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
PDSA 3: Prioritize the Use of the Institution’s Outpatient Pharmacy
Medication changes that occurred because of outpatient insurance formulary denials were a unique challenge; they required a medication change after the discharge treatment plan had been finalized, and a prescription was already submitted to the outpatient pharmacy. In addition, neither our inpatient electronic medical record nor our inpatient hospital pharmacy has access to decision support tools that incorporate outpatient prescription formulary coverage. Alternatively, outpatient pharmacies have a standard workflow that routinely confirms insurance coverage before dispensing medication. The institutional policy was modified to allow for the inpatient administration of patient-supplied medications, pursuant to an inpatient order. Patient-supplied medications include those brought from home or those supplied by the outpatient pharmacy.
Subsequently, we developed a standardized process to confirm outpatient prescription drug coverage by using our hospital-based outpatient pharmacy to dispense ICS for inpatient treatment and asthma education. This new workflow included placing an order for an ICS at admission as a patient-supplied medication with an administration comment to “please administer once available from the outpatient pharmacy” (Figure 1). Then, once the discharge medication plan is finalized, the prescription is submitted to the outpatient pharmacy. Following verification of insurance coverage, the outpatient pharmacy dispenses the ICS, allowing it to be used for patient education and inpatient administration. If the patient is ineligible to have their prescription filled by the outpatient pharmacy for reasons other than formulary coverage, the ICS is dispensed from the hospital inpatient pharmacy as per the previous standard workflow. Inpatient ICS inhalers are then relabeled for home use per the existing practice to support medications-in-hand.
Further workflow improvements occurred following the development of an algorithm to help the outpatient pharmacy contact the correct inpatient team, and augmentation of the medication delivery process included notification of the RT when the ICS was delivered to the inpatient unit.
PDSA 4: Prescriber Education
Prescribers received education regarding PDSA interventions before testing and throughout the improvement cycle. Education sessions included informal coaching by the Asthma Education Coordinator, e-mail reminders containing screenshots of the ordering process, and formal didactic sessions for ordering providers. The Asthma Education Coordinator also provided education to the nursing and respiratory therapy staff regarding the implemented process and workflow changes.
PDSA 5: Real-Time Failure Notification
To supplement education for the complicated process change, the improvement team utilized a decision support tool (Vigilanz Corp., Chicago, IL) linked to EMR data to provide notification of real-time process failures. When a patient with an admission diagnosis of asthma had a prescription for an ICS verified and dispensed by the inpatient pharmacy, an automated message with relevant patient information would be sent to a member of the improvement team. Following a brief chart review, directed feedback could be offered to the ordering provider, allowing the prescription to be redirected to the outpatient pharmacy.
Study of the Improvement
Patients of all ages, with the International Classification of Diseases, Ninth Revision, and Tenth Revision codes for asthma (493.xx or J45.xx) were included in data collection and analysis if they were treated by the Hospital Medicine service, as the first inpatient service or after transfer from the ICU, and prescribed an ICS with or without a long-acting beta-agonist. Data were collected retrospectively and aggregated monthly. The baseline period was from January 2015 through October 2016. The intervention period was from November 2016 through March 2018. The prolonged baseline and study periods were utilized to understand the seasonal nature of asthma exacerbations.
