A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Anticoagulants are one of the most common drug classes involved in medication errors and adverse events. Warfarin, an anticoagulant that plays a key role in the management of many disease states, is implicated in approximately 30% of reported anticoagulant‐related errors.1 Anticoagulation with warfarin is complicated by inter‐individual variability in response to therapy, clinically significant drug interactions, a narrow therapeutic window, and the need for frequent and lifelong monitoring.2

In the hospital setting, warfarin use is complicated due to patient handoff among health care providers, and acute illnesses that impact sensitivity and response to warfarin. Common causes of errors with anticoagulants are knowledge deficits, failure to follow policy/procedure/protocol, and communication issues.1 An added opportunity for warfarin‐related medication errors is the risk associated with the transition from the inpatient‐to‐outpatient setting. Due to the risk and complexity associated with anticoagulant medications, the Joint Commission instituted National Patient Safety Goal (NPSG) 03.05.01 (formerly NPSG 3E): a series of requirements intended to Reduce the likelihood of patient harm with the use of anticoagulation therapy.3 In order to optimally address this National Patient Safety Goal, a systematic intervention would be required to impact each step of the medication use process for anticoagulants.

Several studies have suggested that dedicated anticoagulation management services or clinics improve anticoagulation management in the outpatient setting.2 Non‐physician providers, primarily pharmacists and nurses, frequently manage outpatient anticoagulation management services or clinics. However, very few studies have evaluated the impact of a warfarin management service in the inpatient hospital setting.48 While the few available studies suggest some benefit associated with an inpatient anticoagulation management service, a minority of these studies have assessed the role of these services in facilitating the transition of the anticoagulated patient to the outpatient setting.7

In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS). The purpose of this study was to evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.

METHODS

This study was completed at Henry Ford Hospital, an 802‐bed, tertiary care, level 1 trauma and academic medical center in Detroit, MI. The study was carried out between November 2007 and June 2009. The study was approved by the Henry Ford Hospital Institutional Review Board with waiver of consent.

RESULTS

Anticoagulant Safety

Safety endpoint data is presented in Table 4. The composite safety outcome of INR >5, major bleeding event, or thrombosis occurred in 12.4% of all patients with no early thrombotic events and only three major bleeding events recorded. Excessive INR values >5 occurred less frequently in the PDAS patients, however, differences in this metric and the composite safety outcome were not significantly different. Safety endpoint results in the overall population were driven by a reduction in INR values >5 among newly initiated warfarin patients in the PDAS group (PDAS: 9.5% vs control: 19.7%; P = 0.079; Figure 1). Other subgroup analyses relating to the safety endpoint are presented in Figure 1.

Figure 1

DISCUSSION

This article describes a systematic intervention designed to improve anticoagulation safety and efficacy in the hospital and during the transition to the postdischarge setting. Implementation of a PDAS did not impact patient bleeding and thrombotic outcomes, but did result in improved coordination and documentation of warfarin management and subsequent enhancement in the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting with the Pharmacist‐Directed Anticoagulation Service.

Limited previous work has investigated the role of an anticoagulation service in inpatient management of anticoagulation.48 Only one published study has investigated the impact of this type of service on transition of care issues with warfarin, as was done in our study.7 In that study, management by an inpatient anticoagulation service resulted in a greater proportion of patients referred to an anticoagulation clinic for management (P = 0.001), more patients presenting to the anticoagulation clinic with a therapeutic INR (P = 0.001), and fewer patients presenting to the clinic with supratherapeutic levels of anticoagulation (P = 0.002). These results are somewhat analogous to our findings, in that patients in our study were less likely to require a dose change at the first clinic follow‐up visit after discharge or to have INR values 5.

