An innovative approach to integrated medicines management

Measuring the impact of pharmaceutical care bundle delivery on patient outcomes: an observational study

BACKGROUND

Clinical pharmacists perform activities to optimise medicines use and prevent patient harm. Historically, clinical pharmacy quality indicators have measured individual activities not linked to patient outcomes.

AIM

To determine the proportion of patients who receive a pharmaceutical care bundle (PCB) (consisting of a medication history, medication review, discharge medication list and medicines information on the discharge summary) as well as investigate the relationship between delivery of this PCB and patient outcomes.

METHOD

Pharmaceutical care bundle activities were defined within state-wide (Queensland, Australia) clinical information systems and datasets were linked. An observational study using routinely recorded data was performed at ten participating sites for adult patients who had a non-same day hospital stay. The association between extent of PCB delivery and three patient outcomes were investigated: length of stay (LOS), unplanned readmission, and mortality.

RESULTS

In total 283,813 patient hospital stays were evaluated. The delivery of the PCB occurred in 26.9% of patients at the ten participating hospital sites, ranging from 0.6 to 61.2% across sites. Patients with a longer LOS were more likely to receive delivery of the complete PCB (P < 0.001). There was no correlation between PCB and hospital standardised mortality ratio (r = 0.03, p = 0.93). Higher rates of delivery of the PCB were associated with lower rates of unplanned readmission within 30 days (r = - 0.993, p < 0.001).

CONCLUSION

A complete PCB was delivered to 26.9% of patients and was associated with a significantly lower rate of unplanned readmission within 30 days.

The Medicines Optimisation Innovation Centre: a dedicated centre driving innovation in medicines optimisation-impact and sustainability

BACKGROUND

Sub-optimal medicines use is a challenge globally, contributing to poorer health outcomes, inefficiencies and waste. The Medicines Optimisation Innovation Centre (MOIC) was established in Northern Ireland by the Department of Health (DH) in 2015 to support implementation of the Medicines Optimisation Quality Framework.

AIM

To demonstrate how MOIC informs policy and provides support to commissioners to improve population health and wellbeing.

SETTING

MOIC is a regional centre with multidisciplinary and multi-sector clinical expertise across Health and Social Care and patient representation.

DEVELOPMENT

Core funded by DH, MOIC has a robust governance structure and oversight programme board. An annual business plan is agreed with DH. Rigorous processes have been developed for project adoption and working collaboratively with industry.

IMPLEMENTATION

MOIC has established partnerships with academia, industry, healthcare and representative organisations across Europe, participating in research and development projects and testing integrated technology solutions. A hosting programme has been established and evaluation and dissemination strategies have been developed.

EVALUATION

MOIC has established numerous agreements, partnered in three large EU projects and strengthened networks globally with extensive publications and conference presentations. Informing pathway redesign, sustainability and COVID response, MOIC has also assisted in the development of clinical pharmacy services and antimicrobial stewardship in Europe and Africa. Northern Ireland has been recognised as a 4-star European Active and Healthy Ageing Reference Site and the Integrated Medicines Management model as an example of best practice in Central and Eastern Europe.

CONCLUSION

MOIC has demonstrated considerable success and sustainability and is applicable to health systems globally.

Development and external validation of a prognostic model for time to readmission or death in multimorbid patients

OBJECTIVE

To develop and externally validate a prognostic model built on important factors predisposing multimorbid patients to all-cause readmission and/or death. In addition to identify patients who may benefit most from a comprehensive clinical pharmacist intervention.

METHODS

A multivariable prognostic model was developed based on data from a randomised controlled trial investigating the effect of pharmacist-led medicines management on readmission rate in multimorbid, hospitalised patients. The derivation set comprised 386 patients randomised in a 1:1 manner to the intervention group, i.e. with a pharmacist included in their multidisciplinary treatment team, or the control group receiving standard care at the ward. External validation of the model was performed using data from an independent cohort, in which 100 patients were randomised to the same intervention, or standard care. The setting was an internal medicines ward at a university hospital in Norway.

RESULTS

The number of patients who were readmitted or had died within 18 months after discharge was 297 (76.9 %) in the derivation set, i.e. the randomized controlled trial, and 69 (71.1 %) in the validation set, i.e. the independent cohort. Charlson comorbidity index (CCI; low, moderate or high), previous hospital admissions within the previous six months and heart failure were the strongest prognostic factors and were included in the final model. The efficacy of the pharmaceutical intervention did not prove significant in the model. A prognostic index (PI) was constructed to estimate the hazard of readmission or death (low, intermediate or high-risk groups). Overall, the external validation replicated the result. We were unable to identify a subgroup of the multimorbid patients with better efficacy of the intervention.

CONCLUSIONS

A prognostic model including CCI, previous admissions and heart failure can be used to obtain valid estimates of risk of readmission and death in patients with multimorbidity.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach

BACKGROUND

Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes.

AIM

To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service.

METHOD

A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed.

RESULTS

Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days.

CONCLUSION

Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

A Trial-Based Cost-Utility Analysis of a Medication Optimization Intervention Versus Standard Care in Older Adults

BACKGROUND

Older adults are at greater risk of medication-related harm than younger adults. The Integrated Medication Management model is an interdisciplinary method aiming to optimize medication therapy and improve patient outcomes.

OBJECTIVE

We aimed to investigate the cost effectiveness of a medication optimization intervention compared to standard care in acutely hospitalized older adults.

METHODS

A cost-utility analysis including 285 adults aged ≥ 70 years was carried out alongside the IMMENSE study. Quality-adjusted life years (QALYs) were derived using the EuroQol 5-Dimension 3-Level Health State Questionnaire (EQ-5D-3L). Patient-level data for healthcare use and costs were obtained from administrative registers, taking a healthcare perspective. The incremental cost-effectiveness ratio was estimated for a 12-month follow-up and compared to a societal willingness-to-pay range of €/QALY 27,067-81,200 (NOK 275,000-825,000). Because of a capacity issue in a primary care resulting in extended hospital stays, a subgroup analysis was carried out for non-long and long stayers with hospitalizations < 14 days or ≥ 14 days.

RESULTS

Mean QALYs were 0.023 [95% confidence interval [CI] 0.022-0.025] higher and mean healthcare costs were €4429 [95% CI - 1101 to 11,926] higher for the intervention group in a full population analysis. This produced an incremental cost-effectiveness ratio of €192,565/QALY. For the subgroup analysis, mean QALYs were 0.067 [95% CI 0.066-0.070, n = 222] and - 0.101 [95% CI - 0.035 to 0.048, n = 63] for the intervention group in the non-long stayers and long stayers, respectively. Corresponding mean costs were €- 824 [95% CI - 3869 to 2066] and €1992 [95% CI - 17,964 to 18,811], respectively. The intervention dominated standard care for the non-long stayers with a probability of cost effectiveness of 93.1-99.2% for the whole willingness-to-pay range and 67.8% at a zero willingness to pay. Hospitalizations were the main cost driver, and readmissions contributed the most to the cost difference between the groups.

CONCLUSIONS

According to societal willingness-to-pay thresholds, the medication optimization intervention was not cost effective compared to standard care for the full population. The intervention dominated standard care for the non-long stayers, with a high probability of cost effectiveness.

