A Multicenter RCT of Pharmacist-Directed Transitional Care to Reduce Post-Hospitalization Utilization

社区里最严重的病人是最近住院的老人。其重要组成部分 发病率和死亡率是由药物不良事件（ADEs）引起的。ADE占不良事件的70% 出院后发生，发生率为每例患者0.30起ADE。年龄最大，病情最严重的病人在 最高的风险，因为他们有最复杂和危险的药物治疗方案，但最少 生理储备和最少的社会经济资源。 包括我们自己在内的几项研究已经证明了药剂师领导的出院后 采取措施改善药物管理。其中最突出的是出院后 从药剂师到病人的电话。然而，尽管已证明有效，但这些干预措施 没有得到广泛实施。在本提案中，我们使用RE-AIM模型来理解和解决 现有的研究阻碍了实施。核心的知识差距是，大多数研究 侧重于我们现在所理解的过程或替代终点指标（如药物差异）， 不足以推动组织变革。相反，我们将测量对利用率的影响， 密切跟踪的结果，强烈激励医院领导。我们将使用一个大型随机对照 试验严格评估PHARM-DC对这一结果的影响。我们还将研究障碍， 促进者采取这些干预措施，对此知之甚少。最后，尽管实施成本 对于考虑药师主导出院（PHARM-DC）的组织来说是至关重要的信息 然而，关于这个问题的证据很少。因此，我们的目标是衡量PHARM-DC的影响， 在30天内对出院后的利用进行干预。我们还将确定最常见的患者亚群 可能会受益于PHARM-DC。最后，我们将估计增加的净成本的PHARM从 卫生系统视角。 为了研究这些目标，我们选择了两个站点：1）已经精通院内用药 协调，实施和评估PHARM-DC的先决条件; 2）有一个首席药剂官 承诺在研究期间使用运营资源向患者提供PHARM-DC;以及3） 研究人员是否在研究内容和研究方法方面经验丰富， 上述目标。 这一项目将产生新的知识，以便加强执行和传播 研究已经知道是有效的，从而减少了大量的发病率和死亡率归因于 老年人在出院后高风险时期的ADE。

The sickest patients in the community are recently hospitalized elders. A substantial component of their morbidity and mortality is caused by adverse drug events (ADEs). ADEs account for 70% of adverse events occurring after discharge, which occur at a rate of 0.30 ADEs per patient. The oldest, sickest patients are at highest risk for ADEs because they have the most complex and hazardous medication regimens yet the least physiologic reserve and the fewest social and economic resources. Several studies, including our own, have demonstrated the efficacy of pharmacist-led post-discharge interventions to improve medication management. Most prominent among these have been post-discharge phone calls from pharmacists to patients. However, despite demonstrated efficacy, these interventions have not been widely implemented. In this proposal, we use the RE-AIM model to understand and address gaps in existing research that have hindered implementation. The central knowledge gap is that most research focuses on process or surrogate endpoint measures (like medication discrepancies) that we now understand to be insufficient to motivate organizational change. In contrast, we will measure the effect on utilization, a closely-tracked outcome that strongly motivates hospital leaders. We will use a large randomized controlled trial to rigorously assess the effect of PHARM-DC on this outcome. We will also study the barriers and facilitators of adopting these interventions, about which little is known. Finally, although implementation costs are critically important information for organizations considering pharmacist-led discharge (PHARM-DC) interventions, evidence on this topic is scarce. We thus aim to measure the impact of PHARM-DC interventions on post-discharge utilization within 30 days. We will also identify patient sub-populations most likely to benefit from PHARM-DC. Finally, we will estimate the incremental net cost of PHARMs from the health system perspective. To study these aims, we have selected two sites that: 1) are already proficient at in-hospital medication reconciliation, a prerequisite for implementing and evaluating PHARM-DC; 2) have a Chief Pharmacy Officer committed to using operational resources to provide PHARM-DC to patients during the study period; and 3) have investigators experienced in the research content and methodologies needed to study the aforementioned aims. This project will generate new knowledge allowing for increased implementation and dissemination of research already known to be efficacious, thus reducing the substantial morbidity and mortality attributable to ADEs among seniors in the high risk post-discharge time period.