Leveraging the Outpatient Pharmacy to Reduce Medication Waste in Pediatric Asthma Hospitalizations
BACKGROUND AND OBJECTIVE: Previous local quality improvement focused on discharging patients with inhaled corticosteroids (ICS) “in-hand” decreased healthcare reutilization after hospitalization for an asthma exacerbation. However, as a result of these new processes, some patients admitted for an asthma exacerbation received more than one ICS inhaler during their admission, contributing to medication waste and potential patient confusion regarding their discharge medication regimen. We sought to decrease this waste.
METHODS: We conducted a quality improvement project to reduce the prescribing of multiple ICS inhalers to patients at a large academic children’s hospital. Our primary outcome measure was the monthly percentage of patients admitted with an asthma exacerbation who were administered more than one ICS inhaler. A secondary outcome measure evaluated the reliability of the new process of using the hospital-based outpatient pharmacy to supply ICS “in-hand” and verify insurance coverage. After the process map review, we hypothesized a delay in the initial ICS treatment decision would allow for both a finalized discharge medication plan and a standardized process to verify outpatient insurance coverage. |
RESULTS: The mean percentage of patients receiving more than one ICS inhaler decreased from our baseline of 7.4% to 0.7%. Verification of outpatient prescription insurance coverage via the outpatient pharmacy increased from 0.7% to 50%. The average inpatient cost (average wholesale price) for ICS decreased by 62% to $90.25.
CONCLUSIONS: Our process change to use the outpatient pharmacy to dispense and verify insurance coverage for ICS medication was associated with a reduction in medication waste during admission for an asthma exacerbation.
© 2020 Society of Hospital Medicine
Asthma results in approximately 125,000 hospitalizations for children annually in the United States.1,2 The National Heart, Lung, and Blood Institute guidelines recommend that children with persistent asthma be treated with a daily controller medication, ie, an inhaled corticosteroid (ICS).3 Hospitalization for an asthma exacerbation provides an opportunity to optimize daily controller medications and improve disease self-management by providing access to medications and teaching appropriate use of complicated inhalation devices.
To reduce readmission4 by mitigating low rates of postdischarge filling of ICS prescriptions,5,6 a strategy of “meds-in-hand” was implemented at discharge. “Meds-in-hand” mitigates medication access as a barrier to adherence by ensuring that patients are discharged from the hospital with all required medications in hand, removing any barriers to filling their initial prescriptions.7 The Asthma Improvement Collaborative at Cincinnati Children’s Hospital Medical Center (CCHMC) previously applied quality improvement methodology to implement “meds-in-hand” as a key intervention in a broad strategy that successfully reduced asthma-specific utilization for the 30-day period following an asthma-related hospitalization of publicly insured children from 12% to 7%.8,9
At the onset of the work described in this manuscript, children hospitalized with an acute exacerbation of persistent asthma were most often treated with an ICS while inpatients in addition to a standard short course of oral systemic corticosteroids. Conceptually, inpatient administration of ICS provided the opportunity to teach effective device usage with each inpatient administration and to reinforce daily use of the ICS as part of the patient’s daily home medication regimen. However, a proportion of patients admitted for an asthma exacerbation were noted to receive more than one ICS inhaler during their admission, most commonly due to a change in dose or type of ICS. When this occurred, the initially dispensed inhaler was discarded despite weeks of potential doses remaining. While some hospitals preferentially dispense ICS devices marketed to institutions with fewer doses per device, our pharmacy primarily dispensed ICS devices identical to retail locations containing at least a one-month supply of medication. In addition to the wasted medication, this practice resulted in additional work by healthcare staff, unnecessary patient charges, and potentially contributed to confusion about the discharge medication regimen.
Our specific aim for this quality improvement study was to reduce the monthly percentage of admissions for an acute asthma exacerbation treated with >1 ICS from 7% to 4% over a six-month period.
