Research Question Development



Reducing hospital readmissions in heart failure patients using bedside pharmacy services prior to discharge to assure patients fill prescriptions

Shawn Z Stewart, RN, BSN, CCM

Thomas Edison State College

Nur-530 NG001

Dr. Donna W. Bailey

October 25, 2009

Introduction

Preventing future exacerbations and readmissions for heart failure patients is an important goal that nursing strives for using multiple interventions. I am interested in this area because I believe that more can be done to help prevent readmissions. Sometimes education and instruction are just not enough. My question has been developed utilizing the population, intervention of interest, comparison of interest, and outcome of interest framework (PICO) (Melnyk & Fineout-Overholt, 2005).

My research question is, “Will providing bedside prescription services prior to discharge from the acute care setting result in a reduction in the number of acute care readmissions within 30 days for patients with heart failure?”

Research Summary/Supporting Literature

The research provides a variety of studies done to indicate that medication adherence plays a significant role in whether or not a heart failure patient will experience an acute care readmission. The readmission time frame utilized for this research question is 30 days. The studies below include randomized control studies, cross-sectional surveys, and a systematic review.

Al-Rashed, Wright, Roebuck, Sunter, and Chrystyn (2002) completed a randomized control trial to assess the effects of interventions developed to reduce unplanned visits to the doctor and readmissions to the acute care setting. This was a randomized control trial that focused on elderly people in the hospital who were being discharged to the community. The study included elderly patients who were being discharged with more than four medications. The study group included 43 patients and the control group maintained 40. The mean ages were 80.2 and 81.1 respectively. Each group had an average of 7.1 prescriptions. The intervention was inpatient pharmaceutical counseling done prior to discharge. Results were gathered via interview in the patient's home setting at 2-3 weeks and at 3 months to determine knowledge and compliance of medication regimen. The authors concluded that Inpatient pharmaceutical counseling linked to medication and information summary contributed to reduced unplanned visits to the physician and reduced readmissions.

Esposito, Bagchi, Verdier, Bencio, and Kim (2009) completed a systematic review using Medicare and Medicaid data of medication adherence to determine incidence of emergency department visits and re-hospitalization. The analysis was a retrospective study of Medicaid patients with congestive heart failure (CHF). Multivariate logistic and 2-part linear models were estimated for studying objectives. Beneficiaries were selected if they were hospitalized in 1998 with congestive heart failure or had at least two ambulatory visits in 1998 with a primary diagnosis of congestive heart failure. Adherence was based on an estimation using the medication possession ratio (MPR) and looking at all CHF drug claims data. Adherent beneficiaries were less likely to have a hospitalization and had fewer emergency department visits when compared with non-adherent beneficiaries.

Kripalani, Henderson, Jacobson, and Vaccarino (2008) completed a cross sectional survey to determine medication related problems after discharge from an acute care setting. This study included 84 patients who were discharged after an acute hospitalization with an acute coronary syndrome. The population included both male and female patients, with a mean age of 54.5 years. They conducted interviews and then contacted via telephone approximately 2 weeks later. The results showed that only 40% filled their medications on the day of discharge, 20% filled them 1 or 2 days later, 18% filled prescriptions from day 3 to 9, and 22% had not yet filled their medications ordered on discharge.

Wroth and Pathman (2008) conducted a cross sectional survey to determine primary medication adherence in the rural population. The study utilized a sample population of adults in 150 rural counties in 8 southeastern states. Of the 3,926 respondents who had received care within the previous year, 894 (21.6%) reported that they had delayed or did not fill prescriptions over that time.

Nimpitakpong, P. (2002) completed a randomized control trial to study to evaluate the effect of pharmaceutical medical intervention to impact patient adherence post discharge from an acute care stay and reduce hospital readmission. This randomized control trial study of 125 patients with congestive heart failure who were put in either experimental or control groups to evaluate effectiveness of the pharmaceutical consultation intervention. The experimental group received a pharmacist discharge consultation, follow up visit with home interview. The home interview included a pill count conducted by the researcher. The study concluded that pharmacist intervention can improve heart failure patient's behavioral outcomes and reduce the number of hospital readmissions.

Maniaci, M., Heckman, M., & Dawson, N.. (2008) completed a cross sectional survey to determine medication related problems after discharge from an acute care setting. This study was conducted to assess patients who were discharged from an acute care setting and their knowledge of newly prescribed medication. Only patients with one or more newly prescribed medications were eligible to participate. The sample group included 100 patients with a mean age of 63.1 years. The study concluded only 86% of participants were aware that they were prescribed new medications and a mere 64% could identify the name or number of new medications.

Conclusion

The research selected has been evaluated and although each had its own limitations, they indicate that knowledge and education lead to adherence. Furthermore, they demonstrate adherence leading to a decrease in re-hospitalizations. This proposed study question, “Will providing bedside prescription services prior to discharge from the acute care setting result in a reduction in the number of acute care readmissions within 30 days for patients with heart failure?” seeks to more explicitly prove that improving patient convenience in obtaining education and medications will result in a decrease in readmissions.

Reference

Al-Rashed, S., Wright, D., Roebuck, N., Sunter, W., and Chrystyn, H. (2002). The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. British Journal of Clinical Pharmacology, 54(6), 657-664. Retrieved October 3, 2009.

Esposito, D., Bagchi, A., Verdier, J., Bencio, D., & Kim, M. (2009). Medicaid beneficiaries with congestive heart failure: Association of medication adherence with healthcare use and costs. American Journal of Managed Care, 15(7), 437-445. Retrieved October 5, 2009.

Kripalani, S., Henderson, L., Jacobson, T., & Vaccarino, V. (2008). Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions. Mayo Clinic Proceedings, 83(5), 529-535. Retrieved October 3, 2009.

Maniaci, M., Heckman, M., & Dawson, N.. (2008). Functional health literacy and understanding of medications at discharge. Mayo Clinic Proceedings, 83(5), 554-8. Retrieved October 3, 2009

Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing &

healthcare :A guide to best practice. Philadelphia: Lippincott Williams &

Wilkins.

Nimpitakpong, P. (2002). The effects of pharmacist interventions on patient adherence and rehospitalization in CHF patients in Thailand (Doctoral dissertation, University of Wisconsin, Madison, WI). Retrieved October 8, 2009.

Worth, T. H., and D. E. Pathman. (2006). Primary medication adherence in a rural population: The role of the patient-physician relationship and satisfaction with care. The Journal of the American Board of Family Medicine, 19 (5): 478. Retrieved October 15, 2009.

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