A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.

Recent studies of the growth of the hospitalist movement have confirmed that hospitalists are taking care of an increasing percentage of hospitalized older adults.1, 2 Unfortunately, few hospitalist groups have specific programs or protocols to address the special needs of older patients.3, 4 We were inspired by a top 10 article written by nephrologists for primary care physicians to compile 10 evidence‐based pearls that may be helpful to hospitalists caring for older persons.5

1. Many Health Conditions in Older Patients are Multifactorial and Require a Multifactorial Approach to Care

A geriatric syndrome is a multifactorial condition occurring primarily in frail elderly which is usually due to multiple contributing factors and results from an interaction between patient‐specific impairments and situation‐specific stressors.68 Geriatric syndromes cannot be treated easily with a single intervention; the approach must target each modifiable risk factor. Table 1 illustrates for an example of how this approach differs from the traditional medical approach in the case of falls, a common geriatric syndrome. Hospitalists commonly encounter the geriatric syndromes that either lead to hospitalization, such as falls or dementia, or that can complicate a hospitalization for another condition, such as delirium, falls, or urinary incontinence. Two geriatric syndromes in particular, delirium and falls, are associated with increased length of stay, increased healthcare costs, and substantial morbidity.9, 10 Multifactorial interventions such as the Hospital Elder Life Project (HELP) have been shown to prevent delirium and falls.1114 Studies of the HELP intervention demonstrated benefits on outcomes that are important to hospitalists, including shortened length of stay.10, 15 While implementing these interventions is not possible at every institution, it may be possible to implement some aspects in a targeted fashion (for example, early physical therapy and mobilization to decrease risk of delirium and falls) or to work with hospital administration to implement the larger interventions.

2. Screening Elderly Patients for the Presence of Common Geriatric Syndromes can Improve Care

Comprehensive geriatric assessment, a process of multifactorial health evaluation of the older patient, is an important part of geriatric medicine and has been shown to reduce functional decline.16 While comprehensive geriatric assessment may not be practical in the acute care setting, some basic principles and tools of geriatric assessment, namely screening for geriatric syndromes, can be helpful. Here is one efficient, evidence‐based approach to screening hospitalized elderly patients for cognitive impairment and falls, and then using the results of screening to improve care:

3. Elderly Patients are at Risk for Functional Decline During Hospitalization and Measures Can Be Taken to Prevent This

A cascade to dependency has been described in which the effects of usual aging (eg, fragile skin) and hospitalization (eg, immobilization) interact with each other, often producing complications (eg, pressure ulcers) that can lead to the loss of the ability to live independently.30 Functional decline during hospitalization is common and is associated with poor prognosis. In one study of elderly patients with new Activities of Daily Living (ADL) disability at discharge, over 40% were dead by 12 months after discharge, and only 30% had returned to baseline function.31, 32 Functional status may affect discharge planning, especially if the patient is not able to return safely to his or her previous living environment. Elderly patients are very vulnerable to new ADL dependency and loss of ambulatory ability as a result of a hospitalization.33, 34 The initial evaluation of an elderly patient should always include an inquiry into the patient's functional abilities, including whether the patient requires assistance to perform self‐care (ADL) activities or instrumental activities of daily living (IADLs), and who is available to help at home. We remember ADLs as those activities we learn as a young child (bathing, dressing, feeding, toileting, transfers) and IADLs as activities we learn when we leave our parents' home to live independently (shopping, cooking, laundry, housekeeping, managing money, using public transportation). Patients in assisted living facilities and adult family homes receive varying degrees of help with ADLs and IADLs, and no particular level of assistance can be assumed; assisted living residents may be at higher risk of functional decline during hospitalization than community‐dwelling persons.35