We completed several subgroup analyses to thoroughly explore the impact of the PDAS on the safety endpoint. While firm conclusions cannot be drawn from these subgroup analyses, some hypothesis‐generating observations can be made. First, there was a greater impact of the PDAS on the safety endpoint in patients who are usually more sensitive to the effects of warfarin and therefore more challenging to manage.2 The impact of the PDAS was also greater among patients whose length of stay was more than five days (population median). This is significant because it suggests that when the opportunity for adverse events and miscommunication is greatest (ie, during hospitalizations of longer duration), there appears to be improvement in the safety endpoint with the PDAS.

To our knowledge, this study was the first to explore the impact of an inpatient anticoagulation service on the care of both newly initiated and existing warfarin patients, rather than only patients newly initiated on warfarin. As expected, the greatest influence of the PDAS on the safety endpoint was observed among the newly initiated patients. While the safety impact of the PDAS was noted most significantly among the newly initiated patients, the PDAS had a positive effect on the transition of care metrics regardless of previous warfarin use.

A limitation of our study should be mentioned. While we employed a design in which randomly selected units were exposed to the PDAS, individual patients were not randomized to the service. This cluster randomized design was chosen because it mimics quality improvement processes that would be rolled out to a hospital nursing unit. While lack of randomization at the patient level is a limitation, our cluster randomized study design is pragmatic and represents an improvement over the existing published before and after quasi‐experimental studies in this area.48

An improved system for documentation of communication was built into the PDAS processes on implementation of the service. However, it should also be noted that inadequate communication between inpatient and outpatient providers was an identified root cause for adverse events with warfarin in our institution prior to implementation of the PDAS. Therefore, improvement in the transition of care metrics with the PDAS were likely due to a combination of both improved documentation and true improvement in communication.

The approach of the PDAS was refined in several ways early after implementation of the service. Some major notable improvements included the development of a systematic approach to ensuring appropriate follow‐up and transition of care for patients being discharged to a skilled nursing facility, and creation of a system that required a mandatory conversation between the PDAS and a surgical service if anticoagulation is ordered within 48 hours of a major procedure. An upcoming improvement to the service will be to transition from a home grown electronic database, which was built for the purposes of streamlining clinical workflow and data collection, to a commercially available software program that has recently become available for management of inpatient anticoagulation. The major advantage of the new program will be the clinical decision support capabilities that will help to further streamline the service and allow for greater efficiency.

To understand implications of our PDAS intervention, it is important to remember that the majority of study patients were prescribed warfarin prior to hospital admission, that patients in both study groups were enrolled in an established, multisite anticoagulation clinic, and that patients in both groups were managed with a comprehensive inpatientoutpatient electronic medical record. Therefore, all providers caring for these patients had real‐time access to all warfarin dosing and dose adjustments, INR results, and anticoagulation clinic encounters, even though formal communication between providers was infrequently documented for control group patients in our electronic medical record. Study patients had low rates of bleeding and no adverse thrombotic outcomes across both treatment groups. Therefore, this type of model is likely to produce larger gains in communication and safety outcomes in health care systems without established anticoagulation clinics or comprehensive electronic medical records.

The PDAS was enthusiastically accepted by providers at our institution and expanded hospital‐wide after completion of this pilot. The PDAS model is a viable approach to standardize anticoagulant management with a goal of improving anticoagulant safety in the inpatient setting. Assessment of the effectiveness of models such as the PDAS for improving anticoagulant safety in the inpatient setting is particularly relevant with the current expectations for hospitals set by The Joint Commission's NPSG.03.05.01.3 More importantly the PDAS model can be an option for improving the transition of the anticoagulated patient from the inpatient‐to‐outpatient setting. Follow‐up with the anticoagulation clinic occurred earlier with the PDAS and, while this study was not designed to evaluate the impact of this new service on rehospitalization, recent literature suggests that earlier follow‐up after discharge leads to less rehospitalization.10 Finally, it may be possible to adapt this model to provide more intensive medication therapy management and monitoring for hospitalized patients with other complicated medication regimens or chronic disease.

