Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

Impacts of pharmacist-led medication reconciliation on discrepancies and 30-days post-discharge health services utilization in elderly Jordanians

OBJECTIVES

To assess the impacts of pharmacist-led medication reconciliation (MedRec) on medication discrepancies and post-discharge health services utilization in elderly patients in Jordan. And to identify predictors of post discharge outcomes.

METHOD

Newly admitted patients, aged above 65 years were randomly allocated into either a group receiving pharmacist led MedRec or standard care. Within 24 hours of admission, a clinical pharmacist compiled a list of the Best Possible Medication History (BPMH) using at least two sources of information. The pharmacist compared the BPMHs to the admission charts to identify discrepancies and resolved them accordingly. One month post-discharge, patients were assessed for health services use, namely hospital readmissions, emergency department (ED) visits, and adverse drug events (ADEs). Logistic regressions used to investigate predictors of post discharge outcomes.

RESULTS

A total of 128 patients with 151 medication discrepancies were included: 82 (54.3%) discrepancies in the intervention group, and 69 (45.7%) in the control group. A total of 52 Pharmacist-led interventions were recommended to physicians, of which 49 (94.2%) were accepted/implemented. At discharge, the majority of unintentional discrepancies were successfully resolved (p < 0.001). At 30 days post-discharge, patients who were readmitted to the hospital and visited the ED were significantly from the control group. There was no significant difference with respect to experiencing ADEs among the study groups. Patients who received pharmacist-led MedRec had almost 70% lower likelihood of hospital readmission and ED visits. Discrepancies at discharge was associated with higher odds of hospital readmissions.

CONCLUSION

Pharmacist-led MedRec services improved continuity of care for elderly patients. Implementing a structured reconciliation process successfully resolved discrepancies and reduced hospital readmissions as well as ED visits at 30-days post-discharge. This outlines potentials for healthcare cost savings. Future studies are recommended to explore long-term benefits, cost-effectiveness, and integrating pharmacist-led MedRec into standard discharge planning.

Pharmacist-led interventions at hospital discharge: a scoping review of studies demonstrating reduced readmission rates

BACKGROUND

Substantial numbers of hospital readmissions occur due to medication-related problems. Pharmacists can implement different interventions at hospital discharge that aim to reduce those readmissions. It is unclear which pharmacist-led interventions at hospital discharge are the most promising in reducing readmissions.

AIM

This scoping review aimed to summarise pharmacist-led interventions conducted at hospital discharge that demonstrated a reduction in readmissions.

METHOD

We searched the MEDLINE, EMBASE and CINAHL databases up to February 2024. We included studies that focused on pharmacist-led interventions at hospital discharge and reported significant readmission reductions. Two reviewers independently screened titles, abstracts and full texts. Data extracted included study characteristics, populations and the type of implemented pharmacist-led interventions along with the reduction in readmission rates achieved.

RESULTS

We included 25 articles for data synthesis. Many of the studies included either implemented at least two interventions concurrently or were part of broader programmes involving other healthcare professionals. The most common pharmacist-led interventions associated with reduced readmission rates included medication reconciliation, counselling and post-discharge follow-up by telephone. Follow-up primarily aimed to improve patients' treatment adherence through education about their medications. Furthermore, many studies reported on multi-component interventions that began at hospital admission or during inpatient stays, not only at discharge.

CONCLUSION

Successfully reducing readmissions through pharmacist-led interventions at hospital discharge suggests the effectiveness of a holistic approach incorporating multiple interventions. While these findings offer insights for pharmacists, further research should focus on conducting high-quality studies using a multifaceted approach to identify the most appropriate timing and combination.

Practice Guidelines for the Value Evaluation of Clinical Pharmacy Services (version 2)

Objective

To optimize the construction of pharmaceutical services in medical institutions, advance the development of clinical pharmacy as a discipline, enhance the level of clinical pharmacy services, systematically implement and evaluate clinical pharmacy practices, and improve patient therapeutic outcomes, we have developed the Practice Guidelines for the Value Evaluation of Clinical Pharmacy Services (Version 2).

