergy and contraindication documentation. CONCLUSION: The intervention is insufficient to increase the completeness of documentation by community pharmacies as marginal improvements were achieved. Future studies should evaluate whether electronic infrastructures may help in achieving updated medication records to improve continuity of pharmaceutical care

Completeness of patient records in community pharmacies post-discharge after in-patient medication reconciliation: a before-after study

BACKGROUND: Transfer of discharge medication related information to community pharmacies could improve continuity of care. This requires for community pharmacies to accurately update their patient records when new information is transferred. An instruction manual that specifies how to document information regarding medication changes and clinical information (i.e. allergies/contraindications) could support community pharmacies. OBJECTIVE: To explore the effect of instruction manuals sent to community pharmacies on completeness of their patient records. SETTING: A before-after study was performed (July 2009-August 2010) in the St Lucas Andreas Hospital, a general teaching hospital in Amsterdam, The Netherlands. METHODS: Patients discharged from the cardiology and respiratory ward were included consecutively. The intervention consisted of a training session for community pharmacies regarding documentation problems and faxing an instruction manual to community pharmacies specifying how to document discharge information in their information system. Usual care consisted of faxing a discharge medication overview to community pharmacies without additional instructions. Two weeks after discharge the medication records of community pharmacies were collected by fax. These were compared with the initial discharge overviews regarding completeness of medication changes (i.e. explicit explanation that medication had been changed) and clinical information documentation. MAIN OUTCOME MEASURE OUTCOMES: were the number and percentage of completely documented medication changes (either needing to be dispensed or not) and clinical information items. The sample size was calculated at 107 patients per measurement period. Multivariable logistic regression was used for analysis. RESULTS: Two hundred and eighteen patients (112 before-106 after) were included. Completeness of medication changes documentation increased marginally after the intervention (46.6 vs 56.3 %, adjusted Odds Ratio 1.4 [95 % confidence interval 1.07-1.83]). Documentation increased when medication was actually dispensed by the community pharmacy. No significant improvements were seen for allergy and contraindication documentation. CONCLUSION: The intervention is insufficient to increase the completeness of documentation by community pharmacies as marginal improvements were achieved. Future studies should evaluate whether electronic infrastructures may help in achieving updated medication records to improve continuity of pharmaceutical care

The effect of a pharmaceutical transitional care program on rehospitalisations in internal medicine patients : an interrupted-time-series study

BACKGROUND: Medication errors at transition of care can adversely affect patient safety. The objective of this study is to determine the effect of a transitional pharmaceutical care program on unplanned rehospitalisations. METHODS: An interrupted-time-series study was performed, including patients from the Internal Medicine department using at least one prescription drug. The program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within six months post-discharge. Secondary outcomes were drug-related hospital visits, drug-related problems (DRPs), adherence, believes about medication, and patient satisfaction. Interrupted time series analysis was used for the primary outcome and descriptive statistics were performed for the secondary outcomes. RESULTS: In total 706 patients were included. At 6 months, the change in trend for unplanned rehospitalisations between usual care and the program group was non-significant (- 0.2, 95% CI -4.9;4.6). There was no significant difference for drug-related visits although visits due to medication reconciliation problems occurred less often (4 usual care versus 1 intervention). Interventions to prevent DRPs were present for all patients in the intervention group (mean: 10 interventions/patient). No effect was seen on adherence and beliefs about medication. Patients were significantly more satisfied with discharge counselling (68.9% usual care vs 87.1% program). CONCLUSIONS: The transitional pharmaceutical care program showed no effect on unplanned rehospitalisations. This lack of effect is probably because the reason for rehospitalisations are multifactorial while the transitional care program focused on medication. There were less hospital visits due to medication reconciliation problems, but further large scale studies are needed due to the small number of drug-related visits. (Dutch trial register: NTR1519)

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

BACKGROUND: To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective. METHODS: A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping. RESULTS: In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained. CONCLUSION: The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention. Dutch trial register NTR1519

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

<div><p>Background</p><p>To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective.</p><p>Methods</p><p>A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping.</p><p>Results</p><p>In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained.</p><p>Conclusion</p><p>The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention.</p><p>Dutch trial register NTR1519</p></div

Cost-effectiveness analyses for unplanned rehospitalisations.

<p>(A) Cost-effectiveness plane for the risk of unplanned rehospitalisations. (B) Acceptability curve for the cost-effectiveness analyses.</p

Results of adjusted cost-effectiveness and cost-utility analyses.

<p>Results of adjusted cost-effectiveness and cost-utility analyses.</p