CONCLUSION

The clinical pharmacist is uniquely prepared to manage inter‐individual variability in pharmacodynamic response to drug therapy, as well as to provide high‐quality patient education. This study evaluated a new model of inpatient warfarin management, in which warfarin dosing, monitoring, patient education, and transition of care was coordinated by a specialized team of clinical pharmacists that worked in collaboration with physicians and outpatient anticoagulation clinic staff. Safety and efficiency of the care provided by this new service was improved in certain subsets of more complex patients. The major advantage of this service was improvement in patient handoff, improved communication, and earlier patient follow‐up after discharge. Therefore, implementation of a Pharmacist‐Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

Patients with advanced illness frequently do not receive care that meets their physical and emotional needs at the end of life,1 despite significant expenditures. Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness,26 while achieving hospital cost savings.7 Studies show that palliative care consults are associated with decreased hospitalization cost712 and length of stay13, 14 in the acute care setting.

Identifying which hospitalized patients are likely to benefit most from palliative care has not been well defined. The Hamilton Chart Audit tool was developed to estimate the number of patients that would benefit from a palliative care consult, in order to determine hospital palliative care staffing and financial needs.15 The CARING criteria identifies patients on admission to the hospital who are at high risk of death within one year and may, therefore, benefit from palliative care.16 The literature from the medical intensive care unit (MICU) identifies palliative care core competencies and quality measures, but does not describe patient factors that should trigger a palliative care consult.1719 Norton et al. studied proactive palliative care consultation in the MICU, finding that palliative care consultation in the high‐risk group (serious illness and high risk of dying) was associated with a shorter MICU length of stay without a significant difference in mortality rates.14

The most specific triggers for a palliative care consult comes from the surgical intensive care guidelines. The American College of Surgeons Surgical Palliative Care Task Force published a consensus guideline based on expert opinion identifying the top ten triggers for a palliative care consultation in the surgical intensive care unit (SICU).20 The top 10 criteria to identify SICU patients for palliative care consultation listed in order of priority were: 1) family request; 2) futility considered or declared by the medical team; 3) family disagreement with the team, advance directive, or each other lasting greater than seven days; 4) death expected during the same SICU stay; 5) SICU stay of greater than one month; 6) diagnosis with a median survival of less than six months; 7) greater than three SICU admissions during the same hospitalization; 8) Glasgow Coma Score of less than eight for greater than one week in a patient greater than 75 years old; 9) Glasgow Outcome Score of less than three (i.e., persistent vegetative state); and 10) multisystem organ failure of greater than three systems.

Studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay, as these are patients who may benefit from palliative care. We sought to identify patient characteristics that are associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospicepatients likely to benefit from targeted palliative care services. We hypothesized that hospitalized patients with the following characteristics who died during the hospitalization or were discharged to hospice would have a higher cost per day or longer length of stay: older patients, lack of insurance, and patients receiving care from a critical care specialty.

METHODS

RESULTS

The study population comprised 1155 hospitalizations. Nine hospitalizations were excluded from analysis (five for organ donation, three were erroneousthe patients were not discharged to hospice or did not die during the hospitalization, and one was a pediatric patient), resulting in a study population of n = 1146 hospitalizations.

Table 1 depicts study population characteristics. The average patient age was 62 years (SD = 16), and 96% of patients were insured. The average length of stay was 10.7 days (SD = 14.1), with an average total cost per admission of $44,410 (SD = 76,355), as compared to an overall hospital admission (excluding obstetrics/neonatology) average length of stay of 5.7 days (SD = 8.5) and average total cost per admission of $17,410 (SD = 36,633) during the same time period. The average cost per day was $5095 (SD = $8546). About one‐third of patients were admitted to internal medicine, 20% to pulmonary critical care, and 18% to surgical specialties. The remaining 29% belonged to other specialties.