Methods

This guideline was designed following the World Health Organization (WHO) Guideline Development Manual. The Delphi method was employed to identify clinical questions. A comprehensive systematic search was conducted to collect existing evidence on relevant issues, and the systematic reviews, evidence grading, and evidence summaries were subsequently compiled. The guideline employs the Joanna Briggs Institute (JBI) evidence level system from Australia and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system introduced by WHO in 2004 to classify the quality of evidence. Consensus on the recommendations and evidence levels was achieved through the Delphi method, resulting in the formation of the Practice Guidelines for the Value Evaluation of Clinical Pharmacy Services (Version 2).

Results

Through a questionnaire survey of over 100 experts and the Delphi method voting, 23 preliminary indicators for evaluating the value of clinical pharmacy services were identified. The content of these included indicators was searched according to the PICO principle, followed by systematic reviews, meta-analyses, network meta-analyses, and related original research. Each search strategy was reviewed and approved by the guidelines steering committee. Ultimately, three dimensions for evaluating the value of clinical pharmacy were identified, encompassing 15 indicators, resulting in 20 recommendations.

Conclusion

This guideline presents a set of metrics to assess the quality and effectiveness of clinical pharmacy services, which is crucial for enhancing and elevating clinical pharmacy services in healthcare institutions.

Systematic review registration

http://www.guidelines-registry.org/guide/28502a74-7038-439c-bdee-d355747e2a9d, identifier: PREPARE-2022CN756.

Increasing and sustaining discharges by noon - a multi-year process improvement project

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Impact of pharmacist-supported transition of care services in the Middle East and North Africa: a systematic review and meta-analysis

Background

Transition of care (TOC) is associated with an increased risk of medication-related problems. Despite recent advancements in pharmacy practice and research in the Middle East and North Africa (MENA), the characteristics and impact of regional pharmacy-supported TOC interventions remain unclear.This systematic review and meta-analysis aimed to describe pharmacist-supported TOC interventions in the MENA region and evaluate their effectiveness.

Methods

PubMed, CINAHL, EMBASE, Web of Science, World Health Organization's International Clinical Trials Registry Platform (ICTRP) were searched from their inception to March 9, 2023, for experimental studies published in English, comparing pharmacist-supported TOC interventions with usual care for adults (age ≥18 years) discharged from the hospital. The risk of bias was evaluated using Cochrane's risk-of-bias tool for randomised trials (ROB2) and the risk of bias in non-randomised studies of interventions (ROBINS-I) tool for randomised and non-randomised studies respectively. Narrative syntheses and meta-analysis methods were employed depending on the outcomes evaluated.

Results

Twelve studies (n = 2377 subjects), 10 randomised controlled trials and 2 quasi-experimental studies, were included. Most studies had high or serious risk of bias. The included studies were quite heterogeneous in terms of nature and the delivery of intervention, and assessment of outcome measures. Compared to the usual care group, pharmacist-led TOC interventions contributed to a significant reduction in preventable drug-related (N = 2) and cardiac-related healthcare utilisation (N = 1), a significant reduction in preventable adverse drug events (ADEs) (Odds ratio (OR) 0.34, 95% CI: 0.13-0.94) and an improvement in medication adherence. However, all-cause hospitalisation and medication discrepancies were not significantly reduced.

Conclusion

Pharmacy-supported TOC interventions may improve patient outcomes in the MENA region. However, considering the limited quality of evidence and the variability in intervention delivery, future well-designed clinical trials are needed.

Pharmacist-social worker interprofessional relations and education in mental health: a scoping review

Background

One in eight patients is affected by a mental health condition, and interprofessional mental health teams collaborate to improve patient care. While pharmacists and social workers are recognized as mental health team members, there is a lack of literature describing interprofessional relations and education between these professions, especially as it pertains to mental health. The purpose of this review was to identify and characterize reports describing pharmacist-social worker interprofessional relations and education within mental health.

Methodology

To address this knowledge gap, this scoping review was conducted to collect and characterize reports published between January 1, 1960 and August 18, 2023 describing pharmacist-social worker interprofessional relations and education within the field of mental health. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. Ovid MEDLINE, CINAHL, and Social Work Abstracts were searched using keywords "pharmacy student," "pharmacist," "social work student," "social worker," and "social work." Reports were included if they were published in English and interprofessional relations or education occurred directly between (student) pharmacists and social workers.