Acute Care of Elderly (ACE) units have been shown to reduce functional disability and discharge to long‐term care settings, with length of stay and hospital charges similar to that of usual care.36 Most hospitals do not have ACE units, but implementing some components of the intervention, such as early physical and occupational therapy, early discharge planning, early mobility, and adequate nutrition may reduce functional disability. A Cochrane review found a small decrease in length of stay of about a day among elderly patients who participated in a structured exercise program, which could be extrapolated to support the usefulness of increased mobility and early physical therapy.37

4. Delirium is a Common but Serious Condition Among Hospitalized Elderly Patients and in Some Cases Can Be Prevented

The incidence of delirium appears to be as high as 60% in hospitalized elderly patients with multiple risk factors for this condition.38, 39 Delirium predicts longer hospital stay, increases likelihood of discharge to a skilled nursing facility, and is a marker for significant morbidity and mortality.4042 Cognitive screening, as discussed above, can help determine who is at risk for delirium, and the Confusion Assessment Method (CAM) is becoming more widely used as a bedside screening tool for detecting delirium.43 Other important risk factors for delirium in addition to preexisting cognitive impairment include age over 65, prior delirium, polypharmacy, functional dependence, and sensory impairment.44 A landmark randomized controlled trial by Sharon Inouye et al. showed that delirium can often be prevented in high‐risk patients by ensuring frequent reorientation, maintenance of the patient's usual sleep‐wake cycle, early mobilization, adequate nutrition and hydration, and regular use of sensory aids such as glasses and hearing aids.11

When delirium does occur despite preventive efforts, it should trigger a thorough investigation for an underlying cause. Common contributing factors to delirium in hospitalized patients include infections such as urinary tract infections or hospital‐acquired pneumonia, pain, electrolyte abnormalities, cardiac ischemia, medication side effects, and urinary retention or constipation. Any psychoactive or anticholinergic medication can contribute to, or exacerbate, delirium; common culprits include diphenhydramine, benzodiazepines, and muscle relaxants.44 Although one or more treatable underlying causes should always be sought, many cases of delirium in the hospital are multifactorial.

If pharmacologic treatment for delirium is necessary, low‐dose haloperidol is the first‐line agent, starting with 0.25 mg intravenously or 0.5 mg by mouth, nightly to twice a day. A recent systematic review supported the use of haloperidol as a first‐line agent in the acute setting; second‐generation antipsychotics are an alternative, but studies have shown no benefits of these agents over haloperidol in terms of safety or efficacy.45 Physical restraints should be avoided in delirious patients, as they may actually worsen delirium and have not been proven to reduce falls or secondary injury.46

5. Treating Nondementia Illnesses in Hospitalized Elders With Dementia Requires Consideration of the Patient's Limited Life Expectancy and Cognitive Deficits

Elderly patients with dementia are frequently hospitalized for medical illness and pose special challenges to the hospitalist. Patients with dementia may not be able to accurately report symptoms and side effects of therapy, and may lack decisional capacity. The clinician should also carefully consider the benefits and burdens of a proposed therapy or diagnostic test, taking into account the patient's cognitive deficits and limited life expectancy.47 The median postdiagnosis life expectancy of a patient with Alzheimer disease is about 4 years for men and about 6 years for women, with a range from about 2 to 9 years, according to population‐based studies of incident Alzheimer dementia.48, 49 In a patient with early or mild dementia, the hospitalist may first need to establish whether the patient does indeed have dementia. It is also important to question family about how the patient is managing at home so that appropriate discharge plans can be made.

