Pharmacist-Led Drug Therapy Problem Management in an Interprofessional Geriatric Care Continuum: A Subset of the PIVOTS Group

Drug therapy problems, which are undesirable events that involve medications that can ultimately interfere with a patient’s therapeutic goals, are a major cause of morbidity, mortality, and hospitalizations in older adults. Nearly 100,000 hospitalizations annually in senior populations (ie, aged ≥65 years) result from adverse drug events, and it is estimated that 72 of every 1000 of these hospitalizations are medication-related.^1,2 Similarly, it has been suggested that recurrent hospitalizations in older adults are associated with an increase in 1-year mortality, which suggests the importance of preventing hospitalizations in this patient population.³

Drug therapy problems can take on several forms, all of which have been documented in the literature, including unnecessary drug treatment, the need for additional therapy, the need for a different drug, too-low dosing, too-high dosing, adverse drug reactions, and nonadherence.⁴ Previous research suggests that untreated indications,^5-7 inappropriate drug choices,^6-8 the risk for adverse drug reaction,^8,9 and doses that are too high^5,9 account for a large proportion of the drug therapy problems identified in older adults.

The objective of this study is to quantify the impact of pharmacists in this novel care model by analyzing the most common drug therapy problems identified by pharmacists, the medications that are most frequently involved in drug therapy problems, and the actions taken by pharmacists to resolve drug therapy problems across care settings over a 15-month period.

Several reasons explain why older adults are predisposed to drug therapy problems, including frequent transitions of care, an overall increased number of medical conditions, and the prevalence of polypharmacy.^10-12 In a sample of 248 ambulatory older adults with cancer, the mean number of daily medications was 9.23.¹¹ More acutely, a study of 154 hospitalized Medicare patients who were discharged to a skilled-nursing facility reported that the average number of medications on discharge was 14.¹² Transitions across care settings can introduce new drug therapy problems and medication discrepancies, particularly in patients with multiple morbidities and polypharmacy.¹³

Bishop and colleagues demonstrated that a significantly increased risk for discrepancy existed in patients who were receiving 8 or more medications at hospital discharge,¹⁴ which further complicates the finding that the majority of older adults discharged home after hospitalization have a poor understanding of changes in their medication regimens.¹⁵

These numbers, combined with the physiologic changes (ie, decreases in hepatic and renal blood flow, decreased protein for drug binding, and an increase in body fat), and changes in pharmacokinetic and pharmacodynamic parameters, further increase the risk for adverse drug events.^14,16,17 This patient population is also at risk for intermittent geriatric syndromes, including delirium, dementia, falls, urinary incontinence, and frailty, which can further exacerbate the risk for critical drug therapy problems.¹⁸

In the predominant healthcare delivery model, physicians have limited time to spend per patient, with an average visit for family practice and internal medicine physicians lasting 20.9 and 22.4 minutes, respectively,19 which makes it challenging for providers to coordinate care plans, educate and assess for patient and/or caregiver understanding, manage complex medication regimens, and effectively address drug therapy problems in older adults. As a result, there has been growing interest to include pharmacists in geriatric interprofessional patient care teams, particularly by means of interdisciplinary team training, so that individuals of various disciplines may train together and ultimately incorporate knowledge, skills, and attitudes developed through the training in their future practice.²⁰ Pharmacists are the pharmacotherapy experts who may be optimally positioned to identify, resolve, and prevent critical drug therapy problems that may otherwise go unnoticed.

In addition to the inclusion of pharmacists, there is also a growing body of literature in having the interprofessional team follow patients across the different care settings. Various models involving interprofessional transitions of care teams have been described,^19,20 and have improved the various outcomes studied, such as 30-day readmission rates and healthcare utilization, 90-day readmission rates, and cost.^21,22 Other models have examined the outcomes of the specific roles of the pharmacist and student pharmacists during care transitions, including medication reconciliation,^23,24 but most of these models involve isolated transitions from one location to another (eg, home to hospital or hospital to home). Few programs have been described in which pharmacists are physically present and have direct patient care responsibilities in the coordination of care during transitions of all types (eg, hospital to skilled-nursing facility, skilled-nursing facility to home).

