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Journal of Pharmacy Practice
http://jpp.sagepub.com/content/early/2013/06/21/0897190013491768
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DOI: 10.1177/0897190013491768
published online 24 June 2013Journal of Pharmacy Practice
Andrew Szkiladz, Katherine Carey, Kimberly Ackerbauer, Mark Heelon, Jennifer Friderici and Kathleen Kopcza
Impact of Pharmacy Student and Resident-Led Discharge Counseling on Heart Failure Patients
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Original Manuscript
Impact of Pharmacy Student and
Resident-Led Discharge Counseling
on Heart Failure Patients
Andrew Szkiladz, PharmD, BCPS
1
, Katherine Carey, PharmD, BCPS
2
,
Kimberly Ackerbauer, PharmD, BCPS
3
, Mark Heelon, PharmD
1
,
Jennifer Friderici, MS
1
, and Kathleen Kopcza, PharmD, BCPS
1
Abstract
Purpose: Many health systems have implemented interventions to reduce the rate of heart failure readmissions. Pharmacists have
the training and expertise to provide effective medication-related education. However, few studies have examined the impact of
discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations.
Methods: This was a nonrandomized intervention study evaluating the impact of a pharmacy student and resident-led discharge
counseling program on heart failure readmissions. The primary end point was the 30-day heart failure readmission rate. Secondary
end points included self-reported patient understanding of medications, number of medication errors documented, and estimated
associated cost avoidance. Results: A total of 86 and 94 patients were enrolled into the intervention and control groups, respec-
tively. No statistically significant difference in readmission rates was detected between the intervention and the control groups.
Thirty-four medication errors and discrepancies were documented, or 1 for every 2.5 patients counseled, resulting in an esti-
mated cost avoidance of $4241 for the institution. Eighty-nine percent of patients who received discharge counseling agreed they
had a better understanding of their medications after speaking with a pharmacy resident or student. Conclusions: There was no
statistically significant difference in readmission rates; however, several medication errors were prevented, and a large percentage
of patients expressed an improved understanding of their medications.
Keywords
heart failure, 30-day readmissions, discharge, education, pharmacy
Introduction
Heart failure is a chronic health condition associated with high
mortality, frequent hospitalizations, and complex medications
regimens.
1-3
Rates of readmission for heart failure range from
10% to 19% at 2 weeks to as high as 50% within 3 months.
4
These
readmissions are estimated to cost Medicare approximately $17.4
billion annually. The Patient Protection and Affordable Care Act
(PPACA) legislation will allow the Centers for Medicare and
Medicaid Services (CMS) to withhold a portion of payment if a
patient is readmitted within 30 days.
5
As a result, 30-day readmis-
sion rates must be addressed by all hospitals.
Intense education is often needed to ensure patient under-
standing of the medications and the impact medication adher-
ence has on readmissions.
6,7
Pharmacists have the training
and expertise needed to provide medication-related education
and to resolve medication-related problems at discharge, which
may reduce preventable adverse events, hospital readmissions,
and visits to the emergency department (ED).
8-10
Ideally, phar-
macists would provide medication counseling to heart failure
patients in all the hospitals. However, due to high patient–phar-
macist ratios, this is not always possible. Pharmacy residents
and students may be able to provide a similar service at a lower
cost. This study was designed to evaluate the impact of phar-
macy student and resident discharge counseling on heart failure
readmissions.
Methods
Setting and Participants
This retrospective, nonrandomized intervention study was con-
ducted in the heart failure ward at Baystate Medical Center
(BMC), a 659-bed tertiary care academic teaching hospital.
The study population included patients at least 18 years of age
1
Baystate Medical Center, Springfield, MA, USA
2
Massachusetts College of Pharmacy and Health Sciences, Worcester, MA,
USA
3
Rush University Medical Center, Chicago, IL, USA
Corresponding Author:
Andrew Szkiladz, Baystate Medical Center, 759 Chestnut Street, Springfield,
MA 01199, USA.
Email: andrew.szkiladz@baystatehealth.org
Journal of Pharmacy Practice
00(0) 1-6
ª The Author(s) 2013
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DOI: 10.1177/0897190013491768
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who were discharged between October 1, 2011, and March 31,
2012, with a diagnosis and treatment of heart failure–related
symptoms according to International Classification of Dis-
eases, Ninth Revision (ICD-9) code. Patients who were not
responsible for their own medication administration were
excluded from this study. This study was approved by the BMC
institutional review board.
