The use of artificial intelligence to optimize medication alerts generated by clinical decision support systems: a scoping review

OBJECTIVE

Current Clinical Decision Support Systems (CDSSs) generate medication alerts that are of limited clinical value, causing alert fatigue. Artificial Intelligence (AI)-based methods may help in optimizing medication alerts. Therefore, we conducted a scoping review on the current state of the use of AI to optimize medication alerts in a hospital setting. Specifically, we aimed to identify the applied AI methods used together with their performance measures and main outcome measures.

MATERIALS AND METHODS

We searched Medline, Embase, and Cochrane Library database on May 25, 2023 for studies of any quantitative design, in which the use of AI-based methods was investigated to optimize medication alerts generated by CDSSs in a hospital setting. The screening process was supported by ASReview software.

RESULTS

Out of 5625 citations screened for eligibility, 10 studies were included. Three studies (30%) reported on both statistical performance and clinical outcomes. The most often reported performance measure was positive predictive value ranging from 9% to 100%. Regarding main outcome measures, alerts optimized using AI-based methods resulted in a decreased alert burden, increased identification of inappropriate or atypical prescriptions, and enabled prediction of user responses. In only 2 studies the AI-based alerts were implemented in hospital practice, and none of the studies conducted external validation.

DISCUSSION AND CONCLUSION

AI-based methods can be used to optimize medication alerts in a hospital setting. However, reporting on models' development and validation should be improved, and external validation and implementation in hospital practice should be encouraged.

Patient participation during discharge medication counselling: Observing real-life communication between healthcare professionals and patients

OBJECTIVES

Previous studies on hospital discharge showed limited patient involvement, despite its positive outcomes. In this study, provider-patient communication used to enhance patient participation during discharge medication counselling was examined.

METHODS

This study comprises a qualitative descriptive observational study. Thirty-four discharge consultations were observed, audio recorded and analysed. We conducted a deductive analysis, elaborating on findings from earlier research. We selected themes and underlying codes illustrating professional-patient communication. For every theme, we identified examples to demonstrate its manifestation during discharge medication counselling. We also assessed what information healthcare professionals (HCPs) shared.

RESULTS

HCPs used cues to increase patient participation, e.g. inquired about patient's preferences, showed empathy and support, and verified understanding of information shared. Patient participation occurred through asking questions, and expressing concerns. A central component in discharge medication counselling was the transmission of information from HCPs to patients. This resulted in HCPs taking a leading role.

CONCLUSIONS

Several HCP cues were detected inviting patients to participate in consultations. Some patients participated in discharge medication counselling. This was influenced by timing of discharge consults, the performing HCP and presence of a relative.

PRACTICE IMPLICATIONS

HCPs shared a lot of information with patients. However, this does not automatically mean that patients will be able to understand and apply this information. HCPs should understand the importance of using cues to enable patient participation. One example is using the teach-back method for verifying patient understanding. It may also be desirable to ensure that a relative is present when discharge information is offered.

The effect of emergency department pharmacists on drug overuse and drug underuse in patients with an ADE-related hospitalisation: a controlled intervention study

Background

Drug overuse or drug underuse are the most common causes of adverse drug events and can lead to hospital admissions. Using clinical pharmacists in the emergency department may improve patient safety as they are specialised in recognising of adverse drug events and tackling drug overuse and drug underuse. This study tested the effect of an emergency department pharmacist on the number of medication changes for drug overuse and drug underuse taking place in patients with an adverse drug event-related hospitalisation following an emergency department visit.

Methods

A multicenter prospective non-randomized controlled intervention study was conducted in a university hospital and a general teaching hospital. Trained emergency department pharmacists included patients in the intervention group with a hospital admission related to an adverse drug event. The interdisciplinary intervention consisted of a pharmacist-led medication review, patient counselling regarding medication, and information transmission to general practitioners and community pharmacies after discharge. The control patients were also admitted after an emergency department visit and received the usual care. The primary outcome was the number of medication changes for drug overuse and drug underuse that took place during hospital admission and persisted 6 months thereafter. Poisson regression analysis was used to estimate the difference in these medication changes between the intervention group and the control group.

Results

A total of 216 patients were included (intervention group 104, control group 112). In the intervention group, 156 medication changes for drug overuse and drug underuse persisted 6 months after admission compared to 59 in the control group (adjusted rate ratio 1.22 [95%CI 1.01-1.49] p = 0.039).

Conclusion

Emergency department pharmacists do contribute to reduction of drug overuse and drug underuse of medication in patients with a hospitalisation related to adverse drug events after an emergency department visit.

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study

BACKGROUND

Previous studies on medication therapy management services, e.g. medication reconciliation and medication review, do not show consistent improvements in patient's health-related quality of life. However, these services can reduce adverse drug events.

AIM

To evaluate the correlation between health-related quality of life and adverse events/adverse drug events reported by patients.