The Pharmacist-led Interventions on Transitions of Seniors (PIVOTS) geriatric practice model—which was previously described in detail with a clearly defined role within the team by other team members^25,26—is one potential practice model that addresses physician constraints and care discontinuity challenges that contribute to drug therapy problems in older patients. This geriatric practice model, through the University of Pittsburgh Medical Center (UPMC) St. Margaret, located in Pittsburgh, PA, has fully incorporated 2 clinical pharmacists, and more recently 2 geriatric pharmacy residents, into its patient care team, which consists of geriatric fellowship–trained physicians, geriatric psychiatrists, geriatric physician fellows, nurses, and social workers.

At the time of this study, 3 (and later 4) pharmacists provided direct patient care in 2 outpatient geriatric care centers, 2 skilled-nursing facilities, assisted-living facilities, and in the hospital on an inpatient geriatric service. These pharmacists perform continuous comprehensive medication management to fill in care gaps that are frequently missed in the current healthcare system. Although many patient–pharmacist encounters involved routine follow-up (eg, annual wellness visits), many of these encounters occurred as the patients transitioned from one location to another, including hospitalization discharge follow-up, comprehensive medication reviews on admission to skilled-nursing facilities, and as patients transitioned from their homes to assisted-living facilities. With geriatric providers rotating through the various levels of care, patients often see the same pharmacist at home, in the hospital, and at admission to skilled-nursing facilities.

Methods

This study was a retrospective chart review of electronic medical data from the UPMC St. Margaret Geriatric Care Center and Presbyterian SeniorCare between August 2014 and November 2015. The Institutional Review Board of the University of Pittsburgh approved this study.

Patients were eligible for study inclusion if they were patients of one of the UPMC St. Margaret Geriatric Care Center geriatricians and were seen by a pharmacist in one of the 2 outpatient geriatric care centers, 2 skilled-nursing facilities, or assisted-living facility at least 1 time during the study time frame. Because the pharmacists rounding on the inpatient geriatric service use a software system different from that used in the outpatient, assisted-living, and skilled-nursing facilities to document interventions, pharmacist interventions made at the inpatient level were not included in this study.

Data Collection

To document drug therapy problems, the pharmacists used the Assurance System, which is a state-of-the-art, Windows-based software designed specifically for the documentation of drug therapy problems by category (ie, unnecessary drug treatment, the need for additional therapy, the need for a different drug, dose too low, dose too high, adverse drug reaction, and nonadherence)4 and corresponding pharmacist interventions addressed in medication management services.

The pharmacists documented each drug therapy problem that they identified for each patient care encounter, including the type of drug therapy problem and the specific medications involved. Actions taken to resolve the problem were documented, including initiating prescription drug therapy, initiating over-the-counter drug therapy, changing the drug, changing the dose, changing the dosage form, changing the quantity of a medication prescribed, changing the dosing interval, discontinuing the drug, generic drug substitution, formulary substitution, drug or device use education, chronic disease education, providing a reminder device, initiating laboratory monitoring, initiating nonlaboratory monitoring, and eliminating patient barriers.

Anticoagulation encounters in which the international normalized ratio (INR) was in range did not count toward the total drug therapy problem count unless an additional problem was identified by the pharmacist during the encounter. When a pharmacist deemed it appropriate, a value was assigned to the estimated 90-day impact of the intervention. The options in savings included various 90-day monetary amounts (ie, ≤$10, $11-$25, $26-$50, $51-$100, $101-$200), emergency department visits, home healthcare visits, hospital admissions, long-term care admissions, nursing or other provider visits, office visits, multiple office visits, specialist office visits, and urgent care visits.

The pharmacists also used the Assurance System to document the location where the patient resided (ie, outpatient clinic, assisted-living facility, skilled-nursing facility). Patients were categorized by index location, which is defined as the location at which they resided at the time of the first patient–pharmacist encounter in the 15-month data collection period. Other patient characteristics collected included age, sex, list of chronic conditions, and medications. Pharmacist–patient encounters at transitions of care were labeled as such so that the number of care transitions could be determined for each patient.

Analytics Approach

At the end of the 15-month period, reports were run through the Assurance System, and the data were analyzed in IBM SPSS Statistics 24 (IBM Corporation; Armonk, NY) to address the specific aims.

Descriptive statistics were used to characterize the overall complexity of the sample, as well as by index living location. We made formal comparisons between the patient groups using one-way analysis of variance for continuous variables and chi-square tests for categorical variables.

