With the focus of American healthcare system recently shifting from volume-based to value-based, high healthcare costs are a substantial issue. An estimated 13-27% of emergency room visits in 2008 were deemed inappropriate, preventable with proper primary care or manageable in primary or urgent care settings. Prevention of inappropriate emergency department (ED) utilization can potentially save the US healthcare system up to $4.4 billion per year. There have been some interventions put in place aiming at reducing the inappropriate ED visits, such as educational strategies, patient incentives, electronic medical record tools to facilitate care coordination to name a few, but they have yielded only modest cost savings and variable reductions in ED utilization. A link between potentially inappropriate medication use and healthcare utilization, including ED visits, has been established and a team at the University of Colorado Health System (UCHealth) in a recent article published on July 15, 2020 at the American Journal of Health- System Pharmacy shared their research on the role of pharmacists in decreasing the inappropriate ED visits. But before the role of a pharmacist in the reduction of ED usage could be evaluated, it is important to answer two core questions: what population groups are more likely to be high ED utilizers (defined as 4 or more visits in 12 months), and what type of ED visits may be avoidable with pharmacotherapy-based interventions?
According to the article, frequent ED users (total study population n = 7,593) are typically younger and more likely to be female and/or African American; to be insured with Medicaid; to have chronic health conditions; and to have lower income and education levels compared to low utilizers and non-utilizers. After examining patient population, UCHealth researchers investigated into what common diagnoses seen in ED could benefit from pharmacist-led pharmacotherapy interventions and for which optimal disease management might have prevented an ED visit at the first place. Of top 20 common ED diagnoses, several involve outpatient pharmacotherapy, such as depression, cardiovascular disease, urinary tract infections and migraine. Even though the reduction in inappropriate ED visits is a complicated matter, UCHealth
identified a few areas of opportunity for pharmacist to intervene. Heart failure is one of the conditions commonly associated with frequent ED utilization. Previous studies have shown that appropriate guideline- directed medication therapy decreases mortality, hospitalizations, and re-admissions and even though most of the studies investigate 30-day readmission rates and not ED use directly, the effects are positive and consistent. One of successful examples of pharmacist-led heart failure oriented interventions is a hospital in California that implemented post-discharge interventions by a “continuum of care resident pharmacist” who provided services to patients discharged with a diagnosis of heart failure decreasing the 30-day readmission rate from 24% to 12% (p = 0.005). Another condition where pharmacist-led interventions may decrease inappropriate emergency department services utilization is chronic kidney disease (CKD). In CKD, inappropriate medication dosing may lead to accumulation of drugs, increasing the risk of toxicity, ineffectiveness and failure of treatment. The pharmacists’ unique skills set, clinical knowledge and accessibility can contribute to proper management of CKD dysfunctions. Among other frequent ED diagnoses identified by UCHealth in their research was headache and, interestingly, only about 55% of patients try taking headache relieving medications prior to arriving to emergency department due to headache, which shows an opportunity for pharmacist-led education and appropriate access to headache relieving therapies for potential prevention of such visits. Yet another common reason for inappropriate ED visits as identified in the research is depression, despite the fact that depression is not a common primary discharge diagnosis. Pharmacists may play a role here in supporting and promoting adherence to antidepressant regimens.
In conclusion, reduction of inappropriate ED utilization by pharmacists is a challenging task due to a number of factors that pharmacists may not have direct control over, such as social determinants of health and barriers to adequate access, but there are certain areas that may pose opportunities, such as heart failure and CKD management, headache relief related education and depression adherence counseling. Pharmacist in various practice settings should actively apply their clinical skills and knowledge to provide solutions aiming at reduction of inappropriate ED visits.
Full article: https://academic.oup.com/ajhp/article-abstract/77/14/1153/5857354?redirectedFrom=fulltext
Image credit: www.rwjf.org/en/library/research/2016/06/ambulance-diversion.html
By Olga Ivanova, PharmD Candidate 2022