METHOD

Older patients (≥ 65 years) with polypharmacy (≥ 5 medicines) admitted to orthopaedic or surgical wards were included. Patients were contacted post-discharge to evaluate patient-reported adverse events, health-related quality of life using the EuroQol questionnaire and self-perceived health status on a 5-point Likert scale. The outcomes were the correlation between health-related quality of life and the number of adverse events/adverse drug events, and potential predictors for these events. Spearman correlation and Poisson regression were used for data analysis.

RESULTS

102 patients were included. The correlation between health-related quality of life and adverse events was weak but significant (Spearman correlation coefficient: - 0.328, p = 0.001). No correlation was found for adverse drug events (- 0.064, p = 0.521). Self-perceived health status was a predictor for adverse events, not for adverse drug events. Health-related quality of life was neither a predictor for adverse events, nor for adverse drug events.

CONCLUSION

The correlation between the number of patient-reported adverse events, adverse drug events and health-related quality of life measured by the EuroQol was weak. There is a need for a questionnaire that includes the impact of medication use and is sensitive to outcomes that are affected by medication therapy management services.

Differences in medication reconciliation interventions between six hospitals: a mixed method study

Background

Although medication reconciliation (MedRec) is mandated and effective in decreasing preventable medication errors during transition of care, hospitals implement MedRec differently.

Objective

Quantitatively compare the number and type of MedRec interventions between hospitals upon admission and discharge, followed by a qualitative analysis on potential reasons for differences.

Methods

This explanatory retrospective mixed-method study consisted of a quantitative and a qualitative part. Patients from six hospitals and six different wards i.e. orthopaedics, surgery, pulmonary diseases, internal medicine, cardiology and gastroenterology were included. At these wards, MedRec was implemented both on hospital admission and discharge. The number of pharmacy interventions was collected and classified in two subcategories. First, the number of interventions to resolve unintended discrepancies (elimination of differences between listed medication and the patient’s actual medication use). And second, the number of medication optimizations (optimization of pharmacotherapy e.g. eliminating double medication). Based on these quantitative results and interviews, a focus group was performed to give insight in local MedRec processes to address differences in context between hospitals. Descriptive analysis (quantitative) and content analysis (qualitative) was used.

Results

On admission 765 (85%) patients from six hospitals, received MedRec by trained nurses, pharmacy technicians, pharmaceutical consultants or pharmacists. Of those, 36–95% (mean per patient 2.2 (SD ± 2.4)) had at least one discrepancy. Upon discharge, these numbers were among 632 (70%) of patients, 5–28% (mean per patient 0.7 (SD 1.2)). Optimizations in pharmacotherapy were implemented for 2% (0.4–3.7 interventions per patient upon admission) to 95% (0.1–1.7 interventions per patient upon discharge) of patients. The main themes explaining differences in numbers of interventions were patient-mix, the type of healthcare professionals involved, where and when patient interviews for MedRec were performed and finally, embedding and extent of medication optimization.

Conclusions

Hospitals differed greatly in the number of interventions performed during MedRec. Differences in execution of MedRec and local context determines the number of interventions. This study can support hospitals who want to optimize MedRec processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08118-8.

Medication-Related Readmissions: Documentation of the Medication Involved and Communication in the Care Continuum

Background: Of all readmissions, 21% are medication-related readmissions (MRRs). However, it is unknown whether MRRs are recognized at the time of readmission and are communicated in the care continuum.

Objectives: To identify the prevalence of MRRs that contain a documentation on the medication involved (and therefore are regarded as recognized), and the proportion of communicated MRRs.

Setting: The study was performed in a teaching hospital.

Methods: In a previous study, a multidisciplinary team of physicians and pharmacists assessed the medication-relatedness, the medication involved and preventability of unplanned readmissions from seven departments. In the current cross-sectional study, two pharmacy team members evaluated the patient records independently. An MRR was regarded as recognized when the medication involved was documented in patient records. An MRR was regarded as communicated to the patient and/or the next healthcare provider when the medication involved or a description was mentioned in discharge letters or discharge prescriptions. The relationship between documented MRRs and whether the MRR was preventable as well as the relationship between (un)documented MRRs and the length of stay (LOS) were assessed. Descriptive data analysis was used.

Results: Of 181 included MRRs, 72 (40%) were deemed preventable by the multidisciplinary team. For 159 of 181 MRRs (88%), a documentation on the medication involved was present. Of 159 documented MRRs, 93 (58%) were communicated to patients and/or caregivers, 137 (86%) to the general practitioner, and 4 (3%) to the community pharmacy. The medication involved was documented less often for potentially preventable MRRs than for non-preventable MRRs (78 vs. 95%; p = 0.002). The LOS was longer for MRRs where the medication involved was undocumented (median 8 vs. 5 days; p = 0.062).

Conclusion: The results of this study imply that MRRs are not always recognized, which could impact patients’ well-being. In this study an increased LOS was observed with unrecognized MRRs. Communication of MRRs to the patients and/or the next healthcare providers should be improved.