CLINICAL TRIAL REGISTRATION

The IMMENSE trial was registered in ClinicalTrials.gov on 28 June, 2016 before enrolment started (NCT02816086).

Medication reconciliationis it possible to speed up without compromising quality? A before-after study in the emergency department

OBJECTIVE

The aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more efficient method will enable more patients to receive MR as early as possible after admission to hospital.

METHODS

Potential key factors for improvement of the standard method of MR by clinical pharmacists were identified through an observational period. A revised method was developed, focusing on decreasing time spent on the patient interview by use of a condensed checklist and probing questions based on information from a prescription database. Non-inferior quality (proportion of patients with at least one identified medication discrepancy and number of identified medication discrepancies per patient) of the revised method was evaluated using a before-after study design with 200 individuals in each group. Non-inferiority limit was set at 10%. The Mann-Whitney U test was used for statistical evaluation of the difference in time use per patient in the MR process between the before and after group.

RESULTS

Mean age of the included patients was 78 years in both groups. The time used for MR in the after group was 34% shorter (37 min vs 56 min, p<0.0001) compared with the before group. The revised method was shown to be non-inferior compared with the original method with respect to the proportion of patients with at least one identified discrepancy (81%, 95% CI 76% to 86% vs 79%, 95% CI 73% to 84%). Also, non-inferiority was shown for the number of identified discrepancies per patient, where the average number of discrepancies per patient was 1.9 (95% CI 1.7 to 2.1) in both groups.

CONCLUSION

This study showed that it was possible to speed up the MR process without compromising its effectiveness in identifying medication discrepancies.

Clinical pharmacy interventions in an Austrian hospital: a report highlights the need for the implementation of clinical pharmacy services

BACKGROUND

Clinical pharmacy services face challenges in Austria due to limited implementation and acceptance, outdated legislation and a lack of guidelines and training, despite the evidence from global studies of the positive impact of clinical pharmacists on patient care.

OBJECTIVES

First, to identify the necessary types of clinical pharmacy interventions required at a 360-bed hospital located in Austria. Second, to evaluate the extent to which physicians accept the suggestions made by clinical pharmacists.

METHODS

Over a period of 27 months, a clinical pharmacist made a series of interventions, which were evaluated using a six-point clinical significance scale. To determine the inter-rater reliability, a subset of 25 interventions was assessed for their clinical significance by four independent internal medicine physicians.

RESULTS

A total of 1064 interventions were made by the pharmacist. Clinical pharmacy input was deemed necessary for 986 out of 1364 (72.3%) patients, with an average of 1.08 interventions per patient. The prompt acceptance rate of these interventions by physicians was 83.5% (888/1064), while 12.9% (137/1064) were considered by physicians but not immediately acted upon. The average clinical significance intervention rating was 2.15. The inter-rater reliability agreement between the four MDs and between the four MDs and the pharmacist was classified as 'good' to 'moderate'.

CONCLUSION

This study in a secondary care Austrian hospital demonstrates the requirement for clinical pharmacy services, which are highly valued by other healthcare professionals. The clinical pharmacist is a key member of the multidisciplinary ward team, playing a vital role in reducing drug-related problems and enhancing patient safety. This work should now be scaled and tested in other Austrian hospitals.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

Developing an In-House Comprehensive Medication Review Training Program for Clinical Pharmacists in a Finnish Hospital Pharmacy

Long-term continuing education programs have been a key factor in shifting toward more patient-centered clinical pharmacy services. This narrative review aims to describe the development of Helsinki University Hospital (HUS) Pharmacy's in-house Comprehensive Medication Review Training Program (CMRTP) and how it has impacted clinical pharmacy services in HUS. The CMRTP was developed during the years 2017-2020. The program focuses on developing the special skills and competencies needed in comprehensive medication reviews (CMRs), including interprofessional collaboration and pharmacotherapeutic knowledge. The program consists of two modules: (I) Pharmacist-Led Medication Reconciliation, and (II) CMR. The CMRTP includes teaching sessions, self-learning assignments, medication reconciliations, medication review cases, CMRs, a written final report, and a self-assessment of competence development. The one-year-long program is coordinated by a clinical teacher. The program is continuously developed based on the latest guidelines in evidence-based medicine and international benchmarking in cooperation with the University of Helsinki. With the CMRTP, we have adopted a more patient-centered role for our clinical pharmacists and remarkably expanded the services. This program may be benchmarked in other countries where the local education system does not cover clinical pharmacy competence well enough and in hospitals where the clinical pharmacy services are not yet very patient-oriented.

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.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients.

OBJECTIVES

We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life.

SEARCH METHODS

In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts.

SELECTION CRITERIA

We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence.

MAIN RESULTS

In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial

Background

Suboptimal medication use contributes to a substantial proportion of hospitalizations and emergency department visits in older adults. We designed a clinical pharmacist intervention to optimize medication therapy in older hospitalized patients. Based on the integrated medicine management (IMM) model, the 5-step IMMENSE intervention comprise medication reconciliation, medication review, reconciled medication list upon discharge, patient counselling, and post discharge communication with primary care. The objective of this study was to evaluate the effects of the intervention on healthcare use and mortality.

Methods

A non-blinded parallel group randomized controlled trial was conducted in two internal medicine wards at the University Hospital of North Norway. Acutely admitted patients ≥ 70 years were randomized 1:1 to intervention or standard care (control). The primary outcome was the rate of emergency medical visits (readmissions and emergency department visits) 12 months after discharge.

Results

Of the 1510 patients assessed for eligibility, 662 patients were asked to participate, and 516 were enrolled. After withdrawal of consent and deaths in hospital, the modified intention-to-treat population comprised 480 patients with a mean age of 83.1 years (SD: 6.3); 244 intervention patients and 236 control patients. The number of emergency medical visits in the intervention and control group was 497 and 499, respectively, and no statistically significant difference was observed in rate of the primary outcome between the groups [adjusted incidence rate ratio of 1.02 (95% CI: 0.82–1.27)]. No statistically significant differences between groups were observed for any of the secondary outcomes, neither in subgroups, nor for the per-protocol population.

Conclusions

We did not observe any statistical significant effects of the IMMENSE intervention on the rate of emergency medical visits or any other secondary outcomes after 12 months in hospitalized older adults included in this study.

Trial registration

The trial was registered in clinicaltrials.gov on 28/06/2016, before enrolment started (NCT02816086).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08648-1.

Impact of systematic medication review in emergency department on patients’ post-discharge outcomes—A randomized controlled clinical trial

Introduction

The main objective of this study was to investigate whether systematic medication review conducted by clinical pharmacists can impact clinical outcomes and post-discharge outcomes for patients admitted to the emergency department.

Method

This parallel group, non-blinded, randomized controlled trial was conducted in the emergency department, Diakonhjemmet Hospital, Oslo, Norway. The study was registered in ClinicalTrials.gov, Identifier: NCT03123640 in April 2017. From April 2017 to May 2018, patients ≥18 years were included and randomized (1:1) to intervention- or control group. The control group received standard care from emergency department physicians and nurses. In addition to standard care, the intervention group received systematic medication review including medication reconciliation conducted by pharmacists, during the emergency department stay. The primary outcome was proportion of patients with an unplanned contact with hospital within 12 months from inclusion stay discharge.

