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Comprehensive and Collaborative Pharmacist Transitions of Care Service for Underserved Patients with Chronic Obstructive Pulmonary Disease

PRE-PROOF Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation PRE-PROOF Copyright Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation ©2020 Published online November 25, 2020 doi: https://doi.org/10.15326/jcopdf.2019.0175 Background Mortality risk from chronic obstructive pulmonary disease (COPD) increases significantly in the first year after a 30-day hospital readmission. Objective To evaluate a comprehensive and collaborative pharmacist transitions of care service for patients hospitalized with COPD compared to usual care. Design, Setting, and Participants This was an institutional review board approved, within-site, retrospective study, including underserved adult patients with a primary care provider at the study clinic, admitted to the affiliated hospital with a primary diagnosis of COPD exacerbation. Intervention The service comprised of discharge counseling, medication reconciliation, medication access assistance, therapy changes, and post-discharge long-term follow up. Main Outcomes and Measures The primary outcome was a 180-day composite of COPD-related hospitalizations and emergency department (ED) visits. Secondary outcomes were 30-, 60-, 90-, and 180day events, costs, pharmacist interventions, time to follow up, and pneumonia. Results Sixty-five patients were identified with a total of 101 index admissions. The mean age was 62.5 years, approximately 55.3% were female, and 67.7% were black or African American. The primary composite was significantly lower in the pharmacist intervention group compared to usual care [mean difference 0.82, P = 0.0364, 95% confidence interval (CI) 0.05-1.60], driven by lower 30-day hospitalizations in the intervention group PRE-PROOF Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation PRE-PROOF Copyright Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation ©2020 Published online November 25, 2020 doi: https://doi.org/10.15326/jcopdf.2019.0175 (mean difference 0.15, P = 0.0099, 95% CI 0.04-0.27). Within the intervention group, the primary composite was significantly lower after the intervention compared to before the intervention (P < 0.0247), driven by 30-day hospitalizations (P = 0.0019) and 30and 60-day ED visits (P = 0.0020 and 0.0310, respectively). Cost associated with COPD-related hospitalizations was significantly lower in the pharmacist intervention group compared to usual care ($173,808, P = 0.0330) as well as before intervention ($79,662, P = 0.0233). The most common pharmacist intervention was patient education. There was no significant difference in time to follow up or pneumonia. Conclusions A comprehensive, collaborative pharmacist transitions of care service significantly reduced 30-day COPD-related hospital readmissions, ED re-visits, and associated costs in an underserved population.

continuous readmissions. Around 20% of patients hospitalized for COPD exacerbation are readmitted within 30 days of discharge. Additionally, a history of 2 or more exacerbations in the previous year predicts the 30-day readmission of COPD patients (HR, 2.47; 95% CI, 1.51-4.05), suggesting that many opportunities exist to prevent readmissions and their associated consequences.
Pharmacists have been increasingly involved in reducing readmissions, with an array of activities including discharge counseling, medication reconciliation, therapy changes, dispensing, post-discharge phone calls, and face-to-face visits. 9-24 The National Transitions of Care Coalition supports pharmacist inclusion to help reduce readmissions. 25 Specific to COPD, pharmacist discharge medication reconciliation for elderly (N = 29) reduced 30-day readmissions from 22.2% to 16.0%. 9 Another study of pharmacists dispensing inhalers and providing discharge counseling (N = 620) reduced 30-and 60-day readmissions from 21.4% to 8.7% (p = 0.0016), and 33% to 23% (p = 0.0056), respectively. 10 A therapeutic interchange program for COPD patients was associated with reduced 30-day readmissions (8.3% of 1,535 control patients vs 5.8% of 1,350 intervention patients; P = 0.012), in addition to reduced average inhaled medication cost from $311 to $221 (P < 0.01). 11 The purpose of this study is to evaluate a comprehensive and collaborative pharmacist COPD transitions of care service.

