Ambulatory Medication Reconciliation and Frequency of Hospitalizations and Emergency Department Visits in Patients With Diabetes

Discharge order verification process to reduce prescription errors and optimize diabetes management

BACKGROUND

Prescription errors at discharge have a detrimental impact on patients, especially in high-risk populations like those with diabetes mellitus (DM). A team-based, patient-centered approach has been shown to reduce medication errors and improve patient outcomes. To address this, an inpatient pharmacist-driven initiative was implemented, focusing on a discharge order verification process to review and intervene on antidiabetic prescriptions before they are e-prescribed.

OBJECTIVE

The objective was to evaluate the effectiveness of a discharge order verification process in improving the prescribing of antidiabetic medications and supplies for DM patients before e-prescriptions are transmitted to community pharmacies.

METHODS

This proof of concept study ran over 4 weeks and included adult patients with a diagnosis of DM and who had at least one discharge order for the management of DM. Orders populated into a discharge verification queue built into the electronic health record (EHR) system. When an order was received, an investigator pharmacist reviewed the chart to determine appropriateness, evaluating medication safety, effectiveness, and accessibility. Interventions to address drug-related problems were made in real-time. Once verified, e-prescriptions were transmitted to community pharmacies. Pharmacist interventions were quantified and categorized. Data was collected on the intervention type, proportion of patients discharged on an optimized regimen, length of time an order remained in the queue, interventions unlikely to be detected without EHR access, and intervention acceptance and execution.

RESULTS

Overall, 152 orders were verified on 63 patients. Thirty-eight patients (60.3%) had at least one order requiring intervention, totaling 56 interventions made overall. The most common interventions were additional drug necessary (17.9%), counseling required (16.1%), incorrect instructions (16.1%), and dosing adjustment (14.3%). Twenty-eight patients (73.7%) left on a newly optimized medication regimen.

CONCLUSION

This service model introduced a discharge order verification process for pharmacists to review and intervene on antidiabetic prescriptions before transmission to a community pharmacy. Pharmacist interventions effectively corrected errors, with a high rate of provider acceptance and execution of recommendations.

Effectiveness of a Diabetes-Focused Electronic Discharge Order Set and Postdischarge Nursing Support Among Poorly Controlled Hospitalized Patients: Randomized Controlled Trial

BACKGROUND

Although the use of electronic order sets has become standard practice for inpatient diabetes management, there is limited decision support at discharge.

OBJECTIVE

In this study, we assessed whether an electronic discharge order set (DOS) plus nurse follow-up calls improve discharge orders and postdischarge outcomes among hospitalized patients with type 2 diabetes mellitus.

METHODS

This was a randomized, open-label, single center study that compared an electronic DOS and nurse phone calls to enhanced standard care (ESC) in hospitalized insulin-requiring patients with type 2 diabetes mellitus. The primary outcome was change in glycated hemoglobin (HbA1c) level at 24 weeks after discharge. The secondary outcomes included the completeness and accuracy of discharge prescriptions related to diabetes.

RESULTS

This study was stopped early because of feasibility concerns related to the long-term follow-up. However, 158 participants were enrolled (DOS: n=82; ESC: n=76), of whom 155 had discharge data. The DOS group had a greater frequency of prescriptions for bolus insulin (78% vs 44%; P=.01), needles or syringes (95% vs 63%; P=.03), and glucometers (86% vs 36%; P<.001). The clarity of the orders was similar. HbA1c data were available for 54 participants in each arm at 12 weeks and for 44 and 45 participants in the DOS and ESC arms, respectively, at 24 weeks. The unadjusted difference in change in HbA1c level (DOS - ESC) was -0.6% (SD 0.4%; P=.18) at 12 weeks and -1.1% (SD 0.4%; P=.01) at 24 weeks. The adjusted difference in change in HbA1c level was -0.5% (SD 0.4%; P=.20) at 12 weeks and -0.7% (SD 0.4%; P=.09) at 24 weeks. The achievement of the individualized HbA1c target was greater in the DOS group at 12 weeks but not at 24 weeks.

CONCLUSIONS

An intervention that included a DOS plus a postdischarge nurse phone call resulted in more complete discharge prescriptions. The assessment of postdischarge outcomes was limited, owing to the loss of the long-term follow-up, but it suggested a possible benefit in glucose control.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03455985; https://clinicaltrials.gov/ct2/show/NCT03455985.

Kolb L. An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care Behaviors™

PURPOSE

The ADCES7 Self-Care Behaviors^™ (ADCES7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the Association of Diabetes Care and Education Specialists (ADCES) that at the cornerstone of diabetes self-management education and support, the ADCES7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The ADCES7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management as well as diabetes self-management education and support, ADCES has evaluated the ADCES7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and ADCES's vision and expansion beyond diabetes to refresh the ADCES7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

An Effective Model of Diabetes Care and Education: Revising the AADE7 Self-Care Behaviors®

PURPOSE

The AADE7 Self-Care Behaviors^® (AADE7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the American Association of Diabetes Educators (AADE) that, at the cornerstone of diabetes self-management education and support, the AADE7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The AADE7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management, as well as in diabetes self-management education and support, AADE has evaluated the AADE7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and AADE's vision and expansion beyond diabetes to refresh the AADE7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.