Commentary on the EMA reflection paper on the pharmaceutical development of medicines for use in the older population

Older people are often affected by impaired organ and bodily functions resulting in multimorbidity and polypharmacy, turning them into the main user group of many medicines. Very often, medicines have not specifically been developed for older people, causing practical medication problems for them like limited availability of easy to swallow formulations, easy to open packaging and dosing instructions for enteral administration. In 2020, the European Medicines Agency (EMA) published a reflection paper 'Pharmaceutical development of medicines for use in the older population', which discusses how the emerging needs of an ageing European population can be addressed by medicines regulation. The paper intends to help industry to better consider the needs of older people during pharmaceutical/clinical medicines development by summarising data on the most relevant topics, providing early suggestions on how to move forward and prompting expert discussions and studies into knowledge gaps. Topics include patient acceptability, (dis)advantages of an administration route, formulation, dosage form, packaging, dosing device and user instruction. While the paper is directed at older people and the pharmaceutical industry, the reflections are also relevant to younger patients with similar disease-related needs and of value to other stakeholders parties, e.g., healthcare professionals, academics, patients and caregivers, as the paper makes clear what can be expected from industry and where collaborative work is needed. This commentary provides an overview of the different steps in the development of the reflection paper, discusses points considered most controversial and/or subject to (multidisciplinary) expert discussions and indicates their value for real world clinical practice.

Transition of care in stroke patients discharged home: a single-center prospective cohort study

Introduction

Approximately two-thirds of the patients admitted to the hospital with an ischemic stroke are discharged directly home. Discontinuity of care may result in avoidable patient harm, re-admissions and even death. We hypothesized that the transfer of information is most essential in this patient group since any future care for these patients relies solely on the information that is available to the care provider responsible at that time.

Aim

The objective of this study was to evaluate the continuity of transmural care in ischemic stroke patients by assessing 1) the transfer of clinical information through discharge letters to general practitioners (GPs), 2) subsequent documentation of this information and early follow-up by GPs and 3) the documentation of medication-related information in discharge letters, at GPs and community pharmacies (CPs).

Methods

This prospective cohort study was conducted from September 2019 through March 2020 in OLVG, Amsterdam, the Netherlands, in patients with a first stroke discharged directly home. Outcome measures were derived from national guidelines and regional agreements. Results were analyzed using descriptive analysis.

Results

A total of 33 patients were included. Discharge letters (n = 33) and outpatient clinic letters (n = 24) to GPs contained most of the essential items, but 16% (n = 9) of the letters were sent in time. GPs (n = 31) infrequently adhered to guidelines since 10% (n = 3) of the diagnoses were registered using the correct code and 55% (n = 17) of the patients received follow-up shortly after discharge. Medication overviews were inaccurately communicated to GPs since 62% (n = 150) of all prescriptions (n = 243) were correctly noted in the discharge letter. Further loss of information was seen as only 39% (n = 95) of all prescriptions were documented correctly in GP overviews. We found that 59% (n = 144) of the prescriptions were documented correctly in CP overviews.

Conclusion

In this study, we found that discontinuity of care occurred to a varying extent throughout transmural care in patients with a first stroke who were discharged home.

Identifying medication-related readmissions: Two students using tools vs a multidisciplinary panel

BACKGROUND

Polypharmacy may result in medication-related readmissions (MRRs). Identifying MRRs is time consuming. Screening of readmissions by students could increase efficiency for healthcare professionals. Recently, two screening tools have been published: the Assessment Tool for identifying Hospital Admissions Related to Medications (AT-HARM10) tool and the Drug-Related Admission (DRA) adjudication guide. It is unknown whether pharmacy students could identify MRRs with these tools.

OBJECTIVE

To compare the agreement between two pharmacy students applying the AT-HARM10 tool and DRA adjudication guide in identifying MRRs vs a multidisciplinary panel.

METHODS

A retrospective study was conducted from February to July 2020 at OLVG hospital. Readmissions within 30 days after discharge from seven departments were reviewed by a multidisciplinary panel (pharmacists and physicians). MRRs were defined as readmission where medication was the main cause or medication significantly contributed to the readmission. Two 5th year pharmacy-students volunteered to blindly apply both tools individually on all MRRs and a random sample of non-MRRs. The consensus results of the students and the multidisciplinary panel were compared and displayed as a percentage and Cohen's kappa (κ).

RESULTS

Three hundred sixty-six readmission cases were selected in total, consisting of 181 MRRs and 185 non-MRRs. The agreement between the students using the AT-HARM10 tool vs the multidisciplinary panel was moderate (80%, κ = 0.60 (95% confidence interval (CI): 0.52-0.68)). The DRA adjudication guide had a moderate agreement (81%, κ = 0.62 (CI: 0.54-0.70)). Students misclassified MRRs mainly because the multidisciplinary panel found disease progression more profound than a contribution of medication.