Intervention
Counseling was provided by 4 advanced pharmacy practice
experience (APPE) students and four postgraduate year 1
(PGY-1) pharmacy practice residents. The same 4 APPE stu-
dents provided discharge counseling throughout the academic
year. The students counseled 1 day per week for 1 academic
year, and the pharmacy residents counseled 1 day per week for
a 3-month longitudinal rotation. Prior to participating in the
program, the pharmacy students and residents were trained
extensively by a heart and vascular clinical pharmacy specialist
or the preceding PGY-1 resident. Education included basic
heart failure pathophysiology and pharmacotherapeutic man-
agement. The mechanisms of action, side effects, monitoring
parameters, and drug interactions for medications commonly
used in the management of heart failure were reviewed. This
education was provided using an interactive PowerPoint pre-
sentation, which lasted approximately 2 hours.
The students then practiced counseling using patient cases.
The students were evaluated by the pharmacy resident and
pharmacist coinvestigators. Once the investigators felt the stu-
dents understood the aforementioned topics, the students began
educating patients under the supervision of either the PGY-1
resident or a pharmacist coinvestigator. Each pharmacy student
was individually supervised and assessed for approximately 4
counseling sessions. Students were allowed to counsel indepen-
dently once the investigators felt that the students demonstrated
an appropriate level of expertise.
Several tools were designed to assist the students and resi-
dents in the counseling process. The first tool, the patient evalua-
tion sheet, was designed to aid in evaluating the patient’s
pharmacotherapy regimen. Past medical history, laboratory val-
ues, current medications, and medication and indication match
up (ie, left ventricular ejection fraction <40% and angiotensin-
converting enzyme inhibitors/angiotensin II receptor blockers)
were all assessed and evaluated using this tool (see Appendix A).
Patients were given medication handouts that were devel-
oped based on Micromedex CareNotes. Each patient handout
related to a specific medication or class of medications and was
designed to provide the patient with medication-related infor-
mation directed at a sixth- to eighth-grade reading level in an
easy-to-read, concise format. Patient education handouts
included medication indication, directions for use, storage,
warnings, and side effects. In addition, a patient-specific med-
ication administration schedule was made for each patient. This
medication schedule also provided the indication, brief instruc-
tion, dose, and frequency of patient’s discharge medications.
The heart failure coordinator, a registered nurse specialist,
would inform the pharmacy student or resident of patients to
be discharged daily. They would then evaluate the patient’s
pharmacotherapy regimen using the evaluation tool and pro-
vide counseling, education handouts, and a personalized dis-
charge medication schedule. Counseling points included, but
were not limited to, indication, administration, missed doses,
storage, warning/precautions, and adverse effects. Lifestyle
considerations such as weight monitoring, salt restriction,
physical activity, alcohol restriction, and smoking cessation
were also discussed. The patient’s level of education was not
formally assessed prior to counseling. The ‘‘teach-back
method’’ was used at the end of the counseling session to assess
the patient’s understanding of the education.
Study Design
Discharge counseling by a pharmacy resident or student was
initially provided to 1 heart failure patient each day. If multiple
patients with heart failure were being discharged, the heart fail-
ure coordinator would target patients with more complex med-
ication regimens (ie, multiple medications at discharge or
multiple medication changes) or multiple admissions to be
counseled by the pharmacy resident or student. It was felt that
these patients would be able to benefit the most from this coun-
seling, since all patients were unable to be counseled by a phar-
macy resident or a student. Nurses and case managers were able
to assist in coordinating discharge times, so family members
had the opportunity to be available for the education as well.
All patients received the same standardized discharge edu-
cation from a nurse. This education included information about
the signs and symptoms of heart failure, dietary, and physical
activity instructions as well as discharge medication informa-
tion. The intervention group also received additional discharge
counseling from a resident or a student. The control group con-
sisted of the patients who were discharged during the same time
period but were unable to be counseled by a pharmacy student
or resident. Patients in the control group were also matched to
patients in the intervention group according to their risk of
heart failure readmission using a validated tool. This ensured
that patients in the control group were as similar to patients
in the intervention group as possible, given the nonrandomized
study design. A follow-up phone call was attempted by the
heart failure coordinator to all patients discharged from the
heart failure ward during the week. Questions regarding dis-
charge instructions, including medication education as well
as patient satisfaction, were addressed.
Measurements
The primary outcome was heart failure readmission within 30
days of discharge with a principal or discharge ICD-9 diagnosis
of chronic heart failure. Secondary outcomes included self-
reported patient understanding of medications; the number of
medication errors documented by students and residents; and
cost avoidance. Understanding of medications was assessed
2 Journal of Pharmacy Practice 00(0)
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during the follow-up interview 3 to 5 days postdischarge. Each
patient was asked, ‘‘Overall, would you say that speaking to the
pharmacist or pharmacy student helped you understand your
medications better?’’ Responses were recorded as disagree,
neutral, or agree. Medication errors were documented by stu-
dents and residents. Cost avoidance attributable to interven-
tions was based on the Thomson Reuters Action O-I
Comparative Database.
