Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older.
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ABSTRACT: Background
Older patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients' experience of discharge and their knowledge of their medication.Methods
An observational multicenter prospective study was conducted in 5 hospitals in Brittany, France.Results
Patients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036).Conclusions
This study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients' experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients' ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness.Trial registration
NCT04018781 July 15, 2019.
SUBMITTER: Bajeux E
PROVIDER: S-EPMC9281036 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.
| S-EPMC11007427 | biostudies-literature
Project description:BackgroundDuring transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs).AimTo investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge.MethodIn this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital's community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital's community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs.ResultsOverall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03).ConclusionOur results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.
| S-EPMC9938815 | biostudies-literature
Project description:BackgroundMedication discrepancies commonly occur when patients are transferred between care settings. Despite the presence of medication reconciliation services (MRS), medication discrepancies are still prevalent, which has clinical costs and implications. This study aimed to explore the perspectives of various stakeholders on how the MRS can be optimized in Singapore.MethodsThis is a descriptive qualitative study. Semi-structured interviews with 30 participants from the National Healthcare Group, including family physicians (N = 10), pharmacists (N = 10), patients recently discharged from restructured hospitals (N = 7) and their caregivers (N = 3) were conducted. All transcribed interviews were coded independently by three coders and inductive thematic analysis approach was used.ResultsFive core themes were identified. (1) The MRS enhanced healthcare services in various aspects including efficiency and health literacy; (2) There were several challenges in delivering the MRS covering processes, technology and training; (3) Issues with suitable patient selection and follow-up; (4) Barriers to scaling up of MRS that involve various stakeholders, cross-sector integration and environmental restrictions; and finally (5) Role definition of the pharmacist to all the stakeholders.ConclusionThis study identified the role of MRS in enhancing healthcare services and explored the challenges encountered in the provision of MRS from family physicians, pharmacists, patients and their caregivers. These findings supported the need for a shift of MRS towards a more comprehensive medication review model. Future improvement work to the MRS can be conducted based on the findings.
| S-EPMC10956343 | biostudies-literature
Project description:IntroductionMedication errors are avoidable events that can occur at any stage of the medication use process. They are widespread in healthcare systems and are linked to an increased risk of morbidity and mortality. Several strategies have been studied to reduce their occurrence including different types of pharmacy-based interventions. One of the main pharmacist-led interventions is educational programs, which seem to have promising benefits.ObjectiveTo describe and compare various pharmacist-led educational interventions delivered to healthcare providers and to evaluate their impact qualitatively and quantitatively on medication error rates.MethodsA systematic review and meta-analysis was conducted through searching Cochrane Library, EBSCO, EMBASE, Medline and Google Scholar from inception to June 2020. Only interventional studies that reported medication error rate change after the intervention were included. Two independent authors worked through the data extraction and quality assessment using Crowe Critical Appraisal Tool (CCAT). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Research protocol is available in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42019116465.ResultsTwelve studies involving 115058 participants were included. The two main recipients of the educational interventions were nurses and resident physicians. Educational programs involved lectures, posters, practical teaching sessions, audit and feedback method and flash cards of high-risk abbreviations. All studies included educational sessions as part of their program, either alone or in combination with other approaches, and most studies used errors encountered before implementing the intervention to inform the content of these sessions. Educational programs led by a pharmacist were associated with significant reductions in the overall rate of medication errors occurrence (OR, 0.38; 95% CI, 0.22 to 0.65).ConclusionPharmacist-led educational interventions directed to healthcare providers are effective at reducing medication error rates. This review supports the implementation of pharmacist-led educational intervention aimed at reducing medication errors.