CONCLUSIONS

Two students have an overall agreement of 80% in comparison with the multidisciplinary panel with a moderate Cohen's kappa. Students are more often overestimated, but they may be a good option to preselect potential MRRs to save time for healthcare professionals. However, some MRRs will be missed.

Application of intervention mapping to develop and evaluate a pharmaceutical discharge letter to improve information transfer between hospital and community pharmacists

BACKGROUND

Insufficient information transfer is a major barrier in the transition from hospital to home. This study describes the systematic development and evaluation of an intervention to improve medication information transfer between hospital and community pharmacists.

OBJECTIVE

To develop and evaluate an intervention to improve the medication information transfer between hospital and community pharmacists based on patients', community and hospital pharmacists' needs.

METHODS

The intervention development and evaluation was guided by the six-step Intervention Mapping (IM) approach: (1) needs assessment to identify determinants of the problem, with a scoping review and focus groups with patients and healthcare providers, (2) formulation of intervention objectives with an expert group, (3) inventory of communication models to design the intervention, (4) using literature review and qualitative research with pharmacists and patients to develop the intervention (5) pilot-testing of the intervention in two hospitals, and (6) a qualitative evaluation of the intervention as part of a multicenter before-after study with hospital and community pharmacists.

RESULTS

Barriers in the information transfer are mainly time and content related. The intervention was designed to target a complete, accurate and timely medication information transfer between hospital and community pharmacists. A pharmaceutical discharge letter was developed to improve medication information transfer. Hospital and community pharmacists were positive about the usability, content, and comprehensiveness of the pharmaceutical discharge letter, which gave community pharmacists sufficient knowledge about in-hospital medication changes. However, hospital pharmacists reported that it was time-consuming to draft the discharge letter and not always feasible to send it on time. The intervention showed that pharmacists are positive about the usability, content and comprehensiveness.

CONCLUSION

This study developed an intervention systematically to improve medication information transfer, consisting of a discharge letter to be used by hospital and community pharmacists supporting continuity of care.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial

AIMS

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge.

METHODS

We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group.

RESULTS

For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (P_interaction  = .085). In total, 77.0% of the patients had at least one MRP post-discharge.

CONCLUSIONS

Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy

INTRODUCTION

Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge.

METHODS

A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders.

RESULTS

In total, 369 patients were included (control: n = 195, intervention: n = 174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, OR_adj 0.70 [95% CI 0.38-1.31], university hospital: 63% vs 50%, OR _adj 1.76 [95% CI 0.75-4.13]).

CONCLUSION

The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.

Medication-Related Hospital Readmissions Within 30 Days of Discharge: Prevalence, Preventability, Type of Medication Errors and Risk Factors

Background: Hospital readmission rates are increasingly used as a measure of healthcare quality. Medicines are the most common therapeutic intervention but estimating the contribution of adverse drug events as a cause of readmissions is difficult.

Objectives: To assess the prevalence and preventability of medication-related readmissions within 30 days after hospital discharge and to describe the risk factors, type of medication errors and types of medication involved in these preventable readmissions.

Design: A cross-sectional observational study.

Setting: The study took place across the cardiology, gastroenterology, internal medicine, neurology, psychiatry, pulmonology and general surgery departments in the OLVG teaching hospital, Netherlands.

Participants: Patients with an unplanned readmission within 30 days after discharge from an earlier hospitalization (index hospitalization: IH) were reviewed.

Measurements: The prevalence and preventability of medication-related readmissions were assessed by residents in multidisciplinary meetings. A senior internist and hospital pharmacist reassessed the prevalence and preventability of identified cases. Generalized estimating equation with logistic regression was performed to identify risk factors of potentially preventable medication-related readmissions.

Results: Of 1,111 included readmissions, 181 (16%) were medication-related, of which 72 (40%) were potentially preventable. The number of medication changes at IH (Adjusted odds ratio [OR_adj]: 1.14; 95% CI: 1.05–1.24) and having ≥3 hospitalizations 6 months before IH (ORadj: 2.11; 95% CI: 1.12–3.98) were risk factors of a preventable medication-related readmission. Of these preventable readmissions, 35% were due to prescribing errors, 35% by non-adherence and 30% by transition errors. Medications most frequently involved were diuretics and antidiabetics.

Conclusion: This study shows that 16% of readmissions are medication-related, of which 40% are potentially preventable. If the results are confirmed in larger multicentre studies, this may indicate that more attention should be paid to medication-related harm in order to lower the overall readmission rates.