Results

Three hundred twenty records were identified and three records were included: one cross sectional study, one qualitative educational project, and one case report. Each record suggested positive patient and/or educational outcomes developing from pharmacist-social worker interprofessional relations and education. In clinical practice, pharmacist-social work teams identified mental health risk factors, reduced 30-day readmissions, and improved post-discharge telehealth care. In the classroom, a social worker improved pharmacy students' confidence assessing patient suicidal ideations.

Conclusions

This scoping review identified needs and areas for future research: pharmacist interprofessional education with Master of Social Work and Doctor of Social Work degree students, transitional care and mental health outcome measure reporting using evidence-based outcomes, and development of scholarly teaching projects utilizing higher-level educational frameworks beyond learner reactions.

Impact of a centralized population health pharmacy program on value-based Medicare patients

BACKGROUND

Memorial Healthcare System (MHS) participated in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Advanced value-based program aimed to improve patient care and reduce health care costs. Challenges with medication therapy problems (MTPs) led to the development of a centralized tele-health population health pharmacy program. This innovative approach aimed to provide comprehensive postdischarge medication support and resolve MTPs during the 90-day risk period.

OBJECTIVES

The program aimed to provide longitudinal medication support, resolve MTPs, and affect 90-day readmission rates.

PRACTICE DESCRIPTION

MHS established uniform workflows, a pharmacy task force, and a dual pharmacy team approach with population health registered nurses (PHRNs). The population health pharmacists (PHPs) conducted postdischarge telephonic encounters to resolve MTPs longitudinally throughout the risk period.

PRACTICE INNOVATION

The program used a centralized tele-health model with electronic health record-integrated tools. It targeted readmission rates up to 90 days, beyond the conventional 30-day period. PHPs collaborated with onsite transitions of care pharmacists, PHRNs, and health care professionals for coordinated patient care and MTP resolution.

EVALUATION METHODS

A retrospective analysis using descriptive statistics, a Kruskal-Wallis test, and multivariate regression models after stratifying patients into 4 groups were used to assess MTP resolution rates and differences in readmission rates.

RESULTS

Over 7 months, PHPs completed 801 telephonic visits, identifying 433 MTPs with a 94% resolution rate. The program led to a statistically significant reduction in 90-day readmission rates from 35% to a range of 10%-17% (P < 0.01).

CONCLUSION

The centralized tele-health population health pharmacy program improved patient outcomes, resolved MTPs, and reduced readmission rates. The program serves as a model for integrating pharmacists into value-based care initiatives.

Transitions of Care: Strategies for Medication Optimization and Deprescribing in Older Adults

Older adults have an increased risk of adverse drug events related to polypharmacy and potentially inappropriate medication (PIM) use. These patients are even more vulnerable as they transition through different health care settings. In 2023, the American Geriatrics Society published an updated version of the Beers Criteria®, providing updated guidance on identifying and managing PIMs. Nurses and nurse practitioners play important roles in medication management across the continuum of care. The current article aims to illustrate key concepts regarding medication safety and deprescribing for older adult patients during transitions of care. [Journal of Gerontological Nursing, 49(12), 5-10.].

Clinical and economic effectiveness of a pharmacy and primary care collaborative transition of care program

BACKGROUND

Primary care pharmacists are uniquely positioned to improve care quality by intervening within care transitions in the postdischarge period. However, additional evidence is required to demonstrate that pharmacist-led interventions can reduce health care utilization in a cost-effective manner. The study's objective was to evaluate the clinical and economic effectiveness of a pharmacy-led transition of care (TOC) program within a primary care setting.

METHODS

This cluster randomized trial was conducted between 2019 and 2021 and included three primary care practices. Eligible patients were ≥18 years of age and at high risk of readmission. The multifaceted pharmacy intervention included medication reconciliation, comprehensive medication review, and patient and provider follow-up. The primary composite endpoint included hospital readmissions and emergency department (ED) visits within 30 days of discharge. Differences in outcomes were modeled using a generalized estimated equations approach and outcomes were assumed to be distributed as a Poisson random variable. A cost-benefit analysis was embedded within the study and estimated economic outcomes from a provider group/health system perspective. Cost measures included: net benefit, benefit to cost ratio (BCR), and return on investment (ROI).

