Benefits of Ambulatory Medication Reconciliation in Patients with Diabetes

Researchers seek to determine if implementing process in the ambulatory setting could reducing hospitalization, use of emergency departments.

Medication reconciliation, essentially comparing the medication order with what the patient is taking, is a process performed by many institutions. Reconciliation of medications aims to prevent medication errors like duplications, omissions, interactions, and incorrect/inappropriate dosing. Given that medication errors are extremely costly and commonly associated with severe adverse events, the Joint Commission decided in 2005 to make medication reconciliation a national patient safety goal.

Prior to June 2018, use of medication reconciliation has been mainly used in the inpatient setting and studies have shown merit in its implementation. However, very little is known about the use of this practice in the ambulatory setting. Study investigators sought to determine if implementing this process in the ambulatory setting could lessen patients’ use of healthcare resources, specifically reducing hospitalization and use of emergency departments (ED).

Patients from Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital with diabetes were studied from January 2000 to June 2014. Inclusion into the study required participants to be at least 18 years old, diabetes diagnosis (on electronic health record, HbA1c ≥ 7.0%, three diabetes ICD-9 code), studied for 12 months between 2000-2014, and/or taking one diabetes medication. At the time of the study, both hospitals promoted the use of medication reconciliation. The primary outcome of the study was the number of hospitalizations or ED visits over a 6-month period. Secondary outcomes were hospitalization or ED visits for any cause. It should be noted that steps were taken to prevent double-counting of either outcome.

After exclusion, 31,689 patients (261,765 reconciliations) were assessed. Results showed 67.3% had all medications reconciled, 10.6% had some reconciled, and 22.1% has no diabetes medication reconciled. The results of the composite primary outcome, ED visit, and hospitalization over the 6-month assessment period can be found in Table 1: Primary Outcomes. Following a multivariable analysis, results showed that more diabetes medication reconciliation is associated with lower incidence of composite primary outcome. Patients with some medication reconciliation showed a rate ratio of 0.94, 95% CI (0.90-0.98); p = 0.0046 while those with all diabetes medication reconciled showed a rate ratio of 0.92, 95% CI (0.89-0.95); p < 0.0001. Characteristics attributed to lower rates of hospitalization and ED visits were female gender, improved kidney function, lack of insulin therapy, lower HbA1c, fewer primary care visits, and no hospitalization within the past 12 months. Additionally, reconciliation of all diabetes medications, specifically insulin and sulfonylureas, showed a lower rate ratio compared to those with only some diabetes medications reconciled (RR 0.95, 95% CI 0.92-0.98; p = 0.002 vs. RR 0.97 95% CI 0.95-1.00; p = 0.34).

Table 1: Primary Outcomes
Primary Outcome	Number of Medications Reconciled	Result	P – value
Composite Primary Outcome	All	0.354	P < 0.0001
	Some	0.377
	None	0.384
ED Visit	All	0.223	P = 0.0296
	Some	0.232
	None	0.230
Hospitalization	All	0.132	P < 0.0001
	Some	0.145
	None	0.154

Additionally, the study aimed to determine factors that would increase diabetes medication reconciliation. One major factor found to increase reconciliation rates occurred when feedback was provided to practitioners. Other factors found to increase reconciliation of all diabetes medications included more frequent primary care visits, higher HbA1c, non-white race, and non-English speakers.

Overall, more diabetes medications reconciled corresponded with fewer hospitalizations and ED visits. Reconciliation rates overall improved significantly when providers were given medication reconciliation performance feedback, thus simple comparisons between physicians to their colleagues could be sufficient in promoting this process. The evidence supplied by A. Turchin, et al is promising. With each year, healthcare costs are rising, particularly in those with diabetes. Up until this point, the benefits of this process were well-established only in the inpatient setting, but now the results of this study show merit in its use within the ambulatory setting.

Practice Pearls:

• Turchin, et al found that higher rates of medication reconciliation correspond to fewer hospitalizations and ED visits.
• Medication reconciliation rates are higher when practitioners were given performance feedback.
• Rates of reconciliation of all medications were higher in those who frequently visited their primary care office, had higher HbA1c, were non-English speakers, and were of a non-white race.

Reference:

Turchin, A., Sosina, O., Zhang, H., Shubina, M., Desai, S., Simonson, D., and Testa, M. Ambulatory Medication Reconciliation and Frequency of Hospitalizations and Emergency Department Visits in Patients With Diabetes. Diabetes Care. 2018 May; dc171260. https://doi.org/10.2337/dc17-1260.

Kaytie A. Weierstahl, Pharm.D. Candidate, LECOM School of Pharmacy