BackgroundPharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.MethodsDesign. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.ResultsStudy groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.ConclusionThe pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.Trial registrationClinicaltrials.gov registration: NCT00513903, August 7, 2007.

Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30-day and 90-day medication lists. Main outcome measure: Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist's intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.

Study Objective To determine if recommendations made by pharmacists and accepted by hospital physicians resulted in fewer post-discharge readmissions and urgent care visits compared to recommendations that were not implemented. Design Prospective review of pharmacist recommendations. Setting Patients admitted to a tertiary hospital and discharged to private community-based care. Patients A total of 192 subjects age 18 years or older who were a subsample of a randomized, prospective study, admitted with one of 10 cardiovascular or pulmonary disease or diabetes and utilized private community physicians and community pharmacies. Measurements and Main Results Pharmacy Case Managers (PCMs) performed evaluations for subjects and made recommendations to inpatient physicians. Subjects received medication counseling, a medication list and wallet card at discharge. Data from subjects and private physicians for 90 days post-discharge were collected. PCMs made 546 recommendations to inpatient physicians for 187 (97%) subjects. Overall, 48% of the recommendations were accepted. The acceptance rate was lower for those who ended up with an urgent care visit compared to other subjects (33.6% vs. 52.2%, p=0.033). There were high acceptance rates for medication reconciliation (78%, n=36) and when there was an actual allergy (100%, n=2) or medication error (100%, n=2). Physicians were less likely to accept recommendations related to medication indication (p<0.001), efficacy (p=0.041), and therapeutic disease monitoring (p=0.011). Recommendations made for subjects with a greater number of medications were also less likely to be accepted (p=0.003). Conclusion Recommendations to reconcile medications or address actual allergies or medication errors were frequently accepted. However, only 48% of all recommendations were accepted by inpatient physicians and there was no impact on healthcare utilization 90 days after discharge. This study suggests that recommendations by PCMs were underutilized and the low acceptance rate may have reduced the potential to avoid readmissions.

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