DISCUSSION

We found several characteristics that were significantly associated with higher cost per day or longer length of stay in patients who died during hospitalization or were discharged to hospice. Among this patient population, the surgical specialty services had overall higher cost per day and length of stay than other services. Patients cared for on the cardiothoracic surgery service had higher cost per day and length of stay; in contrast, internal medicine patients had lower cost per day and length of stay. Neurosurgery patients had higher cost per day, while surgical oncology patients had higher length of stay. Patients age 65 years and older had a significantly lower cost per day and shorter length of stay than those less than 65 years of age.

Higher cost per day for cardiothoracic surgery and neurosurgery patients may partially be explained by cardiothoracic surgery patients' usage of clinical services, including operating room services, which are higher in costs compared with those of nonsurgical specialties. Some patients may require repeat surgeries in the same hospitalization which further increases the cost per day. Longer length of stay in surgical oncology patients may be related to complex surgeries and possible postoperative complications that may take longer to recover from than standard surgeries.

Our findings that older patients have lower cost per day and shorter length of stay are corroborated by other studies. Lubitz and Riley21 found that in 1976 and 1988, Medicare payments per person year decreased with age. Levinsky et al.22 had similar findings in a review of Medicare data in 2001, but noted smaller reductions in total costabout $400 decrease for each year above 65. Their explanation of the lower cost is that older patients receive less aggressive care. Physicians, as well as patients and families, may continue to pursue expensive, invasive therapies for terminally ill patients who are younger for a longer period of time than with older patients, which would increase cost per day as well as length of stay.

The finding that patients on the surgical specialty services may be a focus for active palliative care intervention has many implications. The American College of Surgeons Surgical Palliative Care Task Force consensus guideline triggers for a palliative care consultation in SICU applied clinically did not result in a change in palliative care consultation rate.23 The use of triggers for palliative care consultation may be an ineffective approach because knowledge and application of the triggers did not change behavior. Focusing on integrating palliative care interventions or consultation for all high‐risk surgical patients, as opposed to relying upon triggers, may be a more effective approach to meeting these patients' palliative care needs while lowering cost per day and length of stay and warrants further study. For instance, palliative care consult teams may consider routine or daily rounds with the surgical specialty services in order to effectively integrate palliative care for these patients. Such an integrative approach may foster familiarity and comfort with palliative care approaches, facilitating access to palliative care services for those patients with palliative needs.

Our study is limited in that it is a retrospective, single‐center study. Our results may not be applicable to the general population. The experience of additional centers analyzed prospectively would provide additional context. The available administrative data limited the analyses to only a small number of predictors. In the subset population with the highest 10% total hospitalization costs, from which clinical information was gathered, the presence of respiratory failure was associated with shorter LOS (33 days vs 42 days; P = 0.03), but not associated with cost per day. Having sepsis at admission was associated with lower cost per day ($5783 vs $10,071; P = 0.04); however, this finding was based on only four patients with sepsis at admission. Patients who were evaluated by the palliative care service (n = 35) had a significantly lower cost per day ($4896 vs $12,210; P = 0.01) but longer LOS (46.5 vs 35.7 days; P = 0.03) than those who were not. These, and other, clinical characteristics need further testing in larger samples. An additional limitation is that we combined hospital decedents with patients discharged to hospice as our study population. These groups were combined since they are both at high risk of death in the near future; the median hospice length of stay in Colorado is 20 days.24 There may exist important differences in these populations that are not accounted for in our findings. Despite these unidentified differences, both populations are at high risk of death in the near future, making it likely that they would benefit from palliative care. Those who died during hospitalization did have a longer LOS (11.5 vs 9.2 days; P = 0.003) and higher cost per day ($6734 vs $2221; P < 0.0001) than those who were discharged to hospice.

