Impact of a pharmacist-led substance use disorder transitions of care clinic on postdischarge medication treatment retention

Bridging the continuity: Practice-enhancing publications about the ambulatory care medication-use process in 2021

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2021 that can impact ambulatory pharmacy practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement.

SUMMARY

A PubMed search was conducted in January 2022 for the year 2021 using targeted Medical Subject Headings keywords and the tables of contents of selected pharmacy journals were also searched, providing a total of 6,026 articles. A thorough review identified 86 potentially practice-enhancing articles: 10 for transitions of care, 9 for prescribing and collaborative practice, 20 for adherence, 17 for accessing care, 18 for monitoring and quality, and 12 for monitoring and medication therapy management. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article continues a series of articles defining and evaluating the currently published literature around the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Synchronous telepharmacy models of care for adult outpatients: A systematic review

BACKGROUND

Telephone and video consultations have been used as telepharmacy modalities for a number of years, particularly during the COVID-19 pandemic where in-person services were limited. However, a widespread global literature review has yet to be completed on studies since June 2016 regarding the effectiveness of telephone and video consultations as telepharmacy models.

OBJECTIVES

The aim of this review was to summarise the synchronous telepharmacy models of care for adult outpatients since June 2016. The secondary aim was to report on the effect of these models on clinical, service, and user-perspectives and non-clinical outcomes compared to the standard model of care, as well as facilitators and barriers of the telepharmacy models.

METHODS

A PROSPERO registered systematic review was conducted using PubMed, CINAHL, and Embase in March 2023. Key search terms included pharmacy, telepharmacy, and outpatient; data extraction and narrative analysis were then performed and NHMRC level of evidence determined.

RESULTS

From 2129 unique articles reviewed, 103 were eligible for inclusion. Synchronous telepharmacy services in an outpatient setting were delivered by telephone consultations and video consultations, with the majority being delivered by the telephone modality (87 %) and the remainder by video (13 %). Services primarily involved a pharmacist providing a single consultation with a patient. The purpose of this was either to provide counselling, obtain a best possible medication history, or to provide ongoing support as part of a clinical program, such as diabetes and blood pressure monitoring. Patients reported the quality of care received through telepharmacy consultations provided the same level of care or was superior to in-person services. Key facilitators for the success of telepharmacy services were access to training, technical assistance, digital literacy and availability of technology.

CONCLUSIONS

Telephone and video telepharmacy services are being delivered across a range of outpatient clinical areas. More evidence is needed for video consultation services and how this modality may potentially provide further benefit for certain clinical tasks such as counselling and use of medication delivery devices. Overall, telepharmacy services enhance patient accessibility to healthcare and offer a convenient method of delivering high quality services.

Factors associated with presentation to the emergency department during an intensive post-discharge intervention in patients with substance use disorders

BACKGROUND

Early identification of patients with substance use disorders (SUDs) with a higher risk of emergency department (ED) presentations after being discharged can be useful. We performed a chart review of patients from the Intensive Recovery Discharge Team (IRDT) program, which provides two weeks of outpatient support for patients with SUDs discharged from a mental health hospital.

METHOD

Demographic, service utilization, and clinical data from 716 patients enrolled in IRDT from February 2021-February 2023 were extracted from electronic health records. Receiver operating characteristic (ROC) analysis was performed to identify risk factors associated with increased ED presentations during the two weeks of IRDT follow-up with five-fold cross validation.

RESULTS

In two years, 10.7% of IRDT patients presented to the ED during the 2 weeks of follow-up. Having been enrolled in IRDT more than once, not having opioid use disorder (OUD), and self-identifying as male was associated with ED presentations, where an average of 20.1% of patients with all three risk factors presented to the ED. The presence of comorbid mental disorders did not emerge as a significant predictor.

DISCUSSION

Our results suggest that patients who had previous inpatient admissions, a SUD other than OUD, and/or self-identify as male have a higher risk of presenting to the ED post-discharge and may benefit from more intensive follow-up. Larger studies involving multiple sites are required to validate the generalizability of our findings. Findings from our study can be used to guide future studies examining post-discharge programs in patients with SUDs with and without comorbid mental disorders.

Improving Linkage for Patients With Injection-Drug-Use-Related Endocarditis and Osteomyelitis to Medications for Opioid Use Disorder Through a Telephone Intervention

ABSTRACT

The opioid overdose crisis has continued to worsen, with a concomitant increase in serious injection-related infections, such as endocarditis and osteomyelitis. Usual care of these infections involves long-term intravenous antibiotics, typically administered via a peripherally inserted central venous catheter (PICC) at home. In patients with a history of opioid use disorder who inject drugs, a PICC has long been viewed as a high-risk intervention that may contribute to illicit substance use due to ease of venous access; thus, providers are often uncomfortable discharging these patients home to complete their antibiotics. As a result, many patients remain hospitalized or are discharge to skilled nursing facilities (SNFs) in order to complete their antibiotics. Challenges to this model include difficulty finding SNFs that will accept these patients, inability for these SNFs to continue their medication for opioid use disorder (MOUD), and inability to coordinate care with outpatient MOUD providers at SNF discharge. This quality improvement project sought to increase linkage to outpatient MOUD on SNF discharge via a telephone intervention. A total of 11 patients qualified for this intervention. Although patients were still in an SNF, 4/7 (57.1%) of patients were successfully contacted. Once they were discharged from the SNF, only 3/10 (30.0%) of patients were successfully reached. Of those 30.0% who were contacted, all of them had attended their outpatient MOUD appointment. We suggest that future linkage interventions in this population may benefit from utilizing existing care team members to facilitate linkage, to maximize the rapport built during an inpatient stay.

Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy

Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.

Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge

Importance

US Food and Drug Administration-approved medications for alcohol use disorder (MAUD) are significantly underused. Hospitalizations may provide an unmet opportunity to initiate MAUD, but few studies have examined clinical outcomes of patients who initiate these medications at hospital discharge.

Objective

To investigate the association between discharge MAUD initiation and 30-day posthospitalization outcomes.

Design, Setting, and Participants

This cohort study was conducted among patients with Medicare Part D who had alcohol-related hospitalizations in 2016. Data were analyzed from October 2022 to December 2023.

Exposures

Discharge MAUD initiation was defined as oral naltrexone, acamprosate, or disulfiram pharmacy fills within 2 days of discharge.

Main outcomes

The primary outcome was a composite of all-cause mortality or return to hospital (emergency department visits and hospital readmissions) within 30 days of discharge. Secondary outcomes included these components separately, return to hospital for alcohol-related diagnoses, and primary care or mental health follow-up within 30 days of discharge. Propensity score 3:1 matching and modified Poisson regressions were used to compare outcomes between patients who received and did not receive discharge MAUD.

Results

There were 6794 unique individuals representing 9834 alcohol-related hospitalizations (median [IQR] age, 54 [46-62] years; 3205 hospitalizations among females [32.6%]; 1754 hospitalizations among Black [17.8%], 712 hospitalizations among Hispanic [7.2%], and 7060 hospitalizations among White [71.8%] patients). Of these, 192 hospitalizations (2.0%) involved discharge MAUD initiation. After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of the primary outcome (incident rate ratio, 0.58 [95% CI, 0.45 to 0.76]; absolute risk difference, -0.18 [95% CI, -0.26 to -0.11]). These findings were consistent among secondary outcomes (eg, incident rate ratio for all-cause return to hospital, 0.56 [95% CI, 0.43 to 0.73]) except for mortality, which was rare in both groups (incident rate ratio, 3.00 [95% CI, 0.42 to 21.22]). Discharge MAUD initiation was associated with a 51% decreased incidence of alcohol-related return to hospital (incident rate ratio, 0.49 [95% CI, 0.34 to 0.71]; absolute risk difference, -0.15 [95% CI, -0.22 to -0.09]).

Conclusion and relevance

In this cohort study, discharge initiation of MAUD after alcohol-related hospitalization was associated with a large absolute reduction in return to hospital within 30 days. These findings support efforts to increase uptake of MAUD initiation at hospital discharge.

Transitions in care between hospital and community settings for individuals with a substance use disorder: A systematic review

BACKGROUND AND AIMS

Individuals with a substance use disorder (SUD) have high rates of hospital service utilization including emergency department (ED) presentations and hospital admissions. Acute care settings offer a critical opportunity to engage individuals in addiction care and improve health outcomes especially given that the period of transition from hospital to community is challenging. This review summarizes literature on interventions for optimizing transitions in care from hospital to community for individuals with a SUD.

METHODS

The literature search focused on key terms associated with transitions in care and SUD. The search was conducted on three databases: MEDLINE, CINAHL, and PsychInfo. Eligible studies evaluated interventions acting prior to or during transitions in care from hospital to community and reported post-discharge engagement in specialized addiction care and/or return to hospital and were published since 2010.

RESULTS

Title and abstract screening were conducted for 2337 records. Overall, 31 studies met inclusion criteria, including 7 randomized controlled trials and 24 quasi-experimental designs which focused on opioid use (n = 8), alcohol use (n = 5), or polysubstance use (n = 18). Interventions included pharmacotherapy initiation (n = 7), addiction consult services (n = 9), protocol implementation (n = 3), screening, brief intervention, and referral to treatment (n = 2), patient navigation (n = 4), case management (n = 1), and recovery coaching (n = 3).

CONCLUSIONS

Both pharmacologic and psychosocial interventions implemented around transitions from acute to community care settings can improve engagement in care and reduce hospital readmission and ED presentations. Future research should focus on long-term health and social outcomes to improve quality of care for individuals with a SUD.

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

BACKGROUND

The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.

OBJECTIVES

To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.

METHODS

This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.

RESULTS

A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.

CONCLUSION

Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.

Medication prescribing for alcohol use disorders during alcohol-related encounters in a Colorado regional healthcare system

RATIONALE

Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings.

METHODS

We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth.

RESULTS

We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD.

CONCLUSIONS

AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.