Impact of an integrated medicines management service on preventable medicines-related readmission to hospital: a descriptive study

Risk factors for medication-related short-term readmissions in adults - a scoping review

BACKGROUND

Hospital readmissions due to medication-related problems occur frequently, burdening patients and caregivers emotionally and straining health care systems economically. In times of limited health care resources, interventions to mitigate the risk of medication-related readmissions should be prioritized to patients most likely to benefit. Focusing on general internal medicine patients, this scoping review aims to identify risk factors associated with drug-related 30-day hospital readmissions.

METHODS

We began by searching the Medline, Embase, and CINAHL databases from their inception dates to May 17, 2022 for studies reporting risk factors for 30-day drug-related readmissions. We included all peer-reviewed studies, while excluding literature reviews, conference abstracts, proceeding papers, editorials, and expert opinions. We also conducted backward citation searches of the included articles. Within the final sample, we analyzed the types and frequencies of risk factors mentioned.

RESULTS

After deduplication of the initial search results, 1159 titles and abstracts were screened for full-text adjudication. We read 101 full articles, of which we included 37. Thirteen more were collected via backward citation searches, resulting in a final sample of 50 articles. We identified five risk factor categories: (1) patient characteristics, (2) medication groups, (3) medication therapy problems, (4) adverse drug reactions, and (5) readmission diagnoses. The most commonly mentioned risk factors were polypharmacy, prescribing problems-especially underprescribing and suboptimal drug selection-and adherence issues. Medication groups associated with the highest risk of 30-day readmissions (mostly following adverse drug reactions) were antithrombotic agents, insulin, opioid analgesics, and diuretics. Preventable medication-related readmissions most often reflected prescribing problems and/or adherence issues.

CONCLUSIONS

This study's findings will help care teams prioritize patients for interventions to reduce medication-related hospital readmissions, which should increase patient safety. Further research is needed to analyze surrogate social parameters for the most common drug-related factors and their predictive value regarding medication-related readmissions.

The electronic prescribing of subcutaneous infusions: A before-and-after study assessing the impact upon patient safety and service efficiency

OBJECTIVES

To assess the impact of electronically prescribed mixed-drug infusions on the prevalence and types of prescription errors and staff time.

DESIGN, SETTING AND PARTICIPANTS

Before-and-after study on acute medical wards of a large UK teaching hospital, utilising patient and staff data from the assessed wards.

INTERVENTION

Electronically-generated mixed-drug infusions.

MAIN OUTCOME MEASURES

(1) Rate of prescription errors (divided into errors of commission and omission); (2) time taken to process patient discharge prescriptions containing a mixed-drug infusion; and (3) time between prescription and administration of mixed-drug infusions.

RESULTS

100 errors of omission were detected pre-intervention, whilst none were detected post intervention. 6 errors of commission were identified at baseline, whilst 2 were highlighted post intervention (p = 0.149). 14 physicochemically incompatible infusions were prescribed at baseline, post-intervention all infusions were compatible (p < 0.01). Time spent processing discharge prescriptions fell from 60 min (SME±1.7) to 26 min (SME± 2.7; p < 0.01). The median time from prescription to administration reduced from 120 min (95 % CI 106-150) to 65 min (95 % CI 43-85; p < 0.01).

CONCLUSIONS

The intervention eliminated errors of omission and facilitated the prescribing of compatible multicomponent infusions. Electronically prescribed mixed-drug infusions also reduced both the time taken to complete discharge prescriptions and the time taken to commence such infusions.

An Observational Cohort Study to Evaluate the Impact of a Tailored Medicines Optimisation Service on Medication Use, Accident and Emergency Department Visits, and Admissions Among Patients Identified with Medication Support Needs in Secondary Care

PURPOSE

Quantifying the impact of pharmacy interventions, such as tailored medicines optimisation, can be challenging owing to the sometimes-indirect nature of their effect on patient outcomes such A&E (Accident & Emergency) attendance, hospital admission and length of stay. This study aimed to assess the impact of the, Lewisham Integrated Medicines Optimisation Service (LIMOS) on medicines self-management, A&E attendances and hospital admissions.

PATIENTS AND METHODS

The study was conducted as a retrospective and prospective observational evaluation of patients referred to LIMOS at University Hospital Lewisham between April and September 2016. Only patients with an appropriate referral that received a LIMOS intervention within the study period were considered eligible. The main outcomes examined pre- and post-LIMOS included medicines self-management, A&E attendance, number of admissions, as well as length of stay.