Palliative care consultations can lead to improved quality of care for patients and families by addressing suffering and addressing quality of life measures (2, 4, 5, 6). We sought to identify characteristics associated with high cost and prolonged hospitalizations in patients who died during hospitalization, or were discharged to hospice, in order to inform targeting of palliative care services. Our data suggest that younger patients and those cared for by surgical specialty services may have the most palliative needs. Palliative care teams may consider focusing efforts at integrating palliative care with surgical specialty services to address these needs. These findings need to be corroborated in other centers, and include clinical outcomes.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• Identify complications elderly patients are at risk for during hospitalization.

• Suggest evidence‐based strategies to prevent and treat common causes of hospitalization‐related complications in geriatric patients.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.

Adverse drug events (ADEs) occur when patients transition between the hospital and other care settings. Medication reconciliation, a process by which a provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, can prevent transition‐related errors and harm in a variety of care locations.13 Nevertheless, poor intersite communication,4 flawed reconciliation of drug regimens,2 unreliable patient history‐taking, and poor provider decision‐making5 continue to contribute to transition‐related ADEs.

The Joint Commission introduced medication reconciliation as a hospital National Patient Safety Goal in 2006. However, because organizations have had difficulty implementing the process, it stopped citing medication reconciliation deficiencies in its accreditation surveys.6 Although regional and national initiatives have attempted to improve implementation of medication reconciliationusing provider education, workflow, and process reorganization, and organizational change7a recent field review by the Joint Commission suggests that healthcare organizations remain unable to ensure effective medication reconciliation, citing factors beyond the organizations' control, especially unreliable patient histories.8 Still, the process is slated to return as an accreditation requirement of the Joint Commission on July 1, 2011.8

The objective of this study was to determine factors that influenced physicians' and pharmacists' performance of medication reconciliation in a hospital setting with a computerized medical record and medication reconciliation tool, with the goal of informing an organization's approach to implementation. We conducted individual cognitive task analysis (CTA) interviews and focus group interviews to ascertain physicians' and pharmacists' opinions on the purpose and effectiveness of medication reconciliation, their approach to completing the task, and task facilitators and barriers.

METHODS

Setting and Medication Reconciliation Process

The study setting was an urban, academic, tertiary‐care Veterans Affairs (VA) medical center. A computerized medication reconciliation tool and process were developed in 2005 to comply with the Joint Commission's National Patient Safety Goal.6 The tool was embedded in the VA's Computerized Patient Record System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other provider) could: 1) view the patient's outpatient medication use, for the last 90 days, from VA computerized pharmacy data; 2) view current VA inpatient orders; 3) record discrepancies between patient‐reported medications, and outpatient and inpatient medications in the VA computerized database; 4) record diagnostic indications for, and responses to, these discrepancies; and 5) produce a medication reconciliation document, which was a separate progress note (Figure 1). The tool did not directly facilitate ordering; however, in CPRS, outpatient orders could easily be copied to inpatient orders and vice versa.

Figure 1

Two versions of the medication reconciliation process were implemented upon hospital admission: one in which the physician initiated and completed a reconciliation that was then reviewed by a pharmacist (Figure 2A)the process primarily used on the medical and surgical services; and one in which, after the physician wrote admission orders, the pharmacist initiated and completed the reconciliation and communicated his or her findings with the physician (Figure 2B)the process primarily used on the psychiatric service. At discharge, after the physician wrote discharge orders, the pharmacist completed a reconciliation of preadmission, inpatient, and discharge orders using a tool similar to the admission one (Figure 1). The pharmacist then communicated the reconciliation findings to the physician, similar to the admission medication reconciliation process shown in Figure 2B. These processes and tools were in place for 18 months at the time of the cognitive task analysis, which took place in June 2007, and 32 months at the time of the focus groups, which took place in August 2008.