Results

In total, 807 patients were included and randomized, 1:1, to intervention or control group. After excluding 8 patients dying during hospital stay and 10 patients lacking Norwegian personal identification number, the primary analysis comprised 789 patients: 394 intervention group patients and 395 control group patients. Regarding the primary outcome, there was no significant difference in proportion of patients with an unplanned contact with hospital within 12 months after inclusion stay discharge between groups (51.0% of intervention group patients vs. 53.2% of control group patients, p = 0.546).

Conclusion

As currently designed, emergency department pharmacist-led medication review did not significantly influence clinical- or post-discharge outcomes. This study did, however pinpoint important practical implementations, which can be used to design tailored pharmacist-led interventions and workflow regarding drug-related issues in the emergency department setting.

Drug-related emergency department visits: prevalence and risk factors

The study aimed to investigate the prevalence of drug-related emergency department (ED) visits and associated risk factors. This retrospective cohort study was conducted in the ED, Diakonhjemmet Hospital, Oslo, Norway. From April 2017 to May 2018, 402 patients allocated to the intervention group in a randomized controlled trial were included in this sub-study. During their ED visit, these patients received medication reconciliation and medication review conducted by study pharmacists, in addition to standard care. Retrospectively, an interdisciplinary team assessed the reconciled drug list and identified drug-related issues alongside demographics, final diagnosis, and laboratory tests for all patients to determine whether their ED visit was drug-related. The study population's median age was 67 years (IQR 27, range 19-96), and patients used a median of 4 regular drugs (IQR 6, range 0-19). In total, 79 (19.7%) patients had a drug-related ED visits, and identified risk factors were increasing age, increasing number of regular drugs and medical referral reason. Adverse effects (72.2%) and non-adherence (16.5%) were the most common causes of drug-related ED visits. Antithrombotic agents were most frequently involved in drug-related ED visits, while immunosuppressants had the highest relative frequency. Only 11.4% of the identified drug-related ED visits were documented by physicians during ED/hospital stay. In the investigated population, 19.7% had a drug-related ED visit, indicating that drug-related ED visits are a major concern. If not recognized and handled, this could be a threat against patient safety. Identified risk factors can be used to identify patients in need of additional attention regarding their drug list during the ED visit.

‘Everyone should know what they’re on’: a qualitative study of attitudes towards and use of patient held lists of medicines among patients, carers and healthcare professionals in primary and secondary care settings in Ireland

Objectives

Managing multiple medicines can be challenging for patients with multimorbidity, who are at high risk of adverse outcomes, for example, hospitalisation. Patient-held medication lists (PHMLs) can contribute to patient safety and potentially reduce medication errors. The aims of this study are to investigate attitudes towards and use of PHMLs among healthcare professionals (HCPs), patients and carers.

Design

Qualitative study based on 39 semistructured telephone interviews.

Setting

Primary and secondary care settings in Ireland.

Participants

Twenty-one HCPs and 18 people taking medicines and caregivers.

Methods

Telephone interviews were conducted with HCPs, people taking multiple medicines (5+ medicines) and carers of people taking medicines who were purposively sampled via social media, patient groups and research collaborators. Interviews were transcribed and thematically analysed based on the Framework approach, with the Consolidated Framework for Implementation Research and Theoretical Domains Framework.

Results

Three core themes emerged: (1) attitudes to PHML, (2) function and preferred features of PHML and (3) barriers and facilitators to future use of PHML. All participating (patients/carers and HCP) groups considered PHML beneficial for patients and HCPs (eg, empowering for patients and improved adherence). While PHML were used in a variety of situations such as emergencies, concerns about their accuracy were shared across all groups. HCPs and patients differed on the level of detail that should be included in PHML. HCPs’ time constraints, patients’ multiple medicines and cognitive impairments were reported barriers. Key facilitators included access to digital/compact lists and promotion of lists by appropriate HCPs.

Conclusions

Our findings provide insight into the factors that influence use of PHML. Lists were used in a variety of settings, but there were concerns about their accuracy. A range of list formats and encouragement from key HCPs could increase the use of PHML.

Impact of integrated medication management program on medication errors in a medical center: an interrupted time series study

Background

Medication errors (MEs) are harmful to patients during hospitalization, especially elderly patients. To reduce MEs, an integrated medication management (IMM) model was developed in a 2500-bed medical center, allowing a clinical pharmacist to participate in the daily ward round and perform medication reconciliation and medication reviews. This study aimed to evaluate the impact of the IMM model on MEs and medication utilization using a quasi-experimental design.

Methods

We conducted an interrupted time-series study using the aggregated data of monthly admissions from two wards of a medical center, where one ward served as the intervention and the other served as the external control. The pre- and post-intervention phases comprised of 40 and 12 monthly observational units, respectively. The primary outcome was the mean number of ME reports, which were further investigated for different ME types. The mean number of daily inpatient prescriptions, mean number of daily self-prepared medications, and median daily medication costs were measured. All outcomes were measured per admission episode. Segmented regression was used to evaluate the level and slope changes in the outcomes after IMM model implementation, and subgroup analyses were performed to examine the effects on different groups.

Results

After IMM model implementation, the mean number of ME reports increased (level change: 1.02, 95% confidence interval [CI]: 0.68 to 1.35, P < 0.001). The number of reports has shown a dramatic increase in omissions or medication discrepancies, inappropriate drug choices, and inappropriate routes or formulations. Furthermore, the mean number of daily inpatient prescriptions was reduced for patients aged ≥75 years (level change: −1.78, 95% CI: −3.06 to −0.50, P = 0.009). No significant level or slope change was observed in the control ward during the post-intervention phase.

Conclusions

The IMM model improved patient safety and optimized medication utilization by increasing the reporting of MEs and decreasing the number of medications used.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08178-w.

Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist-led interdisciplinary intervention to improve medication safety in older hospitalized patients

WHAT IS KNOWN AND OBJECTIVE

The majority of hospitalized older patients experience medication-related problems (MRPs), and there is a call for interventions to solve MRPs and improve clinical outcomes like medical visits. The IMMENSE study is a randomized controlled trial investigating the impact of a pharmacist-led interdisciplinary intervention on emergency medical visits. Its multistep intervention is based on the integrated medicines management methodology and includes a follow-up step with primary care. This study aims to describe how the intervention in the IMMENSE study was delivered and its process outcomes.

METHODS

The study includes the 221 intervention patients in the per-protocol group of the IMMENSE study. Both intervention delivery, reasons for not performing interventions and process outcomes were registered daily by the study pharmacists in a Microsoft Access^® database. Process outcomes were medication discrepancies, MRPs and how the team solved these.

RESULTS AND DISCUSSION

A total of 121 (54.8%) patients received all intervention steps if appropriate. All patients received medication reconciliation (MedRec) and medication Review (MedRev) (step 1 and 2), while between 10% and 20% of patients were missed for medication list in discharge summary (step 3), patient counselling (step 4), or communication with general practitioner and nurse (step 5). A total of 437 discrepancies were identified in 159 (71.9%) patients during MedRec, and 1042 MRPs were identified in 209 (94.6%) patients during MedRev. Of these, 292 (66.8%) and 700 (67.2%), respectively, were communicated to and solved by the interdisciplinary team during the hospital stay.

