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

社区中病情最严重的患者是最近住院的老年人。他们的一个重要组成部分 发病率和死亡率由药物不良事件(ADE)引起。不良反应占不良反应的70% 发生在出院后，以每名患者0.30例ADE的速度发生。年龄最大、病情最重的病人在 ADE的风险最高，因为它们拥有迄今最复杂和最危险的药物方案 生理储备和最少的社会经济资源。 几项研究，包括我们自己的，已经证明了药剂师领导的出院后的疗效。 改善用药管理的干预措施。其中最突出的是出院后 药剂师给病人打的电话。然而，尽管已证明有效，但这些干预措施 没有得到广泛的实施。在本提案中，我们使用RE-AIM模型来了解和解决 阻碍实施的现有研究。最核心的知识差距是大多数研究 重点关注我们现在了解的流程或替代终点措施(如药物差异) 不足以推动组织变革。相反，我们将衡量对利用率的影响，一个 密切跟踪的结果，强烈激励医院领导人。我们将使用大规模随机对照 严格评估药物-DC对这一结果的影响的试验。我们还将研究障碍和 采取这些干预措施的促进者，人们对此知之甚少。最后，虽然实施成本 对于考虑药剂师主导出院的组织来说，这些信息至关重要 在干预方面，关于这一主题的证据很少。因此，我们的目标是衡量医药-DC的影响 30天内出院后利用的干预措施。我们还将最大限度地识别患者亚群 可能受益于医药-DC。最后，我们将估计PHARM的增量净成本 卫生系统视角。 为了研究这些目标，我们选择了两个地点：1)已经精通医院内用药 对账--实施和评估《医药--DC》的先决条件；2)有一名首席药剂官 致力于在研究期间使用运营资源向患者提供Pharm-DC；以及3) 调查人员在研究所需的研究内容和方法方面是否有经验 前述目标。 该项目将产生新的知识，从而增加执行和传播 已知有效的研究，从而减少了可归因于以下原因的大量发病率和死亡率 在高危出院后时间段的老年人中发生的ADS。

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.