Figure 2

RESULTS

DISCUSSION

In this study of hospital physicians' and pharmacists' perspectives on medication reconciliation, we found that although respondents agreed about its main purposeto improve prescribing safetya near majority believed that it was of uncertain benefit to patients and limited use to providers. This might, in part, be because of a tool that was not adequately integrated into workflow, making it extraneous to patient care. As a consequence, many respondents' indicated that when they had competing tasks, especially other acute care responsibilities, medication reconciliation was displaced in priority. Respondents indicated that unreliability of patient medication histories was also a major barrier, which is consistent with a recent Joint Commission field review in which organizations cited this as a task hindrance beyond their control.8 Lastly, respondents revealed limited perception of it being a team‐oriented task.

Our study also probed providers' perceptions of the effect of computerization on completing medication reconciliation. Although study respondents indicated that the computerized tool reduced the time required to complete the task, they also expressed concern that because medication reconciliation was automated in part at the VA, they spent less time with patients on the process. This finding is important because, according to 1 study, many medications are not captured by the VA's Computerized Patient Record System,15 and a patient's lack of medication adherence may not be evident in the CPRS. This finding is also consistent with our prior work that has not demonstrated an inherent advantage to electronic communication of medication information over paper.16

Our study suggests that, for medication reconciliation to be improved, provider self‐efficacy and engagement with the process must be increased. This might involve addressing negative provider attitudes, changing workflow, and improving provider confidence by improving information reliability. With regard to changing attitudes, team members should be briefed on research evidence that shows that medication reconciliation is effective in preventing ADEs13 and is cost‐effective17 to help to increase the value that providers place on medication reconciliation. With regard to workflow, the tool has to be optimized to facilitate information gathering, processing, and medication ordering. Our findings also suggest that medication reconciliation would benefit from widening the time window in which it should be completed (eg, to the first or second business day after admission), since this increases the time available to access multiple data sources, and for providers to update the preadmission medication history and to act on new medication information. Finally, regional electronic health information exchange would improve information reliability and provider confidence in the information.

Our findings also suggest that assignment of productive teamsconsisting of physicians, physician‐extenders, nurses, pharmacists, and/or administrative support staffrather than individuals to the task might improve task completion. Efficacy and perceived capability might be improved by dividing the task into parts more easily manageable by individual team members. One example would be to assign 1 team member to record all of the sources of medication information available for each patient (the patient's home, pharmacies, doctors, hospitals, etc), and assign 1 or more other team members to access these sources as needed. Another example would be to assign the pharmacist to take and document the preadmission medication history (if not for all patients, then perhaps for the highest‐risk patients), and assign the physician to verify the history, specify the planned action on admission for each medication, and complete the admission orders. These suggestions are consistent with a study that suggested that physician engagement and an effective team are strongly correlated with successful implementation of medication reconciliation.7

A strength of our study was its use of multiple methods (focus groups and cognitive task analysis) to collect data from key users individually while they interfaced with the system and in groups. Nevertheless, a limitation of the study is that it took place in a single hospital. Though it had a limited number of physician and pharmacist participants, the study sample represented a large fraction of the inpatient staff in those disciplines. We also did not include nurses, hospitalist attending physicians, or other disciplines that might be involved in medication reconciliation in other facilities or settings. However, our study explored the relationship between two disciplines (physicians and pharmacists), yielding findings that could apply to optimizing the function of other interdisciplinary teams.

Our findings can be used to inform improvement efforts in hospitals that have struggled to implement medication reconciliation. Given that the process is slated to return as an accreditation requirement of the Joint Commission,8 hospitals will need to find ways to strengthen the process. Our findings suggest that increasing providers' perceived capability, and confidence in the process and its outcomes, would improve their engagement in the process. This could be accomplished by improved information gathering, including better computer information systems and regional electronic health information exchange, a flexible timeframe for the process, provider training and feedback, and teamwork. In addition, hospitals can make sure their process is working by ascertaining a gold standard medication history on a subset of patients, and comparing the gold standard to the team's history, and admission and discharge orders. Because it is a central component of safe medication prescribing, medication reconciliation will continue to be a focus of state,18 national,19 and international safety efforts20 in the near future.