| S-EPMC8221459 | biostudies-literature
Project description:Pharmacists play a role in providing medication reconciliation. However, data on effectiveness on patients' clinical outcomes appear inconclusive. Thus, the aim of this study was to systematically investigate the effect of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions.Systematic review and meta-analysis.We searched PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO from inception to December 2014. Included studies were all published studies in English that compared the effectiveness of pharmacist-led medication reconciliation interventions to usual care, aimed at improving medication reconciliation programmes. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.17 studies involving 21,342 adult patients were included. Eight studies were randomised controlled trials (RCTs). Most studies targeted multiple transitions and compared comprehensive medication reconciliation programmes including telephone follow-up/home visit, patient counselling or both, during the first 30 days of follow-up. The pooled relative risks showed a more substantial reduction of 67%, 28% and 19% in adverse drug event-related hospital revisits (RR 0.33; 95% CI 0.20 to 0.53), emergency department (ED) visits (RR 0.72; 95% CI 0.57 to 0.92) and hospital readmissions (RR 0.81; 95% CI 0.70 to 0.95) in the intervention group than in the usual care group, respectively. The pooled data on mortality (RR 1.05; 95% CI 0.95 to 1.16) and composite readmission and/or ED visit (RR 0.95; 95% CI 0.90 to 1.00) did not differ among the groups. There was significant heterogeneity in the results related to readmissions and ED visits, however. Subgroup analyses based on study design and outcome timing did not show statistically significant results.Pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. This review supports the implementation of pharmacist-led medication reconciliation programmes that include some component aimed at improving medication safety.
| S-EPMC4769405 | biostudies-other
Project description:BackgroundDue to a lack of related research, we aimed to determine the effectiveness of a pharmacist-led medication reconciliation intervention in China.MethodsWe conducted a multicentre, prospective, open-label, assessor-blinded, cluster, nonrandomised controlled study at six county-level hospitals, with hospital wards serving as the clusters. We included patients discharged from the sampled hospitals who were aged ≥60 years; had ≥1 studied diagnoses; and were prescribed with ≥3 medications at discharge. Patients in the intervention group received a pharmacist-led medication reconciliation intervention and those in the control group received standard care. We assessed the incidence of medication discrepancies at discharge, patients' medication adherence, and health care utilisation within 30 days after discharge.ResultsThere were 429 patients in the intervention group (mean age = 72.5 years, standard deviation (SD) = 7.0) and 526 patients in the control group (mean age = 73.6 years, SD = 7.1). Of the 1632 medication discrepancies identified at discharge, fewer occurred in the intervention group (1.9 per patient on average) than the control group (2.6 per patient on average).The intervention significantly reduced the incidence of medication discrepancy by 9.6% (95% confidence interval (CI) = -15.6, -3.6, P = 0.002) and improved patients' medication adherence, with an absolute decrease in the mean adherence score of 2.5 (95% CI = -2.8, -2.2, P < 0.001). There was no significant difference in readmission rates between the intervention and control groups.ConclusionsPharmacist-led medication reconciliation at discharge from Chinese county-level hospitals reduced medication discrepancies and improved patients' adherence among patients aged 60 years or above, though no impact on readmission after discharge was observed.RegistrationChiCTR2100045668.
| S-EPMC11007753 | biostudies-literature
Project description:The development of health information technology available and accessible to professionals is increasing in the last few years. However, a low number of electronic health tools included some kind of information about medication reconciliation. To identify all the electronic medication reconciliation tools aimed at healthcare professionals and summarize their main features, availability, and clinical impact on patient safety. A systematic review of studies that included a description of an electronic medication reconciliation tool (web-based or mobile app) aimed at healthcare professionals was conducted. The review protocol was registered with PROSPERO: registration number CRD42022366662, and followed PRISMA guidelines. The literature search was performed using four healthcare databases: PubMed, EMBASE, Cochrane Library, and Scopus with no language or publication date restrictions. We identified a total of 1227 articles, of which only 12 met the inclusion criteria.Through these articles,12 electronic tools were detected. Viewing and comparing different medication lists and grouping medications into multiple categories were some of the more recurring features of the tools. With respect to the clinical impact on patient safety, a reduction in adverse drug events or medication discrepancies was detected in up to four tools, but no significant differences in emergency room visits or hospital readmissions were found. 12 e-MedRec tools aimed at health professionals have been developed to date but none was designed as a mobile app. The main features that healthcare professionals requested to be included in e-MedRec tools were interoperability, "user-friendly" information, and integration with the ordering process.
