At Mayo Clinic multidisciplinary collaboration is not just a catch phrase, it's a critical element of the culture. Without teamwork, patient care would suffer, as would the ability to conduct research and build evidence leading to improvements in health and health care delivery.

Recently a team of Mayo Clinic researchers published an article in the American Journal of Health-System Pharmacy examining the costs associated with a new collaboration – incorporating a pharmacist into post discharge appointments for medically complex patients who are taking a large number of medications.

"From earlier research, we knew that collaborative visits may reduce the likelihood of readmission for these patients," says Joseph Herges, Pharm.D., the Mayo Clinic pharmacist and health services researcher who led the new study.

Practice innovation research typically focuses on clinical impact – whether the change improves patient outcomes. However, without cost data, other institutions may be reluctant to change their practice, notes Dr. Herges, especially when there is an obvious cost to the intervention, in this case, adding a pharmacist.

The authors found evidence that the collaborative pharmacist visits led to lower costs related to hospital readmissions.

"We expected the hospital cost to be lower," says Dr. Herges. "Interestingly, costs related to emergency department visits and other outpatient care may also be lower."

Dr. Herges attributes this shift potentially to the medication management help the pharmacist provides. "Medication errors can happen when patients transition from one care setting to another then to home," he says. "It is important to very closely review hospital discharge paperwork and ask questions if the care plan is not clear. It may seem like a small thing that will be okay until patients have their next appointment, but it could make a big impact."

In addition to reducing events and therefore costs of hospitalization, emergency care and extra outpatient visits, seeing a pharmacist may lead to less expensive medication regimens.

"When patients hear they are going to be seeing a pharmacist, they may not anticipate that pharmacists evaluate stopping unnecessary medications or finding less costly alternatives, but it is a standard part of the intervention," says Dr. Herges.

Value from the patient perspective

When released from the hospital earlier this year, Gwen Maxson says she was taking about 20 different medications, vitamins and herbal supplements.

She met with Dr. Herges for one of these collaborative appointments shortly after discharge. She admits that she was a bit surprised to have an appointment with a pharmacist, as well as by what they discussed.

"I learned some new things," says Maxson. "I was taking some herbal supplements and even a multivitamin that would interfere with my new medication."

She was able to get answers to questions she hadn't thought to ask her primary care provider. "Was I taking too much? Would any of these things cause me to not feel well? Is there a better alternative?"

Maxson says she found the visit both interesting and very thorough.

"You just don't know," she says, "there are so many interactions that can happen with your medication, supplements, even your diet."

Maxson says that after the appointment she discontinued several supplements, and replaced her multivitamin with one that avoided ingredients against which Dr. Herges advised.

"I think that starting a new medication that can interact with so many things, it was a good idea to have me meet with a pharmacist," she says. "I would definitely recommend it, if you are having a procedure or taking a lot of medications."

For Maxson, the extra appointment added value, and made her feel valued.

"I was impressed how thorough they were [at Mayo Clinic]. They seemed to really care about my health, the outcome after the procedure."

Calculating the cost of practice transformation

In the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, identifying opportunities for practice transformation and the rigorous research to prove – or disprove – their value go hand-in-hand.

Thus, it is likely not surprising that Bijan Borah, Ph.D., and others from the center were part of Dr. Herges' team.

"We built the Cost Data Warehouse a couple of years ago to help Mayo Clinic researchers standardize the way they identify, calculate and report costs of different practice innovations," says Dr. Borah.

"It uses Medicare fee schedules and cost reports as a baseline, and the underlying algorithm is able to adjust for inflation, making it continuously relevant down to the service line level."

Using standardized costs prevents inadvertent release of business-sensitive information, while saving substantial effort for researchers who would otherwise need to create something new for each project.

"In this study, we saw what we hypothesized to see, significant reductions in healthcare costs," says Dr. Borah. "Between our two 500-patient cohorts, we estimated there to be well over $150,000 savings within 30 days, and three-quarters of a million dollars over 6 months."

Drs. Herges and Borah hope their findings will encourage their primary care colleagues to add collaborative pharmacist visits to their patient care toolbox.

Kurt Angstman, M.D., a family medicine physician and senior author of the study agrees.

"From a primary care clinician standpoint, having a pharmacist review the complete medication plan for the patient and make sure that there are no changes from the therapeutic plan is extremely helpful," he says. "Especially so in our complex patients who have recently been hospitalized."

Also part of the research team were James Moriarty, Gregory Garrison, M.D., and Rachel Gullerud. The study was supported by the Mayo Midwest Pharmacy Research Committee and the Mayo Clinic Kern Center for the Science of Health Care Delivery.

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