Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4033 — Results of the Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS)

Lead/Presenter: Caroline Presley
All Authors: Presley CA (Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System; Vanderbilt University Medical Center) Wooldridge KT (Vanderbilt University Medical Center) Byerly SH (GRECC, VA Tennessee Valley Healthcare System; Vanderbilt University Medical Center) Aylor AR (VA-Center for Applied Systems Engineering (VA-CASE), Indianapolis, IN) Roumie CL (GRECC, VA Tennessee Valley Healthcare System; Vanderbilt University Medical Center) Schnipper JL (Brigham and Women's Hospital; Harvard Medical School) Mixon AS (GRECC, VA Tennessee Valley Healthcare System; Vanderbilt University Medical Center)

Objectives:
Unintentional medication discrepancies at care transitions can contribute to adverse drug events that harm Veterans. High quality medication reconciliation decreases unintentional medication discrepancies but has been challenging to implement.

Methods:
R-VA-MARQUIS was a feasibility study to improve inpatient medication reconciliation through mentored-implementation in 3 VA hospitals caring for rural Veterans. Distance mentors guided local improvement teams in implementation of evidence-based toolkit interventions, adapted to the VA setting. Data on unintentional medication discrepancies per Veteran was collected in a sample of control and intervention patients by comparing a study pharmacist-obtained Best Possible Medication History (BPMH) with documented pre-admission medication list and orders upon admission and discharge. Unintentional medication discrepancies per Veteran were plotted on statistical process control charts. Student's t-test compared discrepancies in control and intervention groups at each site. Qualitative data was collected through site visits, structured executive team interviews, and site leader surveys.

Results:
Sites 2 and 3 successfully implemented toolkit components, specifically by clarifying roles and responsibilities and educating providers on how to take a BPMH. Additionally, Site 2 hired pharmacy students to take admission BPMH and implemented risk stratification; Site 3 implemented a pharmacist-driven discharge medication reconciliation and counselling process and hired an inpatient clinical pharmacist. At Site 2, unintentional medication discrepancies per Veteran were higher in intervention patients compared with control (4.48 vs. 3.5, p = 0.01). At Site 3, unintentional medication discrepancies per Veteran were significantly reduced in intervention patients compared with control and this was sustained throughout the study (1.89 vs 4.77, p < 0.01). Interdisciplinary engagement, senior leadership support, and pharmacist involvement were integral to facilitating toolkit implementation. Barriers to intervention effectiveness included lack of competency assessment for BPMH education and limited monitoring of intervention fidelity.

Implications:
In R-VA-MARQUIS an evidence-based toolkit of best practices in medication reconciliation was successfully deployed in 2 of 3 smaller, resource-limited facilities. Our study highlights facilitators and barriers of implementation of medication reconciliation interventions.

Impacts:
R-VA-MARQUIS adds to the understanding of how to implement evidence-based interventions to improve medication reconciliation in smaller VA hospitals, especially those serving rural Veterans.