WHAT IS NEW AND CONCLUSION

The fidelity of the single steps of the intervention was high even though only about half of the patients received all intervention steps. The impact of the intervention may be influenced by not implementing all steps in all patients, but the many discrepancies and MRPs identified and solved for the patients could explain a potential effect of the IMMENSE study.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Integrating the clinical pharmacist into the emergency department interdisciplinary team: a study protocol for a multicentre trial applying a non-randomised stepped-wedge study design

INTRODUCTION

The 'emergency department (ED) pharmacist' is an integrated part of the ED interdisciplinary team in many countries, which have shown to improve medication safety and reduce costs related to hospitalisations. In Norway, few EDs are equipped with ED pharmacists, and research describing effects on patients has not been conducted. The aim of this study is to investigate the impact of introducing clinical pharmacists to the interdisciplinary ED team. In this multicentre study, the intervention will be pragmatically implemented in the regular operation of three EDs in Northern Norway; Tromsø, Bodø and Harstad. Clinical pharmacists will work as an integrated part of the ED team, providing pharmaceutical care services such as medication reconciliation, review and/or counselling. The primary endpoint is 'time in hospital during 30 days after admission to the ED', combining (1) time in ED, (2) time in hospital (if hospitalised) and (3) time in ED and/or hospital if re-hospitalised during 30 days after admission. Secondary endpoints include time to rehospitalisation, length of stay in ED and hospital and rehospitalisation and mortality rates.

METHODS AND ANALYSIS

We will apply a non-randomised stepped-wedge study design, where we in a staggered way implement the ED pharmacists in all three EDs after a 3, 6 and 9 months control period, respectively. We will include all patients going through the three EDs during the 12-month study period. Patient data will be collected retrospectively from national data registries, the hospital system and from patient records.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research Ethics and Local Patient Protection Officers in all hospitals have approved the study. Patients will be informed about the ongoing study on a general basis with ads on posters and flyers.

TRIAL REGISTRATION NUMBER

NCT04722588.

Analysis of activities undertaken by ward-based clinical pharmacy technicians during patient hospital journey

INTRODUCTION

Previous studies recognise insufficient time as an obstacle to pharmacists expanding their clinical-based activities and services. For such a reason, the role of well-trained ward-based clinical pharmacy technicians (CPTs) is to work as an integral part of the pharmacy team to achieve the best patient outcomes and medicines optimisation, releasing pharmacist time to complete more complex clinical-related activities.

OBJECTIVE

To demonstrate quantitatively the range and extent of daily activities undertaken by CPTs during a patient's hospital journey.

METHOD

A prospective-based study has been designed. All daily working services and activities undertaken by ward-based CPTs within a 450-bed Acute District General hospital were quantitatively collected and documented. Data were collected from five medical, two surgical and one cardiology wards of 30 beds in each over a period of 2 weeks for each ward representing a total of 70 working days (14 weeks, excluding weekends).

RESULTS

Results showed the breakdown of seven different ward-based activities throughout a typical working day with the main working load being reviews of the patients' medication charts in order to supply new medicines and refer medicines-related issues to the ward pharmacist, with an average number reviewed of (23.17±0.85) representing 77.23% of the total patients in a 30-bed ward. The CPTs' highest workload was on Mondays and Fridays, mainly during the morning working hours (09:00-12:00). Also, statistically significant differences (p<0.05; Kruskal-Wallis test) existed between the workload of the three different ward specialties (medical, surgical and cardiology) in five clinical activities out of seven undertaken by CPT per day.

CONCLUSION

CPTs are completing more than seven different ward pharmacy-related activities which enhance medicines optimisation, medicines management and patient care. They are a valuable resource carrying out many roles which were previously completed by junior pharmacists. Their prioritising of patients for review ensures pharmacists focus their efforts on the most vulnerable patients.

Supporting medicines management for older people at care transitions - a theory-based analysis of a systematic review of 24 interventions

BACKGROUND

Older patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled.

METHOD

This study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed.

RESULTS

Common behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions.

CONCLUSION

This study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.

The NUPHAC-EU Framework for Nurses' Role in Interprofessional Pharmaceutical Care: Cross-Sectional Evaluation in Europe

Clear role descriptions promote the quality of interprofessional collaboration. Currently, it is unclear to what extent healthcare professionals consider pharmaceutical care (PC) activities to be nurses’ responsibility in order to obtain best care quality. This study aimed to create and evaluate a framework describing potential nursing tasks in PC and to investigate nurses’ level of responsibility. A framework of PC tasks and contextual factors was developed based on literature review and previous DeMoPhaC project results. Tasks and context were cross-sectionally evaluated using an online survey in 14 European countries. A total of 923 nurses, 240 physicians and 199 pharmacists responded. The majority would consider nurses responsible for tasks within: medication self-management (86–97%), patient education (85–96%), medication safety (83–95%), monitoring adherence (82–97%), care coordination (82–95%), and drug monitoring (78–96%). The most prevalent level of responsibility was ‘with shared responsibility’. Prescription management tasks were considered to be nurses’ responsibility by 48–81% of the professionals. All contextual factors were indicated as being relevant for nurses’ role in PC by at least 74% of the participants. No task nor contextual factor was removed from the framework after evaluation. This framework can be used to enable healthcare professionals to openly discuss allocation of specific (shared) responsibilities and tasks.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

Impact of an integrated medication reconciliation model led by a hospital clinical pharmacist on the reduction of post-discharge unintentional discrepancies

WHAT IS KNOWN AND OBJECTIVE

There is no optimal standardized model in the transfer of care between hospitals and primary healthcare facilities. Transfer of care is a critical point during which unintentional discrepancies, that can jeopardize pharmacotherapy outcomes, can occur. The objective was to determine the effect that an integrated medication reconciliation model has on the reduction of the number of post-discharge unintentional discrepancies.

METHODS

A randomized controlled study was conducted on an elderly patient population. The intervention group of patients received a medication reconciliation model, led entirely by a hospital clinical pharmacist (medication reconciliation at admission, review and optimization of pharmacotherapy during hospitalization, patient education and counselling, medication reconciliation at discharge, medication reconciliation as part of primary health care in collaboration with a primary care physician and a community pharmacist). Unintentional discrepancies were identified by comparing the medications listed on the discharge summary with the first list of medications prescribed and issued at primary care level, immediately after discharge. The main outcome measures were incidence, type and potential severity of post-discharge unintentional discrepancies.

RESULTS AND DISCUSSION

A total of 353 patients were analysed (182 in the intervention and 171 in the control group). The medication reconciliation model, led by a hospital clinical pharmacist, significantly reduced the number of patients with unintentional discrepancies by 57.1% (p < 0.001). The intervention reduced the number of patients with unintentional discrepancies associated with a potential moderate harm by 58.6% (p < 0.001) and those associated with a potential severe harm by 68.6% (p = 0.039). The most common discrepancies were incorrect dosage, drug omission and drug commission. Cardiovascular medications were most commonly involved in unintentional discrepancies.

