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optimizing medication therapy. One of the primary methods
employed by pharmacists to optimize medication therapy is
by performing or overseeing medication reconciliation upon
hospital admission and discharge.8
At the University of North Carolina (UNC) Medical
Center, clinical pharmacists are integral members of the medical team and are responsible for managing medication therapy for patients admitted to their assigned services. The
clinical pharmacists review preadmission medications for
each patient admitted to their services to maximize safe and
appropriate medication therapy. Clinical pharmacists are
required to reconcile medications at admission and discharge
and provide counseling if patients are designated as being
moderate-to-high risk for readmission. In addition, pharmacy
technicians and students are employed to collect admission
medication histories for this same-targeted patient population. Patients are classified as moderate readmission risk if
they have had 2 or more admissions within the past year or 2
or more chronic conditions (eg, heart failure, chronic obstructive pulmonary disease, diabetes). Patients are classified as
high readmission risk if they have had at least 3 admissions
within the past year or at least 3 chronic conditions and 10 or
more preadmission medications. Clinical pharmacists document completion of admission and discharge medication reconciliation and counseling in a shared multidisciplinary
progress note within the electronic health record.
Pharmacist-led medication reconciliation services have
become more prominent through the years as hospitals evolve
into value-based care models and improve continuity of care
through all settings. There are several published studies evaluating the impact of pharmacist-led TOC on identification
and resolution of medication discrepancies.9-12 However,
there are no published studies which have evaluated the
impact of ATS protocol use during inpatient admission on
postdischarge therapy with pharmacist-led TOC services.
The objective of this study was to assess the impact of
preidentified ATS protocols on therapeutic duplication and
omission post discharge.

Hospital Pharmacy 52(9)
and had received preidentified medications for which there are
P&T Committee-approved ATS protocols. Due to the high
number of UNC Medical Center P&T-approved ATS protocols,
study investigators opted to select a sample of ATS protocols.
This sample allowed for a broad range of therapeutic classes
that are representative of medications commonly used to manage chronic conditions such as diabetes and chronic obstructive
pulmonary disease. The preidentified ATS protocols included
3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, glaucoma medications, steroid and asthma inhalers, insulin, alpha-1 adrenergic blockers, 5-alpha reductase
inhibitors, and dihydropyridine calcium channel blockers. Table
1 highlights nonformulary medication to formulary medication
substitution for classes included in this study.

Data Collection
Patients who met the inclusion criteria were identified via
Carolina Data Warehouse for Health, which maintains
research, clinical, and administrative data for UNC Health
Care. Data points collected included baseline characteristics
(eg, medical service at the time of discharge), therapeutic
drug class, use of ATS protocol upon inpatient admission,
and assessment of duplication, omission, or appropriate reconciliation of ATS medication upon discharge. Therapeutic
duplication was defined as continuation of both preadmission home medication and formulary equivalent medication
as stated in the after-visit summary document. Omission
was defined as discontinuation of both preadmission home
medication and formulary equivalent medication without
clinically appropriate and documented rationale. Discharge
reconciliation was considered appropriate when a patient
was discharged on the original outpatient therapy, discharged on a clinically appropriate alternative agent, or discharged with a clinically appropriate and documented reason
for discontinuation of the original medication.

Outcomes

This single-center retrospective cohort study was conducted
at a large academic medical center. The cohort included adult
patients who received a preidentified ATS upon admission
from June 2015 to May 2016. Patients were assessed for
appropriate discharge reconciliation of preidentified ATS
medications. The study was granted approval by the UNC
Medical Center Institutional Review Board with waiver of
consent prior to study initiation.

The primary outcome was the overall incidence of therapeutic duplication or omission at the time of discharge. The secondary outcome was the incidence of duplication or omission
at the time of discharge in moderate-to-high readmission
risk patients with completed TOC services compared with
moderate-to-high readmission patients with incomplete TOC
services. Moderate-to-high readmission risk patients with
completed TOC services had documented pharmacist-led
discharge medication reconciliation and received discharge
counseling, whereas moderate-to-high readmission risk
patients with incomplete TOC services had only 1 or neither
of these components documented.

Inclusion Criteria

Statistical Analysis

Patients admitted to UNC Medical Center from June 2015 to
May 2016 were included if they were 18 years of age or older

Descriptive statistics were used to report baseline characteristics and to determine the overall incidence of duplication or

Methods
Study Design

Table of Contents for the Digital Edition of Hospital Pharmacy - October 2017