Any intervention such as surgery or intubation in a patient with dementia should be considered carefully in the context of the patient's dementia, keeping in mind the remaining life expectancy, increased risk for delirium after surgery, and potential difficulty with adherence to postoperative precautions or participation in rehabilitation. Invasive procedures such as mechanical ventilation or central line placement may not be indicated in patients with advanced dementia. In one prospective cohort study, patients with advanced dementia admitted to the hospital for hip fractures or pneumonia had much higher mortality than those without dementia, despite having equal rates of procedures such as mechanical ventilation and central line placement.50

A common scenario in a patient with advanced dementia is the patient presenting with decreased intake and dysphagia; family and/or caregivers inquire about enteral tube feeding and/or long‐term intravenous hydration. This situation requires a thoughtfully presented, informative discussion with the family about artificial feeding in advanced dementia. There is no evidence that artificial feeding improves outcomes, and a recent Cochrane systematic review found insufficient evidence to suggest that enteral tube feeding is beneficial in patients with dementia.5153 Instead, dementia patients at the end of their lives benefit from a palliative approach, which would include hand‐feeding for comfort if the patient indicates hunger.54

6. Frail Elderly Patients are at High Risk for Iatrogenic Complications During Hospitalization

Frail elders are at increased risk for iatrogenic complications, including surgical‐ and procedure‐related events, adverse drug events, nosocomial infections, pressure ulcers, and falls.5557 In the Harvard Medical Practice Study, a retrospective study of adverse events in 30,000 patients, those age 65 and over accounted for 27% of the hospitalized population but 43% of the adverse events. In this study, four types of adverse events occurred at least twice as often in older patients: fractures, falls, nontechnical postoperative complications, and adverse events related to noninvasive treatments.58 The risk of hospital‐acquired infection also rises dramatically with age; risk is ten times higher in patients over 70 than those aged 49 and under, with urinary tract infections and surgical site infections the most common.59 The oldest, most seriously ill and most functionally impaired elderly patients are at particularly high risk of cascade iatrogenesis, where one medical intervention triggers a series of adverse events.60 Frail elderly patients are at greater risk for adverse events during hospitalization, and careful consideration of the need for all diagnostic tests and procedures may reduce risks. Table 3 lists the iatrogenic complications that disproportionately affect the elderly.

7. Pain Should Be Aggressively Identified and Appropriately Treated

Adequate treatment of pain in the elderly can improve functional status, mobility, and mood. Clinicians are understandably wary of prescribing opioids in the elderly, but undertreatment of pain is also common and in hospitalized patients can lead to delirium, delays in rehabilitation, and higher healthcare costs.44, 61 Acetaminophen is generally safe and is recommended as first‐line therapy in most cases of pain. Nonsteroidal antiinflammatory drugs (NSAIDS) should be used with caution, as the risk of gastrointestinal toxicity increases with age; long‐acting agents such as toradol should be avoided.62 A study of adverse drug reactions causing hospitalization in elderly individuals implicated NSAIDs in 23.5% of cases.63 If a patient has severe pain that limits functional capacity but does not respond to acetaminophen, it is reasonable to consider low‐dose opioids. The 2009 American Geriatrics Society guidelines recommend that opioids be used for severe pain, especially when it limits functional capacity. Opioids should be given orally when possible and started at low doses (for example, 2.5 to 5 milligrams of oxycodone offered every 4 hours as needed). Either oxycodone or morphine can be used as a first‐line, short‐acting opioid, but morphine should be used cautiously in patients with renal insufficiency, as toxic metabolites are renally cleared. Methadone should be used very cautiously and ideally by clinicians experienced in its use because of its long and variable half‐life. Serotonin‐norepinephrine reuptake inhibitors such as duloxetine, and anticonvulsants such as gabapentin, can be helpful adjuncts for neuropathic pain; tricyclics should generally be avoided, because the elderly are particularly sensitive to the anticholinergic side effects (ie, sedation, orthostatic hypotension, urinary retention, constipation) of these agents.61 Nortriptyline, which has the least anticholinergic properties of this medication class, may be the best option if a tricyclic is desired.