WHAT IS NEW AND CONCLUSION

The integrated medication reconciliation model, led by a hospital clinical pharmacist in collaboration with all health professionals involved in the patient's pharmacotherapy and treatment, significantly reduced unintentional discrepancies in the transfer of care.

Effects of hospital pharmacist interventions on health outcomes in older polymedicated inpatients: a scoping review

PURPOSE

To identify the evidence that supports the effect of interventions made by hospital pharmacists, individually or in collaboration with a multidisciplinary team, in terms of healthcare outcomes, a more effective utilization of resources and lower costs in older polymedicated inpatients.

METHODS

We searched the following databases: MEDLINE, EMBASE and the Cochrane Library. We also conducted a hand search by checking the references cited in the primary studies and studies included in reviews identified during the process of research. Four review authors working by pairs searched for studies, extracted data, and drew up the results tables.

RESULTS

Twenty-six studies were included in the review. In 13 of them pharmacists carried out their intervention exclusively while the patients were in hospital, whereas in 13 interventions were delivered during admission and after hospital discharge. Outcomes identified were mortality, length of stay, visits to the emergency department, readmissions and reported quality of life, among others. Pharmacist interventions were found to be beneficial in fifteen studies, specifically on hospital readmissions, visits to the emergency department and healthcare costs.

CONCLUSION

There is no hard evidence demonstrating the effectiveness of hospital pharmacist interventions in older polymedicated patients. Mortality does not show as a relevant outcome. Other health care outcomes, such as hospital readmissions, visits to the emergency department and healthcare costs, seem to be more relevant and amenable to change. Interventions that include pharmacists in multidisciplinary geriatric teams seem to be more promising that isolated pharmacist interventions. Interventions prolonged after hospital discharge seem to be more appropriate that interventions delivered only during hospital admission. Better-designed studies should be conducted in the future to provide further insight into the effect of hospital pharmacist interventions.

A pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting

BACKGROUND

There is a paucity of research describing the pharmacist's role in the multidisciplinary care of older adults in the intermediate care setting.

OBJECTIVE

To determine the types of drug-related problems (DRPs) in older patients in this setting, to evaluate the implementation rate of pharmacist recommendations and the factors affecting implementation, and to assess the clinical significance of these recommendations.

METHODS

Data were collected over a 12-week period on one pharmacist's recommendations to reduce clinically relevant DRPs identified during medication reconciliation and review for all patients ≥65 years admitted to an intermediate care unit. The clinical significance of the recommendations was judged by four independent assessors using a validated tool. Statistical significance was predetermined as p < 0.05.

RESULTS

Of 494 clinically relevant DRPs identified in 91 patients (mean age: 82 years), 406 recommendations were communicated to the medical team, and 89.2% were implemented. Overall, 48.5% were communicated verbally, but no difference was found between the implementation rates of verbal and written recommendations (87.8% versus 90.4%; p = 0.4). Medication reconciliation recommendations were implemented more commonly than those regarding medication review (96.5% versus 79.5%; p < 0.0001). Recommendations judged to be of 'moderate significance' (66.8% of total) were implemented more often than those of 'minor significance' (93.2% versus 81.6%; p < 0.001). The consultant was provided with a significantly higher proportion of recommendations of 'moderate significance' when compared to the junior doctor (79.6% versus 63.3%; p = 0.02), but implemented significantly fewer recommendations (69.4% versus 91.9%; p < 0.0001).

CONCLUSION

The high implementation rate in this study shows the importance of pharmacist involvement to reduce DRPs in the multidisciplinary care of older adults in an intermediate care unit. Future research should focus on investigating the impact of pharmacist interventions on older patient outcomes and the associated cost-effectiveness in this setting.

Factors associated with the number of clinical pharmacy recommendations: findings from an observational study in geriatric inpatients

Objectives: Drug-related problems are prevalent in older inpatients and can be reduced by providing clinical pharmacy (CP) services. Details concerning implementation in clinical practice are frequently lacking. The aim was to describe the output of one such CP program and to identify factors associated with CP recommendations.Methods: A CP program was installed at three acute geriatric wards in a teaching hospital. A convenience sample was collected, consisting of inpatients who received a CP consultation at discharge. Medical conditions, patient demographics, and drug use were evaluated retrospectively. Number and type of the CP recommendations were determined. A Poisson regression analysis was performed to determine factors associated with the number of CP recommendations.Results: A cohort of 524 patients, aged 85 (interquartile range (IQR): 82-89) years was included. On admission, 10.31 (standard deviation: 4.49) drugs were taken. Three (IQR: 2-4) CP recommendations were provided per patient, of which 70.2% targeted drug discontinuation. A model was derived, containing the following factors: number of drugs on admission (incidence rate ratio (IRR): 1.063; 95% confidence interval (CI): 1.052-1.074), number of previous contacts with the geriatric department (IRR: 0.869; 95%CI: 0.816-0.926), presence of left-ventricular dysfunction (IRR: 1.179, 95% CI: 1.023-1.360), the number of new drugs (IRR: 1.046; 95% CI: 1.021-1.071) and use of colecalciferol (IRR: 1.22; 95% CI: 1.088-1.367).Conclusions: Five factors were associated with the number of CP recommendations at discharge. This could allow for further patient stratification to increase the efficiency of the CP program.

Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway

BACKGROUND

Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective.

METHODS

Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process.

RESULTS

A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all.

CONCLUSIONS

The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes.

Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.

METHODS

The initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.

RESULTS

The participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.

CONCLUSION

The evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.

Medication review interventions to reduce hospital readmissions in older people

Objective

To assess the efficacy of medication review as an isolated intervention and with several co‐interventions for preventing hospital readmissions in older adults.

Methods

Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co‐interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were “at least one all‐cause hospital readmission within 30 days and at any time after discharge from the index admission.”

Results

Twenty‐five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta‐analysis (NMA) on all‐cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26–0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49–0.84) were associated with a lower risk of all‐cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45–2.51). The NMA on all‐cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74–0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination.

Conclusion

Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co‐interventions was not demonstrated. Trials of higher quality are needed in this field.

Effect of medicines management versus standard care on readmissions in multimorbid patients: a randomised controlled trial

OBJECTIVE

To investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.

DESIGN

Parallel-group, randomised controlled trial.

SETTING

Recruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21-40 months.

PARTICIPANTS

Acutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23-96) and number of diseases 7 (range 2-17).

INTERVENTION

Intervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint.

RESULTS

Pharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21-40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008).

CONCLUSIONS

Pharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale.

TRIAL REGISTRATION NUMBER

NCT02336113.

Medication Counselling in Older Patients Prior to Hospital Discharge: A Systematic Review

BACKGROUND

Older patients are regularly exposed to multiple medication changes during a hospital stay and are more likely to experience problems understanding these changes. Medication counselling is often proposed as an important component of seamless care to ensure appropriate medication use after hospital discharge.

OBJECTIVES

The purpose of this systematic review was to describe the components of medication counselling in older patients (aged ≥ 65 years) prior to hospital discharge and to review the effectiveness of such counselling on reported clinical outcomes.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (PROSPERO CRD42019116036), a systematic search of MEDLINE, EMBASE and CINAHL was conducted. The QualSyst Assessment Tool was used to assess bias. The impact of medication counselling on different outcomes was described and stratified by intervention content.