The effect of an inpatient geriatric stewardship on drug-related problems reported by patients after discharge

Background Drug-related problems after discharge are common among older adults with polypharmacy. Medication review during hospitalization has been proposed as one solution. Inpatient medication review is often based on clinical records only. An obstacle is the lack of insight into the outpatient history. Therefore, a geriatric stewardship was designed and involved an inpatient medication review by a hospital pharmacist and geriatrician based on (I) clinical records to draft initial recommendations, (II) consultations with primary care providers (general practitioner and community pharmacist) to discuss the hospital-based recommendations, (III) patient interviews to assess their needs, and (IV) a multidisciplinary evaluation of all previous steps to draft final recommendations. Objective To assess the effect of the geriatric stewardship on drug-related problems reported by patients after discharge. Setting General teaching hospital. Methods An implementation study (pre-post design) was performed. Orthopaedic and surgical patients (≥ 65 years) with polypharmacy and a frailty risk factor were included. The pre-group received usual care, the post-group received the geriatric stewardship intervention. Two weeks post-discharge, patient-reported drug-related problems were assessed using a validated questionnaire. Drug-related problems were classified into drug-related complaints, practical problems, and questions about medication. Outcomes The outcomes were the number and type of drug-related problems per patient (primary) and the number of initial recommendations that were altered due to primary care provider and patient input (secondary). Results In total, 127 patients were analysed (usual care n = 74, intervention n = 53). Intervention patients reported fewer drug-related problems compared to usual care: 2.8 versus 3.3 per patient (Adjusted relative risk 0.83, 95% confidence interval 0.66-1.05). This difference resulted from a halving in drug-related complaints (p < 0.05), for example pain, drowsiness, nausea or constipation. Nearly 30% of the initial recommendations based on the clinical records were discarded or modified after primary care provider consultations and patient interviews. Conclusion The geriatric stewardship did not significantly reduce drug-related problems, but it significantly halved drug-related complaints. One-in-three initial recommendations were altered due to primary care provider and patient input. Inpatient medication reviews should not be based on clinical records only; they require transmural collaboration and patient participation to ensure continuity of patient care.

Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis

BACKGROUND

Harm due to medications is common during the transition from hospital to home. Approaches that seek to prevent harm often involve isolated medication-related interventions and show conflicting results. However, until now, no review has focused on the effect of intervention components delivered both in hospital and following discharge from hospital to home.

OBJECTIVE

To examine effects of medication-related interventions on hospital readmissions, medication-related problems (MRPs), medication adherence and mortality.

METHODS

For this systematic review and meta-analysis, we searched the PubMed, Embase, CINAHL and CENTRAL databases without language restrictions. Citations of included articles were checked through Web of Science and Scopus from inception to 20 June 2019. We included prospective studies that examined effects of medication-related interventions delivered both in hospital and following discharge from hospital to home compared with usual care. Three authors independently extracted data and assessed study quality in pairs.

RESULTS

Fourteen original studies were included, comprising 8182 patients. Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Nine studies were included in the meta-analysis; compared with usual care (n=3376 patients), medication-related interventions (n=1820 patients) reduced hospital readmissions by 3.8 percentage points within 30 days of discharge (number needed to treat=27, risk ratio (RR) 0.79 (95% CI 0.65 to 0.96)). Meta-regression analysis suggested that readmission rates were reduced by 17% per additional intervention component (RR 0.83 (95% Cl 0.75 to 0.91)). Medication adherence and MRPs may be improved. Effects on mortality were unclear.

CONCLUSIONS

Studied medication-related interventions reduce all-cause hospital readmissions within 30 days. The treatment effect appears to increase with higher intervention intensities. More evidence is needed for recommendations on adherence, mortality and MRPs.

Preventability of unplanned readmissions within 30 days of discharge. A cross-sectional, single-center study

Objectives

To identify the preventability, determinants and causes of unplanned hospital readmissions within 30 days of discharge using a multidisciplinary approach and including patients’ perspectives.

Design

A prospective cross-sectional single-center study.

Setting

Urban teaching hospital in Amsterdam, the Netherlands.

Participants

430 patients were included. Inclusion criteria were: age ≥ 18 years, discharged from one of seven participating clinical departments and an unplanned readmission within 30 days.

Methods

Residents from the participating departments individually assessed whether the readmission was caused by healthcare, the preventability and possible causes of readmissions using a tool. Thereafter, the preventability of the cases was discussed in a multidisciplinary meeting with residents of all participating departments and clinical pharmacists. The primary outcome was the proportion of readmissions that were potentially preventable. Secondary outcomes were the determinants for a readmission, causes for preventable readmissions, the change in the final decision on preventability after the multidisciplinary meeting and the value of patient interviews in assessing preventability. Differences in characteristics of potentially preventable readmissions (PPRs) and non-PPRs were analyzed using multivariable logistic regression.

Results

Of 430 readmissions, 56 (13%) were assessed as PPRs. Age was significantly associated with a PPR (adjusted OR: 2.42; 95%, CI 1.23–4.74; p = 0.01). The main causes for PPRs were diagnostic (30%), medication (27%) and management problems (27%). During the multidisciplinary meeting, the final decision on preventability changed in 11% of the cases. When a patient interview was available, it was used as a source of information to assess preventability in 26% of readmissions. In 7% of cases, the patient interview was mentioned as the most important source.