11
Additional data collected included demographic information,
past medical history, heart failure characteristics, laboratory
data, vitals, admission and discharge medications, and 30-day
readmission risk score developed by the Center for Outcomes
Research and Evaluation (CORE). The readmission risk score
calculator uses patient characteristics such as age, sex, in-
hospital cardiac arrest, a past medical history of diabetes, heart
failure, coronary artery disease, prior percutaneous coronary
intervention, aortic stenosis, stroke, chronic obstructive pulmon-
ary disease, dementia as well as systolic blood pressure, heart
rate, respiratory rate, sodium, blood urea nitrogen, creatinine,
hematocrit, glucose, and left-ventricular ejection fraction at
admission to estimate 30-day readmission rates. The readmis-
sion risk score has been previously validated and is available
online at http://www.readmissionscore.org/heart_failure.php.
12
All data were extracted using electronic medical records.
Statistical Analysis
Bivariable analyses were conducted using independent-sample
t tests (Gaussian) or chi-square (categorical) as appropriate.
Multivariable Poisson regression with robust standard errors
was used to quantify the difference in the proportion readmitted
and calculate 95% confidence intervals while adjusting for pos-
sible imbalances in baseline covariates. The study aimed to
enroll 100 patients per group to achieve 82% power to detect
a difference of 12 percentage points in the primary end point.
Two-sided P values .05 were considered significant.
Results
The study enrolled 86 and 94 patients in the intervention and
control groups, respectively. Of the 86 patients counseled,
80% were counseled by the students. On average, it took the
pharmacy residents and students about 52 minutes to work up
and counsel a patient. The intervention and control groups were
similar for most demographic and clinical characteristics
(Table 1). The mean age of the participants was 71 years, and
48.2% were male. The overall mean readmission risk score was
24.8% and did not vary significantly between groups.
The associations between various patient characteristics and
heart failure readmission are shown in Table 2. Females were
significantly more likely than males to be readmitted for heart
failure. Chronic obstructive pulmonary disease, number of
medications, and readmission risk score were also positively
associated with heart failure readmission, but the differences
were not statistically significant (Table 2).
Approximately 9.4% (95% confidence interval [CI] 5.1%,
13.8%) of the patients were readmitted for heart failure within
30 days, which is consistent with BMC’s heart failure readmis-
sion rate. There was no significant difference found between
the intervention and the control groups in an unadjusted analy-
sis (Table 3). Similarly, no significant difference was found
when adjusting for covariates.
A total of 46 counseled patients were reached for the follow-
up interview. Of those surveyed, 41 (89.1%,95% CI 76.4%,
96.4%) agreed that they had a better understanding of their
Table 1. Baseline Characteristics.
Characteristic
Intervention
(n ¼ 86)
Control
(n ¼ 94)
P value
Mean + SD
or % (n)
Mean + SD
or % (n)
Age, years 70 + 14.8 72 + 14.2 .28
Male 44.2% (38) 52.1% (49) .30
LVEF,% 40 + 20.9 37 + 18.3 .30
Total # of meds 10.9 + 3.9 10.9 + 5.0 .92
Readmission risk score, % 25.3 + 4.6 24.3 + 4.8 .18
In-hosp cardiac arrest 1.2% (1) 1.1% (1) 1.00
DM 59.3% (51) 47.9% (45) .14
CAD 55.8% (48) 57.5% (54) .88
Prior PCI 29.1% (25) 52.1% (49) .002
Aortic stenosis 9.3% (8) 8.5% (8) 1.00
Stroke 11.6% (10) 8.5% (8) .62
COPD 22.1% (19) 21.3% (20) 1.00
Dementia 3.5% (3) 5.3% (5) .72
Abbreviations: CAD, coronary artery disease; COPD, chronic obstructive
pulmonary disease; DM, diabetes mellitus; In-hosp, in-hospital; LVEF, left-
ventricular ejection fraction; PCI, percutaneous coronary intervention; SD,
standard deviation.
Table 2. Predictors of Heart Failure Readmission.