RESULTS

Twenty-nine studies were included. Fifteen different components of medication counselling were identified. Discussing the dose and dosage of patients' medications (19/29; 65.5%), providing a paper-based medication list (19/29; 65.5%) and explaining the indications of the prescribed medications (17/29; 58.6%) were the most frequently encountered components during the counselling session. Twelve different clinical outcomes were investigated in the 29 studies. A positive effect of medication counselling on medication adherence and medication knowledge was found more frequently, compared to its impact on hard outcomes such as hospital readmissions and mortality. Yet, evidence remains inconclusive regarding clinical benefit, owing to study design heterogeneity and different intervention components. Statistically significant results were more frequently observed when counselling was provided as part of a comprehensive intervention before discharge.

CONCLUSIONS

Substantial heterogeneity between the included studies was found for the components of medication counselling and the reported outcomes. Study findings suggest that medication counselling should be part of multifaceted interventions, but the evidence concerning clinical outcomes remains inconclusive.

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.

A novel approach to medicines optimisation post-discharge from hospital: pharmacist-led medicines optimisation clinic

Background There is a major drive within healthcare to reduce patient readmissions, from patient care and cost perspectives. Pharmacist-led innovations have been demonstrated to enhance patient outcomes. Objective To assess the impact of a post-discharge, pharmacist-led medicines optimisation clinic on readmission parameters. Assessment of the economic, clinical and humanistic outcomes were considered. Setting Respiratory and cardiology wards in a district general hospital in Northern Ireland. Method Randomised, controlled trial. Blinded random sequence generation; a closed envelope-based system, with block randomisation. Adult patients with acute unplanned admission to medical wards subject to inclusion criteria were invited to attend clinic. Analysis was carried out for intention-to-treat and per-protocol perspectives. Main Outcome Measure 30-day readmission rate. Results Readmission rate reduction at 30 days was 9.6% (P = 0.42) and the reduction in multiple readmissions over 180-days was 29.1% (P = 0.003) for the intention-to-treat group (n = 31) compared to the control group (n = 31). Incidence rate ratio for control patients for emergency department visits was 1.65 (95% CI 1.05-2.57, P = 0.029) compared with the intention-to-treat group. For unplanned GP consultations the equivalent incident rate ratio was 2.00 (95% CI 1.18-3.58, P = 0.02). Benefit to cost ratio in the intention-to-treat and per-protocol groups was 20.72 and 21.85 respectively. Patient Health Related Quality of Life was significantly higher at 30-day (P < 0.001), 90-day (P < 0.001) and 180-day (P = 0.036) time points. A positive impact was also demonstrated in relation to patient beliefs about their medicines and medication adherence. Conclusion A pharmacist-led post-discharge medicines optimisation clinic was beneficial from a patient care and cost perspective.

Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity

Background

medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity.

Methods

a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible.

Results

twenty-four studies (total participants = 17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions.

Conclusion

our results suggest that interventions that best support older patients’ medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions.

Clinical Pharmacy Services in Older Inpatients: An Evidence-Based Review

BACKGROUND

Hospital admissions in older adults are frequently drug related and avoidable. Clinical pharmacy interventions during hospital stay might reduce drug-related harm and reduce hospital visits. Moreover, several recent positive clinical pharmacy investigations incorporated a transitional care component to further improve medication use after discharge. It is currently unclear what the strength of evidence is and what the exact components should be of such clinical pharmacy interventions in older adults.

OBJECTIVE

An evidence-based review was performed to determine the status of the evidence and also to explore whether a clinical pharmacy intervention incorporating transitional care was associated with reduced hospital visits after discharge.

METHODS

Prospective controlled investigations were included if they contained a clinical pharmacy intervention that was initiated before discharge in older inpatients. Relevant quasi-experimental and randomized controlled trials were searched in MEDLINE. First, an evidence-based review was performed, including a description of the study design, characteristics, and outcomes. Major components of successful clinical pharmacy interventions were described and potential implications for clinical practice and research were determined. Second, the Fisher's exact test was used to explore the association between transitional care and reduced hospital visits. Third, based on these findings, a medication review proposal was developed to improve medication use in older adults.

RESULTS

Thirty-five studies were included, with 26 randomized controlled trials. Median patient follow-up after discharge was 90 days (interquartile range 37-180 days) and investigators enrolled a median of 210 (interquartile range 110-498) study participants. On average, patients were aged 77.5 years (interquartile range 73-82.2 years). Nine randomized controlled trials had sufficient power to detect a reduction in hospital visits after discharge; this was reduced in three randomized controlled trials. Post-discharge follow-up was not associated with reduced post-discharge hospital visits (20 randomized controlled trials: follow-up vs. no follow-up: 6/11 vs. 1/9, p = 0.070). There was a significant reduction in post-discharge hospital visits in patients aged 75 years or older (12 randomized controlled trials: follow-up vs. no follow-up: 5/7 vs. 0/5, p = 0.028). A medication review proposal was developed, consisting of six steps.

CONCLUSIONS

Three powered randomized controlled trials were identified that found a significant association between a pharmacist-led intervention in older adults and a reduction in post-discharge hospital visits. In clinical practice, an intervention consisting of medication reconciliation, review, counseling, and post-discharge follow-up should be provided to such high-risk inpatients. Regarding research priorities, large, multi-center randomized controlled trials should be performed to generate more evidence on the impact of clinical pharmacy interventions on the patient trajectory and economic outcomes.

Value of pharmacy services in an outpatient, preoperative, anesthesia clinic

OBJECTIVE

This pilot study assessed the expansion of pharmacy services to a preoperative, anesthesia clinic.

SETTING

Tertiary care academic medical center.

PRACTICE DESCRIPTION

Medication histories were routinely obtained by clinic nurses, and pharmacy services were not available.

PRACTICE INNOVATION

A prospective, single-center, pilot study enrolled English-speaking patients aged 65 years or older in a preoperative clinic before a scheduled surgery. Patient attributes including health literacy and preparatory activities were measured using verbal and written questionnaires. Home medication lists were obtained by both clinic nurses (routine care) and a pharmacist (research), and the 2 lists were compared to identify medication discrepancies for each patient. Discrepancies were categorized by type and severity.

EVALUATION

This study evaluated the potential impact of medication histories obtained by pharmacists compared with those obtained by clinic nurses during geriatric preoperative clinic visits.

RESULTS

Of the 44 patients who gave their consent and were included in this pilot study, 25% (n = 11) had limited/marginal written and verbal health literacy, and 20% (n = 9) had limited/marginal numerical health literacy. Of the 38 patients who completed the pharmacist medication history interview, only 21% (n = 8) brought a complete list of their current medications to the preoperative clinic, 95% (n = 36) had at least 1 medication discrepancy, and 61% (n = 23) had at least 1 clinically meaningful discrepancy. Clinically meaningful discrepancies were identified for 8% (35 of 459) of medications and occurred most commonly for blood pressure medications, nonsteroidal anti-inflammatory drugs, and beta blockers.

