ORIGINALES

 

Multidisciplinary teams involved: detection of drug-related problems through continuity of care

Equipos multidisciplinares comprometidos: detección de problemas relacionados con los medicamentos a través de la continuidad asistencial

 

 

Elena Yaiza Romero-Ventosa¹, Marisol Samartín-Ucha², Alicia Martín-Vila³, María Lucía Martínez-Sánchez⁴, Isabel Rey Gómez-Serranillos⁵ and Guadalupe Piñeiro-Corrales⁶

^1,2,3,6 Pharmacy Unit, Hospital Álvaro Cunqueiro, Vigo. Pontevedra.
⁴ Primary Care in the Vigo Healthcare Area. Redondela Health Centre, Vigo. Pontevedra.
⁵ Primary Care in the Vigo Healthcare Area. Department of Cases without Hospitalization and Emergencies, Vigo. Pontevedra. Spain.

Correspondence

 

 

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ABSTRACT

Objective: To quantify Drug-Related problems (DRPs) by establishing a Strategic Continuity of Care Program (e-Conecta-Concilia Program; e-CC) focused on the drug therapy of patients within an Integrated Management Structure, in order to guarantee the therapeutical efficiency, safety and traceability of patients.
Method: A prospective study at 8 months. The project included 22 Hospital Pharmacists and 12 Primary Care Pharmacists. Electronic clinical records were used, which can be accessed by all healthcare levels.
Those interventions required in order to create a Standard Operating Procedure (SOP) were carried out (creation of working groups, computing, meeting points), for coordination among pharmacists in different care levels through a common communication system. The working groups formed by pharmacists of both care levels established the following inclusion criteria: patients with chronic diseases and polymedicated, patients for whom drug-related problems (DRP) had been detected, detection of any off-label use in Primary Care, or discrepancies in the standardization of medical prescriptions.
Results: In the setting of the e-CC program, interventions were unified and discrepancies were identified. During this project, 245 drug-related problems were detected; the majority regarding inadequate dosing, regimen, or duration (24%), and involving Group B medications (33%), according to the ATC classification.
Conclusions: The implementation of a Continuity of Care SOP between pharmacists allowed to detect and solve DRPs and discrepancies in patient pharmacotherapy, with a high rate of acceptance (84.1%) of interventions.

Key words: Continuity of Patient Care; Primary Care; Hospital Care; Pharmacists; Transitions of Care; Drug Related Problems; Polymedicated patients; Strategic Programs.

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RESUMEN

Objetivo: Cuantificar los problemas relacionados con los medicamentos (PRMs) mediante el establecimiento de un Programa Estratégico de Continuidad Asistencial (Programa e-Conecta-Concilia; e-CC) enfocado a la farmacoterapia de los pacientes pertenecientes a una Estructura Organizativa de Gestión Integrada, para garantizar la eficiencia, seguridad y trazabilidad terapéutica del paciente.
Método: Estudio prospectivo de 8 meses de duración. Participaron en el proyecto 22 farmacéuticos de hospital y 12 de Atención Primaria. Se utilizó la historia clínica electrónica accesible a todos los niveles.
Se llevaron a cabo las actuaciones necesarias para la creación de un procedimiento normalizado de trabajo (PNT) (creación de los grupos de trabajo, informática, puntos de encuentro) de coordinación entre farmacéuticos de diferentes niveles asistenciales con un sistema de comunicación común. Los grupos de trabajo constituidos por farmacéuticos de ambos niveles asistenciales establecieron los siguientes criterios de inclusión: pacientes con enfermedades crónicas y polimedicados, pacientes en los que se detectaba algún PRM, detección en Atención Primaria de un uso fuera de ficha técnica o discrepancias en la homologación de recetas sanitarias.
Resultados: En el seno del Programa e-CC se unificaron las intervenciones y se identificaron discrepancias. Durante este proyecto se detectaron 245 problemas relacionados con los medicamentos, siendo los mayoritarios los de dosis, pauta o duración no adecuada (24%) y los que afectaban a los medicamentos del grupo B (33%), según la clasificación ATC.
Conclusiones: La implantación de un PNT de Continuidad Asistencial entre farmacéuticos permitió detectar y resolver PRMs y discrepancias en la farmacoterapia de los pacientes, con un alto porcentaje de aceptación (84,1%) de las intervenciones.

Palabras clave: Continuidad de la Atención al Paciente; Atención Primaria de Salud; Atención Hospitalaria; Farmacéuticos; Transición Asistencial; Problemas Relacionados con los Medicamentos; Pacientes Polimedicados; Programas Estratégicos.