| S-EPMC10700201 | biostudies-literature
Project description:BackgroundIn hospital surgical wards, patients are at higher risk for medication errors, in part because physicians may not consider themselves sufficiently trained to prescribe medications. Hence, collaborative teamwork involving the pharmacist is needed.ObjectivesTo assess the impact of medication reconciliation directed by pharmacists on decreasing medication discrepancies after discharge from the surgical ward.MethodsPatients admitted to the surgical unit at a tertiary teaching hospital in Amman, Jordan, between July 2017 and July 2018 were selected and randomly assigned to either the control or the intervention group. Upon admission, the number and kinds of unintentional medication discrepancies were determined for both groups. Medication reconciliation was then provided to patients in the intervention group. The number of unintentional discrepancies was re-evaluated upon discharge for both groups. To assess differences between the control and intervention groups, the χ2 or Fisher exact test was used for categorical variables and an independent-sample t test for continuous data. A paired t test was conducted to determine whether the number of medication discrepancies was reduced as a result of pharmacists' recommendations.ResultsA total of 123 patients met the inclusion criteria, 61 in the intervention group and 62 in the control group. Discrepancies of omission and wrong dose constituted 41 (77%) of the 53 discrepancies in the intervention group and 25 (76%) of the 33 discrepancies in the control group. The number of unintentional discrepancies was significantly reduced from admission to discharge in both the intervention group (p = 0.002) and the control group (p = 0.007). Of 53 recommendations made by pharmacists, 20 (38%) were accepted by the treating physician, and all of these discrepancies were resolved.ConclusionsThis study sheds light on the existence of unintentional medication discrepancies upon admission for surgical patients, which may expose the patients to potential harm upon discharge from hospital. Additional studies with a larger sample size are needed to gain further insights on pharmacists' role in implementing medication reconciliation for surgical patients.
| S-EPMC9245405 | biostudies-literature
Project description:BackgroundOlder adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals.Methods/designThe PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level. The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission.DiscussionIf this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.Trial registrationClinicalTrials.gov Identifier: NCT04071951.
| S-EPMC8276883 | biostudies-literature
Project description:AimsThe aim of this meta-analysis is to examine the impact of in-hospital pharmacist-led medication reviews in paediatric and adult patients.MethodsRelevant studies were identified from the Medline and Cochrane Library databases. Studies were included if they met the following criteria (without any language or date restrictions): design: randomized controlled trial; intervention: in-hospital pharmacist-led medication review (experimental group) vs. usual care (control group); participants: paediatric or adult population. The primary outcome was all-cause readmissions and/or emergency department (ED) visits at different time points. The secondary outcomes were all-cause readmissions, all-cause ED visits, drug-related readmissions, mortality, length of hospital stay, adherence and quality of life. We calculated the relative risk (RR) or mean differences (MD) with 95% confidence intervals (CIs) for each study. We used fixed and/or random effects models. Heterogeneity was assessed using the I2 statistic.ResultsWe systematically reviewed 19 randomized controlled trials (4805 participants). The readmission rates did not differ between the experimental group and the control group (RR = 0.97, 95% CI 0.89; 1.05, p = 0.470). The secondary outcomes did not differ between the two groups, except for in drug-related readmissions, which were lower in the experimental group (RR = 0.25, 95% CI 0.14; 0.45, p < 0.001), and all-cause ED visits (RR = 0.70, 95% CI 0.59; 0.85 p = 0.001).ConclusionThe low-quality evidence in this analysis suggests an impact of pharmacist-led medication reviews on drug-related readmissions and all-cause ED visits. Few studies reported on adherence and quality of life. More high-quality randomized clinical trials are needed to assess the impact of pharmacist-led medication reviews on patient-relevant outcomes, including adherence and quality of life.
| S-EPMC5099542 | biostudies-literature