CONCLUSION

In this study, medication history discrepancies identified by pharmacists suggest that the expansion of pharmacy services into the preoperative clinic is feasible and could potentially prevent meaningful medication errors among geriatric patients being admitted for a scheduled surgery.

The role of clinical pharmacist trainees in medication reconciliation process at hospital admission

Background Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the prevalence and potential risk factors involved in medication discrepancies in China. Objective To determine the frequency of medication discrepancies and the associated risk factors and evaluate the potential harmsof errors prevented by pharmacist trainees performing medication reconciliation process. Setting A tertiary hospital in Shanxi, China. Method Medication reconciliation was conducted at admission to four clinical departments including cardiology, nephrology, endocrinology and pneumology department between 2019 Feb 1st and 2019 Aug 31st by clinical pharmacist trainees. All unintentional medication discrepancies were presented to the expert panel to evaluate. Associations between unintentional medication discrepancies and various factors were examined. Main outcome measure The primary outcome was the prevalence of unintentional medication discrepancies as well as the associated risk factors. Results Overall, 331 patients were included (mean age 59.7 ± 15.2 years; 176 men). The reconciliation process identified 511 drug discrepancies, 98 of which were unintentional medication discrepancies; these occurred in 74 patients. The most common unintentional medication discrepancies type was omission (40.8%), followed by incorrect dose (25.5%), and 73.5% could have caused patients moderate to significant harm and complications. 5 or more drugs and 2 or more chronic diseases at admission associated with unintentional medication discrepancies in a logistic regression analysis. Conclusion Medication reconciliation performed by pharmacist trainees upon admission can reduce unintentional medication discrepancies. Patients taking 5 or more drugs and experiencing more than two chronic diseases were found to be particularly at risk.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review

PURPOSE

Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients.

METHODS

A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology."

RESULTS

Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis.

CONCLUSION

Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Impact of Pharmacist-led Discharge Counseling on Hospital Readmission and Emergency Department Visits: A Systematic Review and Meta-analysis

BACKGROUND

Transitions of care can contribute to medication errors and other adverse drug events.

PURPOSE

The aim of this study was to evaluate the impact of pharmacist-led discharge counseling on hospital readmission and emergency department visits through a systematic review and meta-analysis.

EDATA SOURCES

Lectronic searches were performed in PubMed, Scopus, and DOAJ (Directory of Open Access Journals), along with a manual search (July 2017). PROSPERO registration no. CRD42017068444.

STUDY SELECTION

Two independent reviewers performed all the steps of the systematic review process (screening of titles and abstracts, full-text appraisal, data extraction, and quality assessment), with contributions from a third researcher. We included randomized controlled trials (RCTs) reporting data on pharmacist-led discharge counseling.

DATA EXTRACTION

Primary extracted outcomes were emergency department visits and hospital readmission rates.

DATA SYNTHESIS

Meta-analyses of intervention versus usual care for hospital readmission and emergency department visit rates were performed using the inverse variance method. Results are reported as risk ratios (RRs) with 95% confidence intervals (CIs). Prediction intervals (PIs) were also calculated. Sensitivity and subgroup analyses were performed. A total of 21 RCTs were included in the qualitative synthesis and 18 in the meta-analyses (n = 7,244 patients). The original meta-analysis revealed a significant difference in the impact between pharmacist-led discharge counseling and usual care on overall hospital readmission (RR = 0.864 [95% CI 0.763-0.997], P = .020) and emergency department (RR = 0.697 [95% CI 0.535-0.907], P = .007) visits. However, the small number of included studies, the high heterogeneity among trials (I2 between 40% and 60%), and the wide PIs (hospital readmission: PI 0.542-1.186; emergency department visits: PI 0.027-1.367) prevented drawing further conclusions.

CONCLUSIONS

Insufficient evidence exists regarding the effect of pharmacist-led discharge counseling on hospital readmission and emergency department visits. Further well-designed clinical trials with defined core outcome sets are needed.

The effect of a pharmaceutical transitional care program on rehospitalisations in internal medicine patients: an interrupted-time-series study

Background

Medication errors at transition of care can adversely affect patient safety. The objective of this study is to determine the effect of a transitional pharmaceutical care program on unplanned rehospitalisations.

Methods

An interrupted-time-series study was performed, including patients from the Internal Medicine department using at least one prescription drug. The program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within six months post-discharge. Secondary outcomes were drug-related hospital visits, drug-related problems (DRPs), adherence, believes about medication, and patient satisfaction. Interrupted time series analysis was used for the primary outcome and descriptive statistics were performed for the secondary outcomes.

Results

In total 706 patients were included. At 6 months, the change in trend for unplanned rehospitalisations between usual care and the program group was non-significant (− 0.2, 95% CI -4.9;4.6). There was no significant difference for drug-related visits although visits due to medication reconciliation problems occurred less often (4 usual care versus 1 intervention). Interventions to prevent DRPs were present for all patients in the intervention group (mean: 10 interventions/patient). No effect was seen on adherence and beliefs about medication. Patients were significantly more satisfied with discharge counselling (68.9% usual care vs 87.1% program).

Conclusions

The transitional pharmaceutical care program showed no effect on unplanned rehospitalisations. This lack of effect is probably because the reason for rehospitalisations are multifactorial while the transitional care program focused on medication. There were less hospital visits due to medication reconciliation problems, but further large scale studies are needed due to the small number of drug-related visits. (Dutch trial register: NTR1519).

Prevalence and risk factors of drug-related hospitalizations in multimorbid patients admitted to an internal medicine ward

Background

Knowledge of risk factors for drug-related hospitalizations (DRHs) is limited.

Aim

To examine the prevalence of DRHs and the relationships between DRHs and various variables in multimorbid patients admitted to an internal medicine ward.

Methods

Multimorbid patients ≥ 18 years, using minimum of four regular drugs from minimum two therapeutic classes, were included from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016. Clinical pharmacists prospectively conducted medicines reconciliations and reviews to reveal drug-related problems (DRPs). Blinded for identified DRPs, an interdisciplinary group retrospectively made comprehensive, clinical assessments of each patient case to classify hospitalizations as drug-related (DRH) or non-drug-related (non-DRH). Age, sex distribution, Charlson Comorbidity Index (CCI), renal function, aberrant genotype frequencies, body-mass index, number of drugs, proportion of patients which received assistance for drug administration from the home care service, and/or through multidose-dispensed drugs, and occurrence of specific DRP subgroups, were compared separately between patients with DRHs versus non-DRHs, followed by multiple logistic regression analysis.

Results

Hospitalizations were classified as drug-related in 155 of the 404 included patients (38%). Factors significantly associated with DRHs were occurrence of adverse effect DRPs (adjusted odds ratio (OR) 3.3, 95% confidence interval (CI) 1.4–8.0), adherence issues (OR 2.9, 1.1–7.2), home care (OR 1.9, 1.1–3.5), drug monitoring DRPs (OR 1.9, 1.2–3.0), and CCI score ≥6 (OR 0.33, 0.14–0.77). Frequencies of aberrant genotypes did not differ between the patient groups, but in 41 patients with DRHs (26.5%), gene-drug interactions influenced the assessments of DRHs.

Conclusion

DRHs are prevalent in multimorbid patients with adverse effect DRPs and adherence issues as the most important risk factors.