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Contribution to Scientific Literature

Transition of Care is a critical aspect in the healthcare system. Setting up multidisciplinary models that will guarantee an adequate Transition of Care is a key factor for our current healthcare model based on chronicity.

Our outcomes demonstrate the importance of including Pharmacists in multidisciplinary Continuity of Care Programs, in order to ensure treatment safety and efficacy.

 

Introduction

Over the year, cultural, technological and socioeconomic changes have occurred in society, which represent new challenges for the healthcare system structure. In our National Health System, healthcare is structured within the different autonomous communities, and the autonomic healthcare systems include all the centres and health institutions that will guarantee public healthcare, which should work together regardless of their healthcare level. One of the strategies by healthcare systems is to promote Continuity of Care through a patient-focused structured, which would overcome the traditional separation between Primary Care (PC) and Specialized Care (SC). Primary Care is the basic and initial level of patient care, which ensures the universality and continuity of care throughout the life of the patient, acting as manager, case coordinator, and flow regulator (Law 16/2003, of 17^th May). Specialized Care includes patient care in outpatient units, Day Hospital, hospitalization, support to PC at hospital discharge and, if needed, home hospitalization, mental health, and psychiatric care (Royal Decree 1030/2006, of 1^5th September.). An adequate healthcare service demands coordination between levels, and this becomes more important when the population is ageing and presents multiple health conditions.

Continuity of Care is a current priority for the different healthcare systems; this is confirmed by the Cohesion Program by the Ministry of Health and Consumer Affairs (e-Health) and the European Program epSOS¹, intended to improve the interoperability of healthcare systems in the national and European zone. These new initiatives are targeted to a change in a healthcare model still clinging to healthcare fragmentation, with communication gaps between hospital specialists, PCPs and patients. Innovation and technological development are acting as leverage for change in this sense; this is shown in the INNOVASAUDE and Hospital 2050 Projects by the Galician Health System².

One of the more widely accepted definitions of the Continuity of Care concept is the joint and shared view of healthcare work where multiple professionals are involved, in different centres, acting at different time points, with a common objective as their final outcome: the citizen³. Reid et al.⁴ have also defined Continuity of Care as the level of consistency and union of experiences in healthcare, perceived by patients over time.

According to the Healthcare Barometer by the Ministry of Health and Social Policy (collected in the SERGAS 2014 Strategy)⁵, there has been an increase in chronic conditions and patients with multiple health conditions, and therefore, the healthcare system reorientation towards chronic patients is one of the hottest topics in the healthcare system area ^6,7.

Different risk stratification models for the population are currently being developed in the PC setting of various autonomous communities, such as Galicia⁵, Madrid⁸ or the Basque Country⁹, based on disease self-management, health condition management, and case management. Strategic Plans for Chronic Patient Care¹⁰ by Pharmacy have even been developed with the support of scientific societies, such as the Spanish Society of Hospital Pharmacy. Another similar initiative is the Galician Program for Chronic Polymedicated Patient Care, called "Personal History of Use (current) of Other Medications Over a Long Time". This program consists in the preparation of a report by a PC Pharmacist for the PCP, included in the section of Determinants and Problems of the Electronic Clinical Record¹¹.

However, even though there are tools available for managing this type of patients, and there is interest in improving the coordination between levels, this collaboration is insufficient in daily practice.

The essential elements necessary in order to develop a Strategic Plan for Continuity of Care of this scope within a healthcare system structure are: organization, leadership, cooperation, access to the adequate software, inclusion in protocols, and establishing common communication systems. With the creation of integrated management organization structures (EOXIs) in Galicia, there are management areas available with executive teams and joint budgets. These aspects ensure the availability of an integrated electronic clinical record, which will be accessible to any professional within the healthcare system. The electronic clinical record of this community includes the electronic prescription, the hospital electronic prescription, diagnostic test results, clinical courses of outpatient visits, hospitalization episodes, PC episodes, and tele-consultations.

Our project consisted in the creation of a telematic Strategic Program for Continuity of Care, called e-Conecta-Concilia Program (e-CC), with its respective procedures for multidisciplinary action coordinated between SC and PC professionals. The primary objective of this project was to quantify the discrepancies or DRPs detected in patient pharmacotherapy within this setting.

 

Methods

A prospective study at 8 months (April-November, 2015), conducted in an EOXI managing a population of over 500,000 inhabitants, and formed by three hospitals (1,272 hospital beds) and 53 PC centres.

The coordination or cooperation between PC and SC Pharmacists was initiated with the creation of the healthcare area. The e-CC is a program of coordination with PC; it included 22 Hospital Pharmacists and 12 PC Pharmacists from healthcare centres. The common activities of Pharmacists from both levels were: healthcare standardization of prescriptions, medication information, and review of patient drug therapy.