Conclusion and implications

13% of readmissions were potentially preventable with diagnostic, medication or management problems being main causes. A multidisciplinary review approach and including the patient’s perspective could contribute to a better understanding of the complexity of readmissions and possible improvements.

Patients' and providers' perspectives on medication relatedness and potential preventability of hospital readmissions within 30 days of discharge

Background

Hospital readmissions are increasingly used as an indicator of quality in health care. One potential risk factor of readmissions is polypharmacy. No studies have explored the patients’ perspectives on the medication relatedness and potential preventability of their readmissions.

Objective

To compare the patients’ perspectives on the medication relatedness and potential preventability of their readmissions with the providers’ perspectives.

Methods

Patients unplanned readmitted within 30 days after discharge at one of the participating departments of OLVG Hospital in Amsterdam were interviewed during their readmission. Patients’ perspectives regarding medication relatedness of their readmissions, the potential preventability, possible preventable interventions, and satisfaction with medication information were examined. Health‐care providers also reviewed files of these readmitted patients. Primary outcome was the percentage of medication‐related and potentially preventable readmissions according to the patient vs the provider. Descriptive data analysis was used.

Results

According to patients, 36 of 172 (21%) readmissions were medication‐related, and of these, 21 (58%) were potentially preventable. According to providers, 26 (15%) readmissions were medication‐related and 6 (23%) of these were potentially preventable. Patients and providers agreed on the medication relatedness in 11 of the 172 readmissions, and in two of these, agreement on the potential preventability existed. According to patients, preventive interventions belonged mostly to the hospital level, followed by the primary care level and patient level.

Conclusion

Patients and providers differ substantially on their perspectives regarding the medication relatedness and preventability of readmissions. Patients were more likely to view medication‐related readmissions as preventable.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

[Medication reconciliation: a hell of a job]

Transitions of care pose a risk to medication safety. To reduce patient harm, medication reconciliation is advised. However, implementation of medication reconciliation is difficult due to time constraints. We present two female patients aged 82 and 84 years. In both women, unintentional discrepancies arose, went undetected and led to patient harm. Accurate information transfer is essential for continuity of patient care. Medication reconciliation comprises four steps, i.e. verification (identify discrepancies), clarification (check the collected list), reconciliation (document the reason for medication changes) and transfer (communicate the updated list). This article discusses the steps of medication reconciliation and those medication errors that arise during a patient's transfer from the home setting to hospitalization or a clinic visit. We show that medication reconciliation is not merely an administrative task. As the patient is the only constant factor in health care, patient participation is essential.

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis

Background

A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used.

To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review.

Methods

A literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods.

Results

Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information.

Conclusion

A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0766-0) contains supplementary material, which is available to authorized users.

Validity of a nationwide medication record system in the Netherlands

Background In the Netherlands, a nationwide Medication Record System based on pharmacy dispensing data is used to obtain information about patients' actual medication use. However, it is not clear to what extent the information of the Nationwide Medication Record System corresponds to the medication information obtained with the Best Possible Medication History. Objective To examine the validity of medication dispensing records collected from the Nationwide Medication Record System by comparing them to the Best Possible Medication History. Method An observational study was performed. Patients from several hospital departments were included at admission. To obtain the Best Possible Medication History, pharmacy technicians performed medication reconciliation at admission, using dispensing records from the Nationwide Medication Record System and information from the patient himself. Primary outcome is percentage of patients with no discrepancies between the Nationwide Medication Record System and the Best Possible Medication History. Descriptive analysis was used. Results Eighty-two patients were approached and 66 (80%) were included, with in total 478 medicines in the Best Possible Medication History. Seventeen percent of the patients had no discrepancies and 33% (n = 156) of the medication records contained a discrepancy between the Nationwide Medication Record System and the Best Possible Medication History. Most common type of discrepancy was omission (44%). Conclusion Even with a Nationwide Medication Record System medication reconciliation with the patient remains essential to obtain complete information about patient's actual medication use.

The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study

BACKGROUND

Medication-related problems are common after hospitalization, for example when changes in patients' medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge. We investigated the effect of a pharmacy-led transitional care program on the occurrence of medication-related problems four weeks post-discharge.

METHODS

A prospective multi-center before-after study was conducted in six departments in total of two hospitals and 50 community pharmacies in the Netherlands. We tested a pharmacy-led program incorporating (i) usual care (medication reconciliation at hospital admission and discharge) combined with, (ii) teach-back at hospital discharge, (iii) improved transfer of medication information to primary healthcare providers and (iv) post-discharge home visit by the patient's own community pharmacist, compared with usual care alone. The difference in medication-related problems four weeks post-discharge, measured by means of a validated telephone-interview protocol, was the primary outcome. Multiple logistic regression analysis was used, adjusting for potential confounders after multiple imputation to deal with missing data.