8. Hospitalization Can Be an Opportunity for a Thorough Review and Reduction of Outpatient Medications in Collaboration With the Patient's Primary Care Provider

Adverse drug reactions (ADRs) are potentially life‐threatening for all patients, but elderly individuals are disproportionately affected. It is estimated that 30% of hospital admissions of older patients are due to drug‐related toxicity.64 The Beers criteria provide expert consensus on drugs that should either be avoided or used cautiously in the elderly; we have highlighted some of the drugs on the Beers list that are relevant to the hospitalist in Table 4. Notable inclusions on the most recent Beers list include nitrofurantoin, ferrous sulfate at dosages greater than 325 mg per day, doxazosin, and fluoxetine.65 Anticholinergics (such as oxybutynin) and cholinesterase inhibitors (such as donepezil) should not be used together, because the interaction makes them ineffective.

Many ADRs are caused by medications that are not on the Beers list but have narrow therapeutic windows, especially warfarin and insulin; digoxin, which is on the Beers list, is another common culprit in ADRs leading to emergency room visits.66 Medications that are clearly causing ADRs should be discontinued, with the knowledge and input of the primary care provider, and with written documentation on the discharge summary and clear instructions to the patient. Even when a hospital admission is not a result of an ADR, it may provide an opportunity to review the patient's medication list, clarify that the patient is taking medications as directed by their primary care provider, and determine if the list contains medications where risks now outweigh benefits, in which case those medications should be discontinued. Studies have shown that elimination of medications that are associated with falls reduces the risk of future falls.67 Adjustments to patient's medications should be made in close collaboration with the primary care provider and with a clinical pharmacist, if available.

9. Discharge Planning for an Elderly Patient Should Start Early, Be Comprehensive, and Involve the Patient and Caregivers

A successful discharge plan for an elderly patient must start early, take functional status into account, and perhaps most importantly, the planning process should involve the patient and family, if appropriate. One study of patients over 70 discharged from an urban, academic public hospital found that only 10% recalled receiving written discharge instructions, and only 53% who were prescribed a new medication actually had that medication at home.68 Growing evidence suggests that older patients have poorer functional health literacy regarding medications.69 Care transitions are an active area of research, and multiple studies have shown lower rates of rehospitalization with comprehensive transitional care programs involving transition coaches or advance practice nurses providing home visits and follow‐up telephone calls.70, 71 More research is needed in this area to develop simple, cost‐effective care transitions programs. In the meantime, hospitalists can actively involve a multidisciplinary team (pharmacists and social workers, for example) early in the hospitalization, provide more patient‐friendly discharge materials such as those available as part of the Society of Hospital Medicine's BOOST, and place targeted follow‐up phone calls after discharge.52, 7274 Ensuring that a frail elderly patient's primary care provider is aware of the hospitalization may be particularly important in avoiding postdischarge problems.75

10. Elderly Patients are Often Very Clear About Their Preferences for Treatment. Discussing This on Admission Can Help Clarify the Goals of the Hospitalization

The risks and benefits of any intervention being considered should be presented and discussed with the patient in the context of the likelihood of the intervention restoring an acceptable quality of life to the patient. Many common chronic conditions in the elderly such as Parkinson disease, congestive heart failure, and dementia are progressive and life‐limiting. Qualitative studies confirm that elderly patients want to know the likelihood that a proposed intervention will help them return to their previous level of functioning or a level that is acceptable to them.76, 77 In one prospective cohort study, older age was found to correlate with a higher rate of withholding ventilatory support, dialysis, and surgery.78 However, a more recent study has suggested that patient preferences are more dynamic, and that older patients will make decisions based on current health status rather than core values.76 While families should be involved in the process of clarification of goals of care, the patients' own values should be elicited whenever possible, with bedside assessment of decision‐making capacity to ensure that patients are allowed to speak for themselves if they possess decisional capacity for the decision at hand.79

Hospitalists should have a special approach to the elderly patient which takes into account the elder's increased vulnerability to iatrogenic complications and acute functional decline, the presence of geriatric syndromes, and individual preferences. Early assessment of an elderly patient's cognitive and physical functioning, level of pain, fall risk, and preferences for care are necessary for optimal inpatient care and may result in preserved function and a decrease in adverse events.