RESULTS

Data were collected for a total of 193 patients. Over half (56.4%, n = 109) identified as female with a mean age of 78 years at the time of referral. The number of hospital admissions decreased significantly post-LIMOS (-0.36 ± 1.87, 95% CI -0.63-0.10). Furthermore, the mean reduction in length of stay was significant and decreased by over a week (19.58 vs 11.09 days post-LIMOS, -7.67 ± 48.57, 95% CI -14.57--0.78). There was a significant increase in A&E visits observed post-intervention (0.78 ± 1.93, 95% CI 0.50-1.06); however, the majority (63%, n =165/261) occurred over 90 days post-intervention. There was a significant reduction in the number of patients self-managing medication post-LIMOS, with the number of patients receiving additional support with their medication increasing (-0.38 ± 0.50, 95% CI -0.45--0.31). LIMOS, therefore, successfully identified patients who were unable to manage their medicines.

CONCLUSION

Specialist pharmacy interventions, which include support with medicines management, have a positive impact on admission avoidance and length of hospital stay.

A systematic review of older patients' experiences and perceptions of communication about managing medication across transitions of care

BACKGROUND

Communication about managing medications may be difficult when older people move across transitions of care. Communication breakdowns may result in medication discrepancies or incidents.

OBJECTIVE

The aim of this systematic review was to explore older patients' experiences and perceptions of communication about managing medications across transitions of care.

DESIGN

A systematic review.

METHODS

A comprehensive review was conducted of qualitative, quantitative and mixed method studies using CINAHL Complete, MEDLINE, Embase and PsycINFO, Web of Science, INFORMIT and Scopus. These databases were searched from inception to 14.12.2018. Key article cross-checking and hand searching of reference lists of included papers were also undertaken.

INCLUSION CRITERIA

studies of the medication management perspectives of people aged 65 or older who transferred between care settings. These settings comprised patients' homes, residential aged care and acute and subacute care. Only English language studies were included. Comments, case reports, systematic reviews, letters, editorials were excluded. Thematic analysis was undertaken by synthesising qualitative data, whereas quantitative data were summarised descriptively. Methodological quality was assessed with the Mixed Methods Appraisal Tool.

RESULTS

The final review comprised 33 studies: 12 qualitative, 17 quantitative and 4 mixed methods studies. Twenty studies addressed the link between communication and medication discrepancies; ten studies identified facilitators of self-care through older patient engagement; 18 studies included older patients' experiences with health professionals about their medication regimen; and, 13 studies included strategies for communication about medications with older patients. Poor communication between primary and secondary care settings was reported as a reason for medication discrepancy before discharge. Older patients expected ongoing and tailored communication with providers and timely, accurate and written information about their medications before discharge or available for the post-discharge period.

CONCLUSIONS

Communication about medications was often found to be ineffective. Most emphasis was placed on older patients' perspectives at discharge and in the post-discharge period. There was little exploration of older patients' views of communication about medication management on admission, during hospitalisation, or transfer between settings.

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

BACKGROUND

This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration.

METHODS

It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide.

RESULTS

Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self-management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals.

CONCLUSION

On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

Using Theory to Explore the Determinants of Medication Adherence; Moving Away from a One-Size-Fits-All Approach

Non-adherence to prescribed medicines has been described as "a worldwide problem of striking magnitude", diminishing treatment effects and wasting resources. Evidence syntheses report current adherence interventions achieve modest improvements at best, and highlight the poor progress toward the longstanding aim of a gold-standard intervention, tailored to meet individual need. Techniques such as motivational interviewing and health coaching, which aim to facilitate patient-centred care and improve patient resourcefulness, have shown promise in supporting adherence, especially in patients with psychological barriers to medicine-taking, such as illness perceptions and health beliefs. Despite a plethora of research, there is little recognition that the nature and complexity of non-adherence is such that a one-size-fits-all approach to interventions is never likely to suffice. This commentary re-visits the call for adherence interventions to be tailored to meet individual need, by considering what this means for day-to-day practice and how this can be achieved. It provides an update on advances in psychological theory to identify the root cause of an individual's non-adherence to encourage matching of provided adherence support. It also provides a practical perspective by considering exemplars of innovative practice and evaluating the day-to-day practicalities of taking a novel approach.

Impact of an integrated medicines management service on preventable medicines-related readmission to hospital: a descriptive study

Background

Medication contributes to 5-20% of hospital admissions, of which half are considered preventable. An integrated medicines management service (IMMS) was developed at a large general hospital in London to identify and manage patients at risk of a preventable medicines-related readmission (PMRR) to reduce the risk of PMRR.

Objective

To investigate the effect of the pharmacy IMMS on the rate of PMRR within 30 days of the first discharge.

Method

744 patients were identified between October 2008 and October 2014, using the PREVENT tool. Patients at risk were managed by the IMMS with medication reconciliation, review, consultation and follow-up, as required.

Results

Of 744 patients, 119 were readmitted within 30 days of discharge, with a PMRR for 2 patients (1.7%). The main reason for referral to the service was to assess the need to start a compliance aid. Most interventions involved communication: 84% included patient consultations with 50% involving discussion with the patient's community pharmacist and 32% with their general practitioner surgery.

Conclusions

An IMMS may be an effective method of reducing the rate of PMRR. Further work is needed to establish the cost-effectiveness of the service.