Serum Concentrations and Elimination Rates of Direct-Acting Oral Anticoagulants (DOACs) in Older Hip Fracture Patients Hospitalized for Surgery: A Pilot Study

BACKGROUND

Use of direct-acting oral anticoagulants (DOACs) is increasing, but knowledge about pharmacokinetics and safety in frail patients is lacking.

OBJECTIVE

The aim was to determine serum concentrations and elimination rates of DOACs in older hip fracture patients hospitalized for surgery.

METHODS

The study included patients ≥ 65 years of age hospitalized for acute hip fracture surgery over a period of 6 months. Use of antithrombotic drugs was registered and serum samples collected for analysis of DOACs (apixaban, dabigatran and rivaroxaban) at admission and surgery. Measured concentrations were assessed in relation to reference (therapeutic) ranges of the respective drugs and applied for half-life calculations. Furthermore, waiting time for surgery was compared between DOAC and warfarin users.

RESULTS

Of 167 patients included (median age 84 years), 11 and 14 used DOACs and warfarin, respectively. Seven of the DOAC-treated patients had concentrations above the upper reference range (> 300 nM) at admission, and concentrations were still in the reference range for five of these at surgery. Elimination half-lives could be estimated in eight patients and ranged between 14.6 and 59.7 h (median 21.6). The observed waiting time for surgery was longer for patients using DOACs than warfarin (median 44 vs. 25 h).

CONCLUSION

This pilot study indicates that older patients prone to hip fracture are at risk of being exposed to therapeutic serum concentrations of DOACs during surgery due to reduced drug elimination rates. The observation that almost 50% of the patients had therapeutic concentrations at surgery should be investigated further regarding safety of DOAC use in this frail elderly population.

Effect of a medicines management model on medication-related readmissions in older patients admitted to a medical acute admission unit-A randomized controlled trial

RATIONALE, AIMS, AND OBJECTIVES

Medication-related problems are frequent and can lead to serious adverse events resulting in increased morbidity, mortality, and costs. Medication use in frail older patients is even more complex. The aim of this study was to investigate the effect of a pharmacist-led medicines management model among older patients at admission, during inpatient stay and at discharge on medication-related readmissions.

METHOD

A randomized controlled trial conducted at the acute admission unit in a Danish hospital with acutely admitted medical patients, randomized to either a control group or one of two intervention groups. The intervention consisted of pharmacist-led medication review and patient interview upon admission (intervention ED) or pharmacist-led medication review and patient interview upon admission, medication review during inpatient stay, and medication report and patient counselling at discharge (intervention STAY).

RESULTS

In total, 600 patients were included. The pharmacist identified 920 medication-related problems with 57% of the recommendations accepted by the physician. After 30 days, 25 patients had a medication-related readmission, with no statistical significant difference between the groups on either primary or secondary outcomes.

CONCLUSIONS

This study showed that a clinical pharmacist can be used to identify and solve medication-related problems, but this study did not find any effect on the selected outcomes. The frequency of medication-related readmissions was low, leaving little room for improvement. Future research should consider other study designs or outcome measures.

Ensuring continuity of patient care across the healthcare interface: Telephone follow-up post-hospitalization

AIMS

To implement pharmacist-led, postdischarge telephone follow-up (TFU) intervention and to evaluate its impact on rehospitalization parameters in polypharmacy patients, via comparison with a well-matched control group.

METHOD

Pragmatic, prospective, quasi-experimental study. Intervention patients were matched by propensity score techniques with a control group. Guided by results from a pilot study, clinical pharmacists implemented TFU intervention, added to routine integrated medicines management service.

RESULTS

Using an intention to treat approach, reductions in 30- and 90-day readmission rates for intervention patients compared with controls were 9.9% [odds ratio = 0.57; 95% confidence interval (CI): 0.36-0.90; P < 0.001] and 15.2% (odds ratio = 0.53; 95% CI: 0.36-0.79; P = 0.021) respectively. Marginal mean time to readmission was 70.9 days (95% CI: 66.9-74.9) for intervention group compared with 60.1 days (95% CI: 55.4-64.7) for controls. Mean length of hospital stay compared with control was (8.3 days vs. 6.7 days; P < 0.001). Benefit: cost ratio for 30-day readmissions was 29.62, and 23.58 for 90-day interval. Per protocol analyses gave more marked improvements. In intervention patients, mean concern scale score, using Beliefs about Medicine Questionnaire, was reduced 3.2 (95% CI: -4.22 to -2.27; P < 0.001). Mean difference in Medication Adherence Report Scale was 1.4 (22.7 vs. 24.1; P < 0.001). Most patients (83.8%) reported having better control of their medicines after the intervention.

CONCLUSIONS

Pharmacist-led postdischarge structured TFU intervention can reduce 30- and 90-day readmission rates. Positive impacts were noted on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence and satisfaction.

Reuse of patients' own drugs in hospitals in Ghana; the evidence to support policy

Background

Given the documented benefits of Patient Own Drugs (PODs) in most developed countries and scanty data on PODs management in developing countries the aim of the study was to evaluate the assessment, quality and extent of PODs use among hospitalised patients. Furthermore the perceived benefits and challenges in executing PODs management by the pharmacy staff in the hospital setting were explored.

Method

This was a cross-sectional descriptive study. Three hundred patients with chronic diseases admitted in a teaching hospital were purposively sampled. Quality assessment criteria was developed as part of the data collection tool for assessing the quality of PODs. Furthermore, two ward pharmacists and two in-charge nurses at the medical ward were purposively sampled for a face to face interview using an interview guide to find out the hospitals’ medicines management system and policy for PODs. In addition, 130 pharmacy staff were interviewed using a structured questionnaire to find out how PODs were managed. Data was analysed with SPSS version 17.

Results

The study showed that 140 (46.6%) of patients brought their PODs on admission. Of these, only 38 (12.7%) were told to bring them whenever they were on admission. Of the 115 (38.3) patients whose PODs were documented as part of medication history, 28 (24.3%) of them had their PODs continued whilst on admission and 11(9.5%) of discharged prescription included PODs. In assessing the quality of PODs 61.6% of 845 PODs were suitable for reuse. Only 19.8% of pharmacy staff attested to the fact that all PODs identified were assessed. The common benefit of PODs cited by pharmacy staff was improving medication history taking whilst the major challenge was difficulty in determining the expiry dates of PODs without original packages.

Conclusion

About a half of patients with chronic diseases brought PODs with them on admission. The majority of PODs appeared to be suitable for use as presented but only a few were actually used for the patients. Most pharmacy staff were not involved in patients own drugs management at the hospital. There is the need for a policy to streamline PODs management in the teaching hospital.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3860-9) contains supplementary material, which is available to authorized users.

Effectiveness and cost effectiveness of pharmacist input at the ward level: a systematic review and meta-analysis

BACKGROUND

Pharmacists play important role in ensuring timely care delivery at the ward level. The optimal level of pharmacist input, however, is not clearly defined.

OBJECTIVE

To systematically review the evidence that assessed the outcomes of ward pharmacist input for people admitted with acute or emergent illness.

METHODS

The protocol and search strategies were developed with input from