The project was conducted in different phases:

- Phase I: Program Design. The whole team was led by the top authorities in each level of care (the Head of the Hospital Pharmacy and the PC Pharmacy Coordinator), who contacted those SC or PC physicians needed to participate in the e-CC Program. The Project leaders also conducted meetings and managed the creation of two work groups formed by 4 pharmacists (2 from each level of care). In this phase, the needs for detecting, communicating, solving and recording DRPs were also identified: circuit standardization, software management, network unification, and computer recording program.

- Phase II: Setting the pilot. The management of all software required was processed, and a computer platform was created, which was telematic and part of a network, for communication and record of discrepancies (with a classification agreed upon by consensus and validated, based on the Classification of DRPs and Negative Outcomes Associated with Medication (NOMs) by the Third Consensus of Granada ¹² (Table 1).

- Phase III: Project development, where DRPs were quantified. Once the circuits of activity among Pharmacists were standardized, whenever a discrepancy was detected in those patients who underwent a Transition of Care, the Pharmacist of reference contacted the PC or SC physician (according to each case), through a corporate warning e-mail, in order to solve the DRP. In Figure 1 we can see the circuit of action / communication between levels through a corporate warning e-mail. Besides, the discrepancies detected were classified in the e-CC Program, and DRPs were associated with these discrepancies (Table 2).

The following criteria for patient inclusion were established for DRP detection:

(1) Patients with chronic conditions and polymedicated that are discharged from hospital (Emergencies Unit or Short Stay Unit). As there is no consensus about the number of medications which defines the concept of polymedication, we adopted qualitative criteria (taking more medications than clinically adequate, whether prescribed by a professional or OTC).

(2) Patients for whom any DRP is detected, both in SC and in PC.

(3) Detection in PC of the off-label use of a medication.

(4) Discrepancies detected in prescription standardization.

The ATC Classification (Anatomical Therapeutic Chemical Classification System) was used to classify the medications object of the interventions.

DRP detection was targeted towards health education and the identification of warning signs in patients at risk (adverse reactions, interactions, dose adjustments, etc.).

Two quantitative process indicators were determined in order to quantify the information: the proportion of hospitalization units with a SOP for medication reconciliation at admission (MRA), and the proportion of hospitalization units with a SOP for medication reconciliation at hospital discharge (MRD). These indicators will allow to quantify the expansion of this program to other clinical units within the next years. This program was developed in the Emergency Unit and the Short Stay Unit, but in the future it will be extended to other clinical units, such as Cardiology, for example, and with these indicators we will be able to quantify the increase in patient care activity.

Regarding the statistical analysis, the qualitative variables analyzed in this article were expressed through frequency and percentage statistics.

 

Results

Two hundred and forty-five (245) interventions in 196 patients were recorded during the period studied.

The distribution of interventions by health centre and hospital was collected for statistical purposes (data not shown), and there was a balanced collaboration (53% of interventions were conducted at hospital, and 47% were conducted in health centres). The medications with more interventions conducted belonged to the group with action upon blood and hematopoietic organs (Group B, 33%), and on the nervous system (Group N, 21%). Within the largest group (Group B), direct-acting anticoagulants were the cause of the highest number of interventions (35%). The percentages in other groups were: Group A (alimentary tract and metabolism: 14%), Group C (cardiovascular system: 13%) and Group M (musculoskeletal system: 5%). Figure 2 shows the distribution of all interventions according to the ATC Classification. Ninety-one per cent (91%) of interventions were conducted on capsules, tablets, pills or powders, 3% on patches, 3% on inhalers, 2% on injectables, and 1% on eye drops. The DRPs which triggered the e-CC Program circuit are collected in Figure 3; the most frequent are: inadequate dosing, regimen, and/or duration (24%) and prescription errors (21%).

The process indicators for MRA and MRD were estimated. MRA has been standardized with a SOP in 9.5% of hospital units. Regarding discharge, MRD has been standardized in the Pulmonology Unit, Special Care Unit, and Cardiology (14.3% of the hospital units).

There was an 81.4% rate of intervention acceptance, and 6.1% of these were pending solution at the time of data analysis.

 

Discussion

The need for a more efficient coordination between hospital care and primary care^13,14 has become evident over the years; this has been demonstrated by the first publications on this topic¹⁵.

