Title: Impact of a Transitions of Care Pharmacist Program on Reducing Hospital Readmissions in Patients Initiated on Subcutaneous Insulin at Discharge
Authors: Christina Le, PharmD; Allison Chow, PharmD; Ryan Nguyen, PharmD
Presentation Objective: At the conclusion of my presentation, the participants will be able to describe the types of interventions a transition of care pharmacist can perform.
Self-Assessment Question: (True/False) One of the types of intervention a transitions of care pharmacist can perform is clarifying a prescription of a medication prior to discharge.
Objectives: This study aims to evaluate if pharmacist-led interventions improve transitions of care (TOC) by reducing hospital readmissions in patients newly initiated on insulin therapy.
Methods: This retrospective study reviewed charts of patients ≥18 years with type 2 diabetes during two sequential 6-month periods. The standard-of-care prior to TOC implementation group included patients discharged between January–June 2023, and the TOC implementation group included patients discharged between January–June 2024. Eligible patients had no documented insulin use within the prior two years. In the TOC group, patients were included if there is documentation of TOC pharmacist insulin education. Baseline demographics and clinical characteristics were summarized descriptively and compared between groups. The primary outcome was 30-day hospital readmission rate defined as at least one readmission to any Hackensack Meridian Health hospital. Secondary outcomes included 90-day hospital readmission rate, median change in A1C, and the proportion of patients who have documented follow-up A1C within 6 months. Tertiary outcomes included the type of intervention documented by TOC pharmacists.
Results: Thirty-day readmission rates were not statistically significant between the standard-of-care and the TOC implementation group (2.1% vs 7.7%, p=0.321). Although the TOC implementation group demonstrated a higher rate of 30-day readmission rate compared to the standard of care group (OR: 4.17, 95% CI 0.43-93.7; p=0.25), the estimate was imprecise and not statistically significant. Sex, baseline A1C, and completion of follow-up A1C testing within 3–6 months were not associated with 30-day readmission (all p>0.40).
Conclusion: Patients initiated on subcutaneous insulin therapy prior to discharge, both before and after implementation of the TOC pharmacy service, did not demonstrate a difference in 30-day readmission rates. These findings should be interpreted cautiously given the small sample size and wide confidence intervals. Additional studies are needed to further evaluate the impact of the TOC pharmacy service on readmissions.
PGY-1 Pharmacy Resident, Hackensack Meridian Health JFK University Medical Center
I am Christina Le, PharmD, RPh and I am currently a PGY-1 Pharmacy Resident at Hackensack Meridian Health JFK University Medical Center located in Edison, New Jersey. I completed pharmacy school and obtained my Doctorate in Pharmacy at University Rhode Island in Kingston, Rhode Island... Read More →
Authors Catherine Murphy, PharmD; Andrew Webb, PharmD; Riley Johnson, PharmD
Learning Objective Describe outpatient nimodipine prescribing practices upon hospital discharge in patients with aneurysmal subarachnoid hemorrhage.
Background/Objective It is unclear if the full 21-day nimodipine course is needed for patients with aneurysmal subarachnoid hemorrhage (aSAH) who are ready for discharge prior to day 21. Thus, we assessed nimodipine prescription rates at discharge in patients with aSAH.
Methods This was a single-center, retrospective cohort study of adults (age ≥18 years) admitted for the management of aSAH who were treated with nimodipine during their hospitalization and discharged prior to day 14. Data collected included age, sex, past medical history, aneurysm characteristics, duration of hospitalization, duration of inpatient nimodipine, and outpatient nimodipine prescribing information. The primary outcome was the rate of nimodipine continuation after discharge, which was defined as a prescription being issued to an outpatient pharmacy. Secondary outcomes included the duration of hospitalization;, the duration of outpatient nimodipine treatment;, number of 90-day follow-up appointments;, rehospitalizations,; occurrence of cerebral vasospasm and delayed cerebral ischemia during admission,; and occurrence of rebleeds.
Results A total of 94 patients admitted between 2016 and 2025 were assessed, of which 88 patients were included. The median age was 55.5 years, and 58 patients (66%) were female. The median modified Fisher and Hunt Hess scores were 3 and 2, respectively. Overall, 47 patients (53.4%) were issued a prescription for nimodipine at discharge. Of the patients prescribed nimodipine, 3 (6.4%) were nonadherent to nimodipine therapy, 8 (17%) had documentation of adherence, and 36 (76.6%) of patients had unknown adherence. 4 patients who continued nimodipine had a significant finding on their follow-up angiogram, defined as a recurrence of aneurysm or evidence of vasospasm, compared to 8 patients in those who did not continue it (11% vs. 20%; p=0.05).
Conclusion In patients with aSAH ready for discharge prior to completing their nimodipine, we found that nearly half of patients were not prescribed nimodipine at hospital discharge if medically ready for discharge prior to day 14 of hospitalization. We intended to evaluate functional outcomes, but due to a lack of follow-up appointments within the time frame of interest, these data were not available. Future studies with stricter prescribing practices assessing outpatient nimodipine and clinical status would be useful to determine the necessity of a complete course of nimodipine.