RESULTS

We included 234 (January-April 2016) and 222 (July-November 2016) patients in the usual care and intervention group, respectively. Complete data on the primary outcome was available for 400 patients. The proportion of patients with any medication-related problem was 65.9% (211/400) in the usual care group compared to 52.4% (189/400) in the intervention group (p = 0.01). After multiple imputation, the proportion of patients with any medication-related problem remained lower in the intervention group (unadjusted odds ratio 0.57; 95% CI 0.38-0.86, adjusted odds ratio 0.50; 95% CI 0.31-0.79).

CONCLUSIONS

A pharmacy-led transitional care program reduced medication-related problems after discharge. Implementation research is needed to determine how best to embed these interventions in existing processes.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

BACKGROUND

After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation.

METHODS

In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden.

DISCUSSION

This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.

TRIAL REGISTRATION

NTR6316 . Date of registration: April 6, 2017.

Informational needs and recall of in-hospital medication changes of recently discharged patients

PURPOSE

The need for information for patients and caregivers at the point of hospital discharge is paramount and potentially extensive.

OBJECTIVE

The objective of this study was to assess patients' informational needs at hospital discharge, patients' recall of medication changes implemented in the hospital and patients' medication related problems experienced one week after hospital discharge.

METHODS

The study was conducted in a teaching hospital where patients received structured discharge counseling. Patients were interviewed at hospital discharge regarding their informational needs. One week post-discharge, patients were interviewed by phone to assess any changes in informational needs, their recall regarding in-hospital medication changes and the medication related problems. Descriptive analysis and logistic regression were used to address study objectives.

RESULTS

The 124 patients in the study regarded the following topics as most relevant for counseling: what the medicine is for (57%), side effects (52%), drug-drug interactions (45%), action of the drug (37%) and reimbursement (31%). In 9% of patients the informational needs changed post-discharge, e.g. the topic side effects increased in importance. Forty-nine percent could recall whether and which medication was changed during hospitalization. Medication-related problems and side effects were reported by respectively 27% and 15% of patients, whereas only 7% contacted their doctor or pharmacist.

CONCLUSIONS

Patients' informational needs are very individual and can change post-discharge. Despite structured counseling, only half of the patients were able to recall the medication changes implemented in the hospital. Furthermore, patients reported several problems for which they did not consult a healthcare provider. This insight could help in smoothing the transition from hospital to the primary care setting.

Patients' appropriateness, acceptability, usability and preferences for pharmaceutical preparations: Results from a literature review on clinical evidence

Patients play an important role in achieving the desired therapeutic outcomes, as they are frequently responsible for their own medication management. To facilitate drug administration and overcome medication issues, the patients' needs and preferences should be considered in the pharmaceutical drug product design. With the aim to evaluate the current state of evidence for patient appropriateness, acceptability, usability and preference for aspects of this design, a literature search was performed. Comparative clinical studies that assessed such endpoints for different patient populations were included and summarized descriptively. The search identified 45 publications that met the inclusion criteria. A detailed analysis of the studies identified two main areas investigating either packaging design (n=10) or dosage form design (n=35). Studies on packaging design showed preferences for wing top and screw cap openings, push-through blisters and suppositories with slide system. Additionally, child-resistant containers should be avoided concerning specific patient populations. Regarding dosage form design, sprinkles and minitablets were the most preferred in studies involving young patients, while preferences varied considerably depending on route of administration and geographical region in studies with adult patients. Review of the methodology used in the studies revealed that ten studies had used well-defined protocols and observational endpoints to investigate patient appropriateness. Studies focusing on methodology for testing the appropriateness and usability of drug products by patients were not found. In conclusion, more interdisciplinary scientific efforts are required to develop and increase research in understanding patient needs and preferences.

Completeness of medication-related information in discharge letters and post-discharge general practitioner overviews

BACKGROUND

Communication and documentation of medication-related information are needed to improve continuity of care.

OBJECTIVE

To assess the completeness of medication-related information in discharge letters and post-discharge general practitioner (GP)-overviews.

SETTING

A general teaching hospital in Amsterdam, the Netherlands.

METHOD

An observational study was performed. Patients from several departments were included after medication reconciliation at hospital discharge. In liaison with the resident and patient, a pharmacy team prepared a Transitional Pharmaceutical Care (TPC)-overview of current medications, including changes and allergies. The resident was instructed to download the TPC-overview into the discharge letter instead of typing a self-made medication list. Medication overviews were gathered from the GP 2 weeks after the handover of the discharge letter. The TPC-overview (gold standard) was compared with the information in the discharge letter and post-discharge GP-overviews regarding correct medications and allergies. Descriptive data analysis was used.

MAIN OUTCOME MEASURE

The number and percentage of complete medication-related information in the discharge letter and the GP-overview were compared to the TPC-overview.

RESULTS

Ninety-nine patients were included. Medication-related information was complete in 62 (63 %) of 99 discharge letters. Sixteen of 99 GP-overviews (16 %) were complete. Communication of medication-related information increased documentation by the GP, but the medication history could still be incomplete, mainly regarding medication changes and allergies.