Continuity of Care is conducted beyond our country limits¹⁶ and besides, all healthcare professionals are involved. In many occasions, nursing staff¹⁷ is selected as the adequate staff for case management, but there are also publications which involve, as an additional value, SC and PC Pharmacists, as well as Community Pharmacists, in this on-going process¹⁸ within multidisciplinary teams.

In a study conducted in 2003 through discussion groups and open interviews, it was found that one of the concerns of patients were the barriers for access to specialized healthcare¹⁹. An aspect that has facilitated the integration of the different levels of care in our healthcare area has been the single electronic record, because it allows all healthcare professionals to access information. Another tool that has been useful for conducting this task was the Polymedicated Patient Program, coordinated from the Unit for Prescription Support of the Subdirectorate of Pharmacy¹¹.

There are experiences similar to ours in other autonomous communities; some of these strategies are: the "Service for Continuity of Care for Home Care" initiated in the Canary Islands, with a Liaison Nurse between Primary and Specialized Care²⁰; the Andalusian Health System also features this role²¹. The so-called Integrated Healthcare Organizations have been created in Catalonia²² and in the Basque Country²³. Our project is based on the role of the Pharmacist as the integrator of Continuity of Care in a multidisciplinary setting, who will communicate any DRP detected.

In a DRP study conducted by German Pharmacists, 271 DRPs were detected in 105 patients within a period of 6 months²⁴. Our study includes more patients and a lower number of interventions, but data are similar.

The drugs upon which more frequent interventions have been conducted are those included in Groups B, N, A and C. These data coincide with the medications upon which more interventions have been conducted in other studies described in bibliography^25,26. This result can be due to the fact that Group N medications are some of the most widely used^27; regarding Group B, this can be caused by the incorporation of new oral anticoagulants to the market. These medications are prescribed by specialists and are subject to standardization (in Galicia, this standardization is conducted by PC and SC Pharmacists).

The most frequent DRPs are similar to those described in bibliography. Thus, in the reconciliation study by Ucha-Samartin²⁸, the most common DRP was dosing/ inadequate interval.

The actions in this project were to detect and solve DRPs, and any DRP prevented translates into adverse reaction prevention, reduction of visits to Emergency, and even prevention of re-hospitalizations²⁹. Our project intends to add, improve, and provide new ideas to the concept of Continuity of Care, by involving the Pharmacist in patient care, and making them participate in the responsibility required by a safe and efficient drug therapy. The inclusion of the Pharmacist has a very important value in Continuity of Care, because this study was focused on healthcare education and identification of warming signs. A Pharmacist integrated in a multidisciplinary team will also be able to participate in the preparation of protocols for medication follow-up and reports, as well as acting upon adherence and other areas. The connection between the Primary Care Physician and the Primary Care Pharmacist and/ or the SC Physician and the SC Pharmacist already existed within the same level of care. The additional value of this project was to join SC and PC through Pharmacist groups, as they are the professionals who will detect the DRP and communicate it to the rest of the multidisciplinary team.

One of the limitations of this study is that an integrated clinical record is required for its extrapolation, and not all autonomous communities have access to this system. However, any country or autonomous community with Pharmacists in both levels (even from the Community Pharmacy setting), will be able to set up similar multidisciplinary models of action. On the other hand, our outcomes don't allow us to obtain data about the reduction in number of re-hospitalizations or preventable deaths, as these are not the object of our practice of care. In the future, it will be necessary to validate this program, to quantify the severity of the DRPs detected, and to measure the economic impact of their prevention. It will also be necessary to measure the benefit achieved by optimization the drug therapy of patients, increasing the safety of the Continuity of Care process.

Despite these limitations, we consider that the number of interventions is adequate in order to create awareness in professionals regarding the fact that Transition of Care is a real problem in our health system, regardless of the existence of integrated clinical records. The strengths of an on-going, safe and integrated Program for Transition of Care are: to ensure the best outcome in drug therapy for patients, and to guarantee access to the medication with an efficient and effective use. An adequate Transition of Care represents a challenge for the health system. If there is no adequate continuity, and the impenetrability of levels of care is not eliminated, DRPs will appear that can generate additional costs for the patient and the system; therefore, projects like this represent an improvement in patient care, as has been demonstrated by other studies³⁰.

Summing up, discrepancies / DRPs in patient records regarding drug therapy were detected and solved through the implementation of the e-CC Program among Pharmacists in both levels of care, with a high acceptance of interventions (84%).

 

Conflict of Interests

The authors hereby declare that there is no conflict of interests.

 

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Correspondence:
Correo electrónico: elena.yaiza.romero.ventosa2@sergas.es
(Elena Yaiza Romero-Ventosa).

Recibido el 3 de marzo de 2016;
aceptado el 15 de septiembre de 2016.