The percentages of drug therapy problem types that fell into each category were calculated, and the drug therapy problems were analyzed by the medication involved to determine the percentage of problems that were related to each medication. Actions taken by the pharmacist to resolve drug therapy problems were also described using descriptive statistics.

The estimated number of emergency department visits, home health visits, hospital admissions, long-term care admissions, office visits, nursing or other provider visits, and specialist office visits were added together, and the corresponding dollar amounts were calculated. This value was added to the estimated dollar amount that was saved.

Results

In the 15 months of data collection, 452 patients were seen, for a total of 3309 patient–pharmacist encounters, in which 3100 drug therapy problems were identified by a pharmacist (Table 1). The majority (48.7%) of patients resided in a skilled-nursing facility at the time of the first encounter, 42% of patients were living at home and were seen in an outpatient geriatric clinic, and 9.3% resided in an assisted-living facility.

The mean patient age was 81.4 years (standard deviation [SD], ± 9.3 years), with the oldest patients living in an assisted-living facility (mean age, 86.4 years; SD, ± 5.2 years), and the youngest patients living at home (mean age, 79.1 years; SD, ± 9.5 years); 70.8% of the patients were female. For each patient, the pharmacist identified a mean of 6.9 ± 7.1 drug therapy problems over the 15-month time frame.

Drug Therapy Problems

Across all care settings, the most common drug therapy problems were a dose too low (33.6% of drug therapy problems) and a dose too high (25.7% of drug therapy problems). Other common drug therapy problems were needing additional therapy (11.6% of the problems) and adverse drug reaction (9.1% of the problems). Examples of dose too low include ineffective doses, inappropriate frequencies or durations, incorrect storage or administration, and drug interactions causing concentrations to decrease. Specifically, a patient could have been receiving a low-intensity statin when a moderate-intensity statin would have been warranted, or a therapeutic bridge with enoxaparin to warfarin that needs to be continued for a longer duration as a result of persistently subtherapeutic INRs. The Figure depicts the percentage of drug therapy problem type at each level of patient care.

Pharmacists intervened on 275 different medications or dietary supplements. The agents that were most frequently associated with problems in this patient population were those that are generally used to manage geriatric syndromes and common geriatric disease states, such as constipation, osteoporosis, osteoarthritis, atrial fibrillation, and heart failure. The medication that was most often associated with problems was warfarin, and 1310 (42.3%) of the 3100 drug therapy problems involved warfarin. The second most common agent associated with drug therapy problems was enoxaparin, followed by insulin (all types), acetaminophen, aspirin, calcium, vitamin D, and metoprolol (both formulations; Table 2).

Pharmacists identified drug therapy problems on a much wider variety of medications for patients who resided at home, because only 20.4% of the drug therapy problems for home-dwelling patients involved warfarin. After warfarin, the 3 agents that were the most often associated with problems and the corresponding interventions included acetaminophen, insulin, and calcium. In the assisted-living setting, the 3 agents that were associated with the greatest number of problems after warfarin were enoxaparin, acetaminophen, and aspirin, whereas the 3 most common agents associated with problems in the skilled-nursing facility were enoxaparin, insulin, and calcium.

During the 15-month data collection period, pharmacists provided 4921 interventions for the drug therapy problems they identified (Table 3). The most common overall intervention was to initiate laboratory monitoring (32.8%), followed by the recommendation of a dose change (28.8%). The third most common intervention at the assisted-living level of care was the initiation of nonlaboratory monitoring (3.6% of interventions for patients residing in an assisted-living facility), whereas discontinuation of a drug was the third most common pharmacist intervention for patients living at home (12.9%) or in a skilled-nursing facility (6.8%). Of the interventions made for home-dwelling patients, 12.9% involved the discontinuation of a drug (vs 3.5% and 6.8% for patients residing in an assisted-living or a skilled-nursing facility, respectively), and 15.8% involved disease or drug/device use education (3.7% and 1.5% for patients residing in an assisted-living or a skilled-nursing facility, respectively).