RESULTS

Of 300 eligible patients, 36 were in the intervention group and 264 in the control group. The intervention significantly reduced the primary composite outcome of all-cause readmissions and ED visits within 30 days (adjusted incidence rate ratio [aIRR], 0.54; 95% CI, 0.44-0.66; P < 0.001). There were significant reductions in both 30-day all-cause readmissions (aIRR, 0.64; 95% CI, 0.60-0.67; P < 0.001) and ED visits (aIRR, 0.25; 95% CI, 0.20, 0.31; P < 0.001) between groups. The net benefit of the intervention was $9,078, with a BCR of 2.11 and a ROI of 111%. Sensitivity analyses were robust to changes in economic inputs.

CONCLUSION

This care transition program had positive clinical and economic benefits, providing further support for the essential role pharmacists demonstrate in providing TOC services.

Improving inpatient discharge workflows through pharmacist pending discharge medication orders

PURPOSE

Hospital discharge represents a difficult care transition for patients, with the potential for medication-related problems (MRPs) and adverse events. Medication reconciliation is widely accepted as a best practice to minimize MRPs at the time of discharge. Pharmacists can play a key role in identification and resolution of MRPs, although pharmacist reconciliation usually occurs after provider medication reconciliation. This workflow is often inefficient and results in duplication of work within the care team. A prospective pharmacist-led pilot program with preparation of discharge medication orders for provider review, also known as pended medication orders, was investigated to determine its impact on MRPs and discharge processing time.

SUMMARY

Patient discharges from February through April 2022 were compared for 2 hospital medicine services at a large academic medical center. One group participated in the pilot workflow, while the other used standard discharge workflows. The pilot group had a significant decrease in the average number of clinical interventions made by a pharmacist after provider orders were placed (52.4% decrease; P = 0.03) and a nonsignificant reduction in the time from provider order entry to completion of the final pharmacist medication reconciliation (47.6% reduction; P = 0.18) compared to the group using standard workflows.

CONCLUSION

Pharmacist-led, prospective discharge medication reconciliation with pending of medication orders for provider review increases overall discharge efficiency. Data from this project and previous studies support an expanded pharmacist role in the discharge process and continued high-level collaboration between pharmacists and providers.

Impact of a pharmacist collaborative drug therapy management protocol on utilization of a discharge prescription program and hospital readmissions

PURPOSE

To evaluate the impact of a collaborative drug therapy management (CDTM) agreement allowing a pharmacist to automatically prescribe refills of discharge medications to patients' preferred outpatient pharmacy on utilization of a hospital discharge prescription program and hospital readmission rates.

METHODS

This was a single-center, quasi-experimental pre-post intervention study. Patients aged 18 years or older discharged from the cardiology services to home were eligible for inclusion in the study. The CDTM agreement was initiated on July 1, 2019. Patients discharged to home from July 1, 2018, to June 30, 2019, were assigned to the historical control group. The primary outcome was the difference in the proportion of 
patients who used the bedside medication delivery service at hospital discharge between the groups. Secondary outcomes included 30-day hospital readmissions and a descriptive analysis of medications prescribed by a pharmacist through the program. A χ2 test was used to assess the primary outcome, and multivariable logistic regression was used to assess hospital readmissions.

RESULTS

In total, 1,704 and 2,200 patients were discharged in the control and CDTM groups, respectively. The CDTM group had a greater proportion of patients who participated in the discharge prescription program compared to the historical control group (77.8% vs 68.7%; P < 0.0001). There was no difference in 30-day hospital readmission rate between the groups (adjusted odds ratio, 1.01; 95% confidence interval, 0.83-1.23; 
P = 0.94).

CONCLUSION

A CDTM protocol to improve the availability of medication refills at a patient's regular outpatient pharmacy improved utilization of a bedside medication delivery service but did not change 30-day readmission rates.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists

BACKGROUND

existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists.

METHODS

articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test.

RESULTS

a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.