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Information for Hospital Pharmacists
More Certified Geriatric Pharmacists practice in the hospital than in any other practice setting. The number of hospital pharmacists becoming board certified in geriatrics has been increasing rapidly in recent years. Discover the Top Ten Reasons Why Hospitals Need Board Certified Geriatric Pharmacists.
Benefits of Geriatric Pharmacists on Healthcare Teams
Jeannie K. Lee and colleagues published a systematic review and meta-analysis of the performance of U. S. geriatric pharmacists on healthcare teams. Twenty studies were included in the final analysis, conducted mostly in ambulatory clinics and inpatient hospital settings. The authors concluded: "Pharmacist intervention has favorable effects on therapeutic, safety, hospitalization, and adherence outcomes in older adults. Pharmacists should be involved in team-based care of older adults."
Changes in Hospital Reimbursement
During the hospital stay, the primary focus of hospital personnel has traditionally been on the acute condition that led to the hospitalization. The goal has been to restore the patient to function and discharge to a lower level of care.
The Centers for Medicare & Medicaid Services (CMS), however, has been implementing changes in the way that Medicare pays for the hospital care of older adults in the United States. Because nearly one in five older adults discharged from the hospital returns within 30 days, at an annual cost of $17.4 billion, Medicare is beginning to penalize hospitals with higher than expected rehospitalization rates. An important aspect of these transitions of care in older adults is medication reconciliation, a role for which pharmacists are particularly well suited. Medicare has also stopped payment for certain "never events" such as falls in the elderly and hospital-acquired infections.
CMS has established the Partnership for Patients, a public-private partnership working to improve the quality, safety and affordability of health care for all Americans. The Partnership is now focused on two goals: Making Care Safer, by decreasing preventable hospital-acquired conditions; and Improving Care Transitions, from one care setting to another, so that hospital readmissions will be reduced.
These changes provide an incentive for a greater understanding and application of principles of geriatric care to the older adult patients of hospitals. Certified Geriatric Pharmacists have demonstrated an understanding of these principles and the ability to focus on the total patient, not just the specific disease or problem that resulted in the hospitalization. Hospitals could benefit by having pharmacists with board certification in geriatrics.
The Geriatric Hospital Team
An increasing number of hospitals are adopting a formal interprofessional team approach to caring for older adult hospital inpatients. One example of this approach is the ACE (Acute Care of the Elderly) Program. This link goes to a brief video about the ACE program at Mt. Sinai Hospital, which includes Certified Geriatric Pharmacist Chris Fan-Lun on the team.
Nursing departments have often led the way in focusing on older adults in hospitals. The NICHE (Nurses Improving Care for Healthsystem Elders) and HELP (Hospital Elder Life Program) are two additional examples of hospital programs that focus on improving care for older adults. The HELP Program is especially focused on prevention of delirium and offers a variety of tools and resources on this topic.
In many hospitals, the Certified Geriatric Pharmacist is part of the team involved in planning and implementing care for older adult patients. As the population of older adults grows, more hospitals should adopt these programs and more pharmacists should get involved in these hospital programs.
Reports on Medication-Related Adverse Events in Hospitalized Older Adults
Recent reports have demonstrated that room for improvement exists with respect to use of medications in hospitalized older adults. Pharmacists with expertise in geriatrics could be very helpful to hospitals that seek to improve medication use in this population. Having pharmacists with board certification in geriatrics is also a way to demonstrate to accrediting bodies that the hospital is making efforts to address medication-related problems that are specific to older adults and Medicare beneficiaries.
- A report from the HHS Office of Inspector General (1) found that about 1 in 7 hospitalized Medicare beneficiaries experienced an adverse event. Of the adverse events identified, 31% were medication-related. Medication errors were also the leading cause of lethal adverse events in this study.
- A review of rates of patient harm in North Carolina hospitals (2) found that 25 harms were identified per 100 adult admissions. Of these harms, 28% were medication-related.
- A study reported in 2011 (3) found that one third of adult patients admitted to hospitals experience an adverse event. Medication-related events accounted for 38% of these events. Older patients were more likely to experience an adverse event. The average age of patients whose records were reviewed in this study was 59 years.
- A 2013 review article (4) updated the estimate of the annual number of premature deaths associated with preventable harm to patients, providing a revised estimate of 400,000 deaths per year in the United States. This makes medical errors the third leading cause of death in the U.S., after heart disease and cancer. The authors aggregated data from four recent studies (including 1-3 above), to develop this estimate. In these four studies, 18% of the lethal adverse events were medication-related and 44% of these were deemed preventable. This leads to an estimate of about 32,000 preventable medication-related deaths per year.
- The AHRQ Statistical Brief #158 (5) reviews the origin of adverse drug events in U.S. hospitals in 2011, across all payers. The research found that adverse drug events in U.S. hospitals were three times more likely to be present on admission than to originate during the hospital stay. Data on adverse drug events by age groups was not presented in this analysis. This key finding highlights the importance of identifying and recognizing adverse drug events as underlying causes or contributing factors to hospital admissions during the admission process.
- An observational study in the Journal of the American Geriatrics Society by Lund and colleaguesreports a significant increase in use of potentially inappropriate medications (PIM) by elderly Medicare beneficiaries upon discharge from the hospital. The use of PIMs is greater at discharge (8.6%) than at admission (7.7%) - P < .001. (7)
About 40% of Certified Geriatric Pharmacists practice in the hospital setting, either in acute care or in ambulatory clinics. This may not be surprising since a recent statistical brief from AHRQ indicates that the majority of adult non-maternal hospital stays are now paid by Medicare. Compared to other payers, Medicare patients also have the longest hospital visits. With the aging of the population, the proportion of hospital patients who are older adults will continue to increase in the future.
Transitions of Care and Adverse Drug Events
Older adults are at increased risk of adverse drug events following discharge from the hospital. Kanaan and colleagues (6) evaluated 1,000 consecutive hospital discharges of older adults and found that 19% of the patients experienced an ADE during the 45 days following discharge, and more than half of these ADEs occurred within 14 days. About one-third of these ADEs were deemed to be preventable, and about one-third of the preventable ADEs were deemed to be serious.
With the aging of the Baby Boomers in the United States, and aging populations around the globe, the need for Certified Geriatric Pharmacists in hospitals will only increase in the future. Hospital pharmacists, and pharmacists considering a hospital career, should find the CGP credential to be a valuable asset.
1. Department of Health and Human Services, Office of the Inspector General. Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Washington, DC; 2010.
2. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124-2134.
3. Classen DC, Resar R, Griffin F, et al. "Global trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30:581-589.
4. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122-128.
5. Statistical Brief #158. Healthcare Cost and Utilization Project (HCUP). September 2013. Agency for Healthcare Research and Quality, Rockville, MD.
6. Kanaan AO, Donovan JL, Duchin NP, et al. Adverse Drug Events After Hospital Discharge in Older Adults: Types, Severity, and Involvement of Beers Criteria Medications. J Am Geriatr Soc 2013;61(11)1894-99.
7. Lund BC, Schroeder MC, Middendorff G, et al. Effect of hospitalization on inappropriate prescribing in elderly Medicare beneficiaries. J Am Geriatr Soc early view online, 8 Apr 2015.