Impact of an Outpatient Pharmacist Intervention on Medication Discrepancies and Health Care Resource Utilization in Posthospitalization Care Transitions

Abstract

Purpose: Medication errors related to hospital discharge result in rehospitalization and emergency department (ED) visits, yet no systematic approach has been implemented nationally to decrease these medication errors. Pharmacist involvement during postdischarge transitions of care may be an important strategy to prevent and correct medication discrepancies and reduce costly rehospitalization and ED visits. Methods: This prospective, randomized, open-label, pilot study evaluated the effect of a pharmacy clinic visit focused on medication reconciliation and patient education after hospital discharge on the incidence of rehospitalization and ED visits and the resolution of medication discrepancies. Results: Of the 61 subjects included in the study, 33 (54%) had medication discrepancies identified at discharge. Fifty percent of medication discrepancies were resolved in subjects randomized to the pharmacist intervention arm compared with 9.5% in the usual care arm (P = .015). Patients randomized to the intervention arm had significantly lower rates of the primary composite outcome of 30-day rehospitalization and ED visits compared with the usual care arm (0% vs 40.5%, P < .001). Conclusion: A pharmacist-driven intervention focused on patient education and medication reconciliation after discharge improved medication use and reduced health care resource utilization in this pilot study.

Post-Hospital Discharge Care: A Retrospective Cohort Study Exploring the Value of Pharmacist-Enhanced Care and Describing Medication-Related Problems

“…In 2013, moderate and highrisk patients accounted for approximately 84% of all UNC rehospitalizations (40% for moderate-risk and 44% for high-risk). Studies evaluating the impact of similar face-toface pharmacist interventions at UNC in moderate to highrisk patients have demonstrated significant and pronounced reductions in utilization [18,23,35].…”

“…complete list of medication information-should not be performed alone, but combined with counseling and a clinical medication review [18,22,23,35,36].…”

“…This prospective, randomized, open-label study demonstrated resolution of medication discrepancies and significant reductions in emergency department (ED) visits and readmissions in high-risk patients [18]. The patients had either more than 3 hospitalizations in the past 5 years; 8 or more scheduled medications anticipated at discharge; or a reason for admission of heart failure, chronic obstructive pulmonary disease (COPD), stroke, unstable angina, or non-ST segment myocardial infarction.…”

“…Furthermore, our institution's internal readmission risk stratification considers patients with 3 or more hospital admissions in the last year, or at least 3 chronic conditions and at least 10 medications, as high-risk; 2 or more hospital admissions in the last year, or at least 2 chronic conditions with no regard to medications, as moderate-risk; and all other patients as low-risk [23]. Studies evaluating the impact of similar face-to-face pharmacist interventions at UNC in moderate to high-risk patients have demonstrated significant reductions in utilization [18,23].…”

Decreasing Unintended Medication Discrepancies in Medication Reconciliation through Simple Yet Effective Interventions

“…After medication reconciliation there was a reduction in the discrepancy from 97.5% to 82.5%. However the mean rate for the discrepancy did not achieve statistical significance (0.994 vs. 0.715 p=0.255) [20].…”