CONCLUSIONS

Medication-related information is lost in discharge letters and GP-overviews post-discharge despite in-hospital medication reconciliation. This could result in discontinuity of care.

Identifying the Optimal Role for Pharmacists in Care Transitions: A Systematic Review

BACKGROUND

A transition from one health care setting to another increases the risk of medication errors. Several strategies have been applied to improve care transitions and reduce adverse clinical outcomes. Pharmacist intervention during and after hospitalization has been frequently studied and show a variable effect on these outcomes.

OBJECTIVE

To identify the components of pharmacist intervention that improve clinical outcomes during care transitions.

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts, and Web of Science databases were searched for randomized controlled trials (RCTs) that studied pharmacist intervention with regard to hospitalization. Two reviewers independently screened all references published from inception to November 2014, extracted data, and assessed risk of bias.

RESULTS

A total of 30 studies met the inclusion criteria. A model was created to categorize and cluster components of pharmacist intervention. The average number of components deployed, stages of hospitalization covered, and intervention targets were equally distributed between effective and ineffective studies. A best evidence synthesis of 15 studies revealed strong evidence for a clinical medication review in multifaceted programs (5 effective vs. 0 ineffective studies). Conflicting evidence was found for an isolated postdischarge intervention, admission medication reconciliation, combining postdischarge interventions with in-hospital interventions, and covering of multiple stages. Closely collaborating with other health care providers enhanced the effectiveness.

CONCLUSIONS

Although there is a need for well-designed and well-reported RCTs, the study heterogeneity enabled a best evidence synthesis to elucidate effective components of pharmacist intervention. In isolated postdischarge intervention programs, evidence tends towards collaborating with nurses and tailoring to individual patient needs. In multifaceted intervention programs, performing medication reconciliation alone is insufficient in reducing postdischarge clinical outcomes and should be combined with active patient counseling and a clinical medication review. Furthermore, close collaboration between pharmacists and physicians is beneficial. Finally, it is important to secure continuity of care by integrating pharmacists in these multifaceted programs across health care settings. Ultimately, pharmacists need to know patient clinical background and previous hospital experience.

Effect of Medication Reconciliation on Medication Costs After Hospital Discharge in Relation to Hospital Pharmacy Labor Costs

Background:

Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs.

Objective:

To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs.

Methods:

A prospective observational study was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed medication errors prevented by medication reconciliation. Interventions were classified into 3 categories: correcting hospital formulary-induced medication changes (eg, reinstating less costly generic drugs used before admission), optimizing pharmacotherapy (eg. discontinuing unnecessary laxative), and eliminating discrepancies (eg, restarting omitted preadmission medication). Because eliminating discrepancies does not represent real costs to society (before hospitalization, the patient was also using the medication), these medication costs were not included in the cost calculation. Medication costs at 1 month and 6 months after hospital discharge and the associated tabor costs were assessed using descriptive statistics and scenario analyses. For the 6-month extrapolation, only medication intended for chronic use was included.

Results:

Two hundred sixty-two patients were included. Correcting hospital formulary changes saved €1 63/patient (exchange rate: EUR 1 = USD 1.3443) in medication costs at 1 month after discharge and €9.79 at 6 months. Optimizing pharmacotherapy saved €20.13/patient in medication costs at 1 month and €86.86 at 6 months. The associated labor costs for performing medication reconciliation were €41.04/patient. Medication cost savings from correcting hospital formulary-induced changes and optimizing of pharmacotherapy (€96.65/patient) outweighed the labor costs at 6 months extrapolation by €55.62/patient (sensitivity analysis €37.25–71.10).

Conclusions:

Preventing medication errors through medication reconciliation results in higher benefits than the costs related to the net time investment.

Information needs about medication according to patients discharged from a general hospital

OBJECTIVE

Medication regimens change during hospital admission, and these discrepancies can lead to an increased risk of patient harm after hospital discharge. Information about medication according to the patient's needs may contribute to patient safety by improvement of knowledge and adherence. The goal of this study is to explore the patient's needs on information about medication at hospital discharge.

RESEARCH DESIGN AND METHODS

Qualitative, semi-structured interviews were performed with 31 patients from the pulmonology, internal medicine and cardiology departments who were discharged with at least one prescribed drug from the hospital to primary care in the Netherlands. Interviews were analysed with content analysis.

RESULTS

Patients had variable needs concerning information about discharge medication. Most patients wanted to receive basic information about their medication, alternatives for the prescribed medication and side effects. Some patients did not need basic information or explicitly mentioned that information about side effects would negatively influence their attitude towards medication. Patients preferred a combination of oral instructions and written information.

CONCLUSIONS

Information at discharge should be tailored to the individual needs of the patient.

PRACTICE IMPLICATIONS

In the process of providing patient information at hospital discharge, the preference of some patients for non-disclosure of information should be recognised.