Cate Murphy is a current PGY-1 Pharmacy Resident at Massachusetts General Hospital (MGH). She earned her Doctor of Pharmacy degree from Northeastern University in Boston, MA. Upon completion of the residency year, she will remain at MGH to complete her PGY-2 residency in oncology... Read More →
Learning Objective: This study evaluates the frequency of newly initiated insulin at hospital discharge in insulin-naive adults with type 2 diabetes and hemoglobin A1c (HbA1c) 6.5–10%, assesses potential eligibility for glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy, and examines associated clinical outcomes, including 30-day all-cause readmissions, emergency department visits, and urgent care visits.
Self-Assessment Question: When are GLP-1 receptor agonists (GLP-1RAs) appropriate for hospitalized insulin-naive adults with type 2 diabetes and hemoglobin A1c 6.5–10% who are discharged on insulin, and how might this choice affect 30-day readmission rates?
Background/Objective: Guidelines favor GLP-1RAs over insulin in type 2 diabetes and a HbA1c under 10%. Studies show these patients are often discharged on insulin, although GLP-1RAs give similar glycemic control and cardiovascular, renal, and weight loss benefits.
Methods: This retrospective chart review included adults 18 years or older with type 2 diabetes discharged home from WellSpan hospitals, HbA1c 6.5–10%, and no insulin prior to admission. Exclusion criteria included type 1 diabetes, gestational diabetes, latent autoimmune diabetes in adults, pregnancy, insulin or GLP-1RA on home medication list, and insulin orders from the (diabetic ketoacidosis/hyperosmolar hyperglycemic state) DKA/HHS order-set. The primary outcome was potential GLP-1RA therapy eligibility. Secondary outcomes included frequency of insulin-naive patients discharged on an insulin regimen and 30-day all-cause readmissions and emergency department or urgent care visits.
Results: Among 193 patients, 91.2% met criteria for potential GLP-1RA therapy eligibility. Regarding discharge practices, 12 patients were discharged on an insulin regimen while 181 were not. Among those discharged on insulin, 4 patients (33.3%) experienced a 30-day all-cause readmission. In comparison, 37 patients (20.4%) not discharged on insulin were readmitted within 30 days. Emergency department or urgent care visit rates followed a similar trend, with higher utilization observed in the insulin-discharge group. Overall, a large proportion of patients were eligible for GLP-1RA therapy, while discharge on insulin was less frequent but associated with higher short-term healthcare utilization.
Conclusions: Most patients were eligible for GLP-1RA therapy, and few were discharged on insulin. Differences in 30-day readmissions and acute care utilization were observed between groups, though interpretation is limited by small sample size. These findings highlight an opportunity to optimize discharge processes within transitions of care and support guideline-concordant outpatient diabetes management, including greater consideration of GLP-1RA therapy when clinically appropriate.
Authors: Jaden Wills, PharmD; Kevin Pritt, PharmD, BCPS Learning Objective: Determine if a pharmacist-led medication reconciliation and discharge counseling pilot program affects thirty-day all-cause readmission rates in specific patient subsets admitted to a general medicine unit. Self-Assessment Question: Does pharmacist-led medication reconciliation during transitions of care, compared to standard nurse-led medication reconciliation, reduce 30-day hospital readmission rates? Background: Hospital readmissions are a significant driver of healthcare utilization. This study assessed the impact of a novel, pharmacist-led medication reconciliation and discharge counseling during care transitions on thirty-day hospital readmission rates. Methods: This pre-post retrospective study evaluated the impact of pharmacist-led medication reconciliation and discharge counseling on adult patients with a heart failure (HF) diagnosis (new onset or acute exacerbation) or those insured through Peak Medicare Advantage at an acute care hospital. The pre-intervention group included patients who received standard nurse-led medication reconciliation prior to November 1st, 2025. The post-intervention group included patients admitted after November 1st, 2025, and discharged prior to February 8th, 2026. The primary outcome was thirty-day readmission rates. Secondary outcomes included the number and class of medication interventions, provider acceptance rate, and proportion of patients receiving both medication reconciliation and discharge counseling. Data was collected using a secure Microsoft Excel spreadsheet and analyzed using descriptive statistics. Results: Thirty patients were included in both the pre- and post-implementation groups. Thirty-day readmissions in the heart failure cohort decreased from 23.3% to 18.5% after implementation of pharmacist-led medication reconciliation and discharge counseling. PEAK readmission data is currently being collected and analyzed. Pharmacist involvement increased discrepancies discovered per patient (3.8 vs. 2.7) and achieved a 100% resolution rate compared to 70% in the pre-intervention group. The most common discrepancy in both groups was “patient not taking”. Notably, unintentional omission (n=13) and incorrect dose (n=6) were identified only in the pharmacist group. Discharge counseling rates increased by 10% post-implementation. Conclusion: A structured, pharmacist-led care transition program is a vital component to reducing thirty-day readmission rates while also identifying and resolving clinically relevant medication discrepancies, particularly omissions and dose errors. The review’s findings emphasize both the clinical value and potential cost avoidance associated with integrating pharmacists into care transition programs. Future research should target larger populations, additional patient groups, and a prospective approach.
Pediatric surgery, gastroenterology, and liver transplant; assistant professor department of surgery Johns Hopkins University, The Johns Hopkins Hospital