Setting
The study site was a primary care internal medicine residency clinic located within a 536-bed community teaching hospital. Of approximately 2,000 total patients, time, attending physicians requested pharmacist involvement with transitions of care.
The hospital 30-day readmission rate for COPD was 19.6%, which was consistent with the national average. 26 For the transitions of care daily workflow (Figure 1), the pharmacist identified patients using an electronic health record (EHR) function called patient lists. All patients admitted to the hospital while the pharmacist was on service, whose primary care provider (PCP) was on the internal medicine residency team, were reviewed by the pharmacist, who then provided discharge counseling, medication reconciliation, medication access assistance, and therapy optimization (contacted physicians with recommendations and implemented changes).
After discharge, the pharmacist called patients by phone within 1 week to further evaluate medication use and symptoms (Figure 1). At clinic appointments, the pharmacist met with patients, PCPs, and nurses to complete medication reconciliation and assist with other interventions (e.g. vaccines, smoking cessation) and education.
During these visits, the pharmacist collaborated with the clinic social worker and financial counselor, as well as community pharmacies, if needed for medication access.
Following clinic visits, the pharmacist called patients monthly for 3 months, and then every 3-6 months. The pharmacist utilized teach-back during all patient interactions and provided handouts during face-to-face encounters.
Other pharmacist activities included COPD education to attending and resident physicians annually (1-hour lecture, 30-minute device education). Additionally, the procured and managed inhaled medication samples (bronchodilators, inhaled corticosteroids) for immediate access, and helped with long-term medication access as well. Pharmacy residents and students on rotation participated in all activities.
Design This is a retrospective study approved by the health system institutional review board. Adult patients were included if they had a PCP from a physician residency clinic and were admitted to the hospital with a primary diagnosis of COPD (diagnosis-related group codes beginning with J44.0 27 ) during a 3-year period (May 2016 through April 2019). Patients who received pharmacist intervention as described above were assigned to the intervention group; those who did not receive the service were assigned to the usual care group. Each new patient admission during this time period was counted as an index admission. Subsequent admissions for the same patients were only counted as additional index admissions if they occurred more than 180 days after the first index admission. Hospitalizations were excluded if they were not found in the EHR due to occurring within another health system without electronic charting or with an EHR that does not interface with the EHR used in the study, or for patients with PCPs outside the study health system. Station, Texas) was utilized to analyze data. 29 The estimated sample size needed was 50 index admissions (power = 0.80 with a 2-sided alpha of 0.05) to detect an anticipated 66% relative risk, presuming a readmission rate of approximately 35% based on internal data. Visit data, length of stay, and costs were compared using t-tests (paired t-tests for pre-post data). Pharmacist interventions were characterized with descriptive statistics.

Results
Sixty-five patients were identified with a total of 101 index admissions, the groups were matched according to baseline characteristics ( Table 1). The mean age was 62.5 years,  Table 2).
Cost associated with COPD-related hospitalizations was significantly lower in the pharmacist intervention group compared to usual care (mean difference $173,808, P = 0.0330) (Table 4), and compared to before intervention (mean difference $79,662, P = 0.0233) ( Table 5). The most common pharmacist interventions included patient education (30%), medication access assistance (23%), sending refill requests to PCPs (11%), therapy changes (8%), and smoking cessation support (8%) (Figure 2). The most common therapy change (59%) was the addition of a long-acting muscarinic antagonist ( Figure 3). Although numerically lower, there were no significant differences between usual care and pharmacist intervention regarding time to follow up (mean days to phone call 5.3 and 3.0, respectively, P = 0.2573; mean days to appointment 18.8 vs 12.7, respectively, P = 0.3126) or pneumonia (5 vs 2, respectively, P = 0.4378).

Discussion
The comprehensive pharmacist intervention resulted in significantly lower hospital admissions and ED visits. Pharmacists have also demonstrated reduced COPD readmissions in a variety of other settings. 9-11 A constellation of interventions with multidisciplinary collaboration can yield the most significant changes, as suggested by Eisenhower. 9 Our 30-day pre-post hospital admission comparison, a common outcome seen in the literature and associated with significantly increased mortality risk 2,3 , resulted in an absolute risk reduction of 22% and a relative risk reduction of 84.6%, exceeding those previously published (Table 5).
We attributed our outcomes to a collation of activities (discharge counselling, Between-group outcomes beyond 30 days, and pre-post outcomes beyond 60 days were not statistically lower in our study. It is possible that more frequent follow up should occur. For instance, after the first post-discharge PCP visit, we followed up every 1 to 6 months. Perhaps following up monthly or every 1 to 3 months would have a significant impact. Outcomes beyond 30 days were numerically lower and, therefore, could be clinically and financially meaningful. We also had a small sample size. A larger quality initiatives. Therefore, the pharmacist capture rate varied over time and was difficult to monitor (estimated around 50-80% during the study). We also did not capture patients with hospital visits in other health systems. Also, the pharmacist only intervened in patients who were admitted to the hospital rather than those who visited the ED without hospitalization. Some patients were not admitted to the hospital long enough for pharmacist identification. In 2019, the pharmacist implemented a new process to capture all patients who visit the hospital for COPD.
In 2017, the GOLD refined ABCD grouping such that pharmacotherapy recommendations are based on exacerbation history and symptoms, irrespective of spirometry. 37 Patients hospitalized with one or more COPD exacerbations in the past year are recommended to be at least on a long-acting muscarinic antagonist (LAMA).
The preferred next step is to add a long-acting beta agonist (LABA). Inhaled We selected outcomes based on data accessible to investigators and encourage others to adapt outcomes pertinent to their setting.