Characteristic
Readmitted
(n ¼ 17)
Not readmitted
(n ¼ 163)
P value
Mean + SD
or % (n)
Mean + SD
or % (n)
Age, y 73 + 11.5 71 + 14.8 .49
Male gender, % 17.6% (3) 51.5% (84) .01
LVEF, % 44 + 17.9 38 + 19.7 .16
Total # of meds 12.7 + 4.2 10.7 + 4.5 .08
Readmission risk score, % 26.6 + 5.5 24.6 + 4.6 .09
In-hosp cardiac arrest 5.9% (1) 0.6% (1) .18
DM 47.1% (8) 54.0% (88) .62
CAD 52.9% (9) 57.1% (93) .80
Prior PCI 47.1% (8) 40.5% (66) .61
Aortic stenosis 5.9% (1) 9.2% (15) 1.00
Stroke 0.0% (0) 11.0% (18) .23
COPD 41.2%(7) 19.6% (32) .06
Dementia 0.0% (0) 4.9% (8) 1.00
Counseled 52.9% (9) 47.2% (77) .80
Abbreviations: CAD, coronary artery disease; COPD, chronic obstructive
pulmonary disease; DM, diabetes mellitus; In-hosp, in-hospital; LVEF, left-
ventricular ejection fraction; PCI, percutaneous coronary intervention; SD,
standard deviation.
Szkiladz et al 3
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medications after speaking with a pharmacist or pharmacy stu-
dent. Four (8.7%,95% CI 2.4%, 20.8%) were neutral and 1
(2.2%,95% CI 0.0, 11.5%) disagreed. A total of 34 interven-
tions were documented for the 86 patients counseled, resulting
in 1 intervention per 2.5 patients. These interventions lead to a
total estimated cost avoidance of $4241, or $57.44 per hour of
student or resident time based on intervention cost data
obtained from the Thomson Reuters Action O-I Comparative
Database.
Discussion
The pharmacy student and resident-led heart failure discharge
counseling program resulted in an estimated cost avoidance
of $4241. The students recorded 26 interventions in 69 patients
that they counseled, resulting in 1 clinical intervention in 38%
of the patients counseled by students alone. Patients participat-
ing in the program reported a better understanding of their med-
ications after speaking with a pharmacy student or resident.
Although several studies have shown the benefit and effective-
ness of various interventions in reducing heart failure readmis-
sions rates,
13-21
our counseling intervention did not reduce
30-day heart failure readmissions. It should be noted that the
metric in several of the earlier interventions
13,15,19
was 90-
day readmissions; thus, our intervention might have effected sim-
ilar reductions over the long term (though 30-day readmission is
of greatest interest at this time due to Medicare reimbursement
policies).
It is not clear why immediate benefits (eg, self-reported
understanding and medication errors) did not translate into a
reduction in 30-day heart failure readmission. The 3 percentage
point difference in 30-day readmission rates between treatment
groups was a very small effect size (Cohen’s w of .03) and our
study had only 8% power to detect this difference, with a 2-
sided critical significance level of .05.
It is possible that the intervention conferred a survival ben-
efit, such that a higher proportion of counseled patients sur-
vived long enough to be readmitted after the index
hospitalization. If this occurred, any reduction to readmissions
conferred by counseling might be offset by a survival bias. It is
also possible that the counseling heightened patients’ aware-
ness of adverse medication reactions and/or signs of heart fail-
ure exacerbation (eg, precipitous weight gain). Either of these
scenarios offset reductions in 30-day heart failure readmission
rates in the intervention group; thus, future studies should cap-
ture death outcomes and examine admission complaints to
identify possible biases. Finally, 30-day heart failure readmis-
sion rates had been declining steadily in our institution for sev-
eral years at the time our study was conducted, possibly making
improvements difficult to achieve and/or detect with precision.
Although the intervention did not appear to affect 30-day read-
mission rates, our study has several implications for further
incorporation of both pharmacy residents and, more impor-
tantly, students into clinical practice. We successfully and
effectively incorporated pharmacy students and residents into
a heart failure discharge program and developed working rela-
tionships with the other health care professionals while meeting
the goals and objectives set by the American Society of Health-
System Pharmacists (ASHP) Pharmacy Practice Model Initia-
tive.
22
Our utilization of students and residents allowed for
an improvement in patient understanding of medications,
reduced medication errors, and provided a significant cost
avoidance without impacting pharmacy staffing.
Table 3. Heart Failure Readmission by Intervention Group.
Proportions
Intervention (%) Control (%) P value
Unadjusted 10.5 8.5 .80
Adjusted
a
11.1 8.1 .52
Abbreviations: DM, diabetes mellitus; PCI, percutaneous coronary
intervention.
a
Adjusted for DM and history of PCI.
4 Journal of Pharmacy Practice 00(0)
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Acknowledgment
The authors would like to thank Ivy Lim, PharmD, for her assistance
in this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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