The pharmacists estimated that their interventions prevented 25 emergency department visits, 4 home health visits, 21 hospital admissions, 3 long-term care admissions, 35 office visits, 14 nursing or other provider visits, 7 specialist visits, and 4 urgent care visits (Table 4). The estimated cost-savings from this 15-month period was between $335,862 and $338,239 (or $268,690-$270,591 annually). The prevented long-term care admission costs were not included in this calculation, because of the high degree of variability in cost (ie, short-term rehabilitation vs long-term residence).

Discussion

Drug therapy problems, which are a major cause of morbidity, mortality, and hospitalizations in older adults, are prevalent in the geriatric patient population across the various levels of care and at transitions from one care setting to another. This study shows that pharmacists identified and addressed a large number of drug therapy problems within the context of this innovative PIVOTS interprofessional care model, while preventing many visits to the emergency department, urgent care, other office visits, and hospitalizations. We are unaware of previous research exploring pharmacist identification, resolution, and prevention of drug therapy problems in older adults across the various care settings. This study offers 3 additional results that suggest ways that pharmacists are of particular benefit to the care of geriatric patients as they transition into and out of various care settings.

First, older adults are a medically complex patient population. With a mean of 12.2 medications and 6.6 conditions per patient in the study sample, this population requires extra attention and contact with the healthcare system to minimize the existing drug therapy problems. These findings reinforce the need for pharmacists to provide medication management to these particularly complex patients, especially as they transition through the various levels of care.

Second, although 42% of the drug therapy problems identified in this study involved anticoagulation monitoring, pharmacists continue to provide a wide range of medication management, which is evident by their 3100 interventions for 275 unique medications. Many of the medications that are the most frequently associated with drug therapy problems in this patient population are implicated in the various geriatric syndromes and disease states, such as falls, constipation, osteoarthritis, osteoporosis, atrial fibrillation, and heart failure. For example, insulin and metoprolol were the third and eighth most common medications, respectively, requiring intervention.

As a result of the many factors associated with aging, including gait instability, cognitive dysfunction, depression, urinary incontinence, and the use of sedative medications, older adults are at an increased risk for falls,^27,28 particularly when blood glucose, heart rate, or blood pressure are suboptimal.29,30 Calcium and vitamin D were the sixth and seventh most intervened on agents, respectively. Adequate calcium (1200 mg/day for women aged ≥51 years and men ≥71 years; 1000 mg/day for men aged 50-70 years) and vitamin D (800-1000 IU/day if aged ≥50 years) are recommended by the National Osteoporosis Foundation in all women, which may confer benefit in the prevention of fractures and vitamin D in the prevention of falls.³¹ In addition, pharmacists made many interventions related to pain management and the optimization of bowel regimens, which indicates the necessity to recognize and have the ability to manage various geriatric syndromes.

Although the most common interventions were laboratory monitoring and dose change recommendations for safety and efficacy, pharmacists also provided services such as medication reconciliation at care transitions, chronic disease education, reminder devices (eg, pill boxes and calendars), and recommendations to change dosage forms. Meaningful interventions such as these are made possible by pharmacists to improve access to care for patients with drug therapy problems, while freeing physicians and other staff to care for other patients.

Finally, drug therapy problems vary across the levels of care. Home-dwelling patients generally had more drug therapy problems associated with adherence and unnecessary drug therapy than patients at the other care settings. Because many home-dwelling patients are heavily involved in their own care, pharmacists were able to work directly with the patients to ensure that drug therapy problems that are of concern to patients and providers could be addressed at the visit. In those situations, pharmacists were able to provide education, eliminate barriers (eg, cost), and discontinue medications to simplify medication regimens.

Limitations

This study has several limitations. First, we do not know the counterfactual, which is the number of drug therapy problems that would have been identified in this patient population under a traditional care model, and consequently, whether the actions in response to the identification of drug therapy problems would have been any different in that practice model. A 1993 study compared the number of interventions on drug therapy problems between a clinic that had a pharmacist versus one that did not have a pharmacist over a 2-week time frame, and found that the implementation of an intervention was significantly greater in the clinic with the pharmacist, with an estimated drug cost-savings of $176,724.32 Despite this lack of comparison for our own practice setting, a large number of drug therapy problems were identified and addressed for each patient, suggesting a high patient need and a high value of employing a pharmacist in this manner.

Second, there were limitations to the data collection process. Because the Assurance System is not interfaced with the electronic health record, drug therapy problems and interventions were entered separately from routine clinical documentation. As a result, pharmacists were double documenting interventions, once in the medical record and once in the Assurance System. Anticoagulation encounters are repetitive and were systematically entered into the Assurance System as a part of their anticoagulation workflow. By contrast, nursing home admissions were usually documented in the health record in real time, whereas drug therapy problems and interventions were entered at a later date, which could account for missing interventions.

In addition, it was difficult to capture every single intervention made by a pharmacist, because of busy schedules and high volumes of work. Many recommendations were made “on the fly” as a response to a verbal drug information question posed to a physician in passing or quickly to a patient. These interventions may not have all been entered into the Assurance System. Care transitions were also challenging to document and are immensely underestimated. Because of the capabilities of our data collection methods, the patients who transitioned from one level of care to another remained at the level of care that they initially presented during the analysis.

Regarding the 90-day impact documentation, pharmacists were hesitant to predict when large savings were made (eg, hospital admission prevention), and long-term care admission prevention was not included in the cost estimation because of the significant variability in length of stay (ie, short-term rehabilitation vs long-term care). For these reasons, the calculated financial impact is likely to be grossly underestimated.

Finally, the number of anticoagulation encounters makes it challenging to fully observe any differences in drug therapy problem and intervention type across care settings. All encounters involving anticoagulation resulted in pharmacists advising patients to return for follow-up INR monitoring at a time that was specified by the pharmacist. Therefore, the recommendation of laboratory monitoring was entered as an intervention for all of these encounters. In addition, if the patient required a dose change, “dose too high” or “dose too low” was documented, which falsely skewed the data to show a greater incidence of these drug therapy problems. In the future, we plan to conduct an analysis on nonwarfarin drug therapy problems during anticoagulation encounters to further quantify the scope of service that pharmacists provide.

Conclusion

Geriatric clinical pharmacists provide a wide range of services, including dose change and laboratory monitoring recommendations, deprescribing, the initiation of essential medications, and medication and device education, to older adults across all care settings. These interventions resulted in significant cost-savings and harm reduction through the prevention of unnecessary hospitalizations, office visits, and visits to the emergency department. Positioning pharmacists across all care settings allows them to make many recommendations in real-­time to patients and their physician colleagues to prevent harm and to optimize clinical outcomes in this complex patient population.

The medications that are frequently involved in drug therapy problems in this patient population are often implicated in the treatment of geriatric syndromes, as well as in the potential to cause problems when combined with geriatric syndromes. For this reason, it is essential that pharmacists with a strong passion and training in geriatric medicine be incorporated into the care of this high-risk patient population in the outpatient setting, as well as across all levels of care and at care transitions. These findings lay a foundation to examine the effect of these interventions, particularly those at care transitions, on patient outcomes and to create a sustainable, replicable, and transferable interprofessional practice.

Acknowledgments

The authors would like to thank Chelsea Hawley and Camden Harley for assistance with data entry, as well as Ashley Higbea, PharmD, BCPS, and Nicole Payette, PharmD, BCPS, for their contributions to the PIVOTS group.

Funding Source

This study was supported by grant funding from the Jewish Healthcare Foundation and the ASHP Research and Education Foundation.

Author Disclosure Statement

The authors have no conflicts of interest to report.

Dr Campbell is Assistant Professor, Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson; Dr Coley is Professor, Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, PA; Dr Corbo is Clinical Pharmacy Specialist, South Texas Veterans Health Care System, San Antonio; Dr DeLellis is Assistant Professor, Pharmacy Practice, Manchester University College of Pharmacy, Natural & Health Sciences, Fort Wayne, IN; Dr Joseph is Clinical Pharmacist, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center (UPMC); Dr Thorpe is Associate Professor, Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, and Research Health Scientist, VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Dr McGivney is Associate Dean for Community Partnerships and Associate Professor, Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy; Dr Klatt is Clinical Pharmacist, UPMC St. Margaret; Dr Cox-Vance is Chief, Geriatrics and Extended Care, Chillicothe VA Medical Center, OH; Dr Balestrino is Director, Geriatric Services, UPMC St. Margaret; Dr Sakely is Clinical Pharmacist, UPMC St. Margaret.

This study was presented at the American Geriatrics Society Annual Meeting 2015, the Society of Teachers of Family Medicine Annual Meeting 2015, and the Pennsylvania Academy of Family Physicians Research Day 2016.

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