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Shah et al
Table 1. P&T Committee-Approved ATS Protocols Selected for
Evaluation.

Finasteride

reconciliation at the time of discharge. Figure 1 includes the
discharge services for all assessed ATS protocol encounters.
The majority of encounters were reconciled by medicine
and surgery discharge services. Also, of the 689 ATS protocol encounters, 287 were assessed for the secondary outcome, which focused on moderate-to-high readmission risk
patients.

Doxazosin
Tamsulosin

Primary Outcome

Formulary equivalent
medication

Nonformulary medication

5-alpha reductase inhibitors
Dutasteride
Alpha-1 adrenergic blockers
Terazosin
Alfuzosin SR
Silodosin
Insulin
Insulin aspart
Insulin lispro
Nondihydropyridine calcium channel blockers
Felodipine
Amlodipine
Isradipine, Isradipine CR
Nicardipine, Nicardipine SR
Glaucoma medications
Levobunolol
Timolol
Metipranolol
Brinzolamide
Dorzolamide
Bimatoprost
Latanoprost
Travoprost
HMG-CoA reductase inhibitors
Fluvastatin, Fluvastatin XL
Simvastatin
Pitavastatin
Rosuvastatin
Atorvastatin
Steroid and asthma inhalers
Budesonide
Fluticasone
Flunisolide
Levalbuterol
Albuterol
Note. P&T = Pharmacy & Therapeutics; ATS = automatic therapeutic
substitution; HMG-CoA = 3-hydroxy-3-methylglutaryl-coenzyme A.

omission at the time of discharge. The Fisher exact test was
utilized to compare the incidence of duplication or omission
between moderate-to-high readmission risk patients who
received completed TOC services compared with incomplete
TOC services. A 2-tailed test for statistical significance was
conducted using a predefined alpha value ≤0.05. All analyses
were performed by SPSS Statistics 24.0 (IBM Corp, Armonk,
New York).

Results
ATS Protocol Encounters
In the study, 760 potential ATS protocol encounters were
identified; 71 of these encounters were excluded because
ATS protocols were not used during inpatient admission.
Therefore, 689 ATS protocol encounters were assessed for
appropriate reconciliation, duplication, or omission at the
time of discharge. There were a small number of instances
when the ATS was not performed according to protocol, but
the substitution was clinically appropriate; therefore, the
actual substitution utilized was assessed for appropriate

The overall incidence of ATS protocol encounter-related discrepancies at the time of discharge was 9% (n = 62); 5% (n =
36) of discrepancies were due to duplication and 4% (n = 26)
were due to omission. Of note, patients experienced either a
duplication or omission at the time of discharge 23% (n = 20)
of the time for steroid and asthma inhalers, and approximately 10% of the time for insulin (n = 12), 5-alpha reductase inhibitors (n = 4), and glaucoma medications (n = 3). For
patients receiving HMG-CoA reductase inhibitors (n = 11),
dihydropyridine calcium channel blockers (n = 1), or alpha-1
adrenergic blockers (n = 3), either a duplication or omission
at the time of discharge occurred approximately 4% of the
time (Table 2).

Secondary Outcome
The rate of ATS protocol encounter-related duplication and
omission at the time of discharge was 10% (n = 19) in the
completed TOC services group and 8% (n = 8) in the incomplete TOC services group (P = .6763).

Discussion
The value and role of ATS protocols for inpatient admissions
has increased over recent decades as health care institutions
have expanded and implemented efficient formulary management strategies.1,3,4 However, with the use of ATS protocols, there is a potential for discharge discrepancies.
Discrepancies due to incomplete or inaccurate discharge reconciliation of ATS protocols may lead to duplication or omission of therapies, which could result in adherence issues and
medication errors. This study found that 9% (n = 62) of ATS
protocol encounters were inappropriately reconciled at the
time of discharge resulting in medication discrepancies.
Interestingly, there was not a statistically significant difference in ATS protocol medication-related discrepancies at
the time of discharge for moderate-to-high readmission risk
patients who received completed TOC services compared
with those who did not receive completed TOC services.
This finding may be due to an overall low number of discrepancies observed indicating a larger sample size would
have been needed to observe a statistically significant difference in ATS protocol-related discrepancies between the
groups. Also, the low overall number of discrepancies may
well be due to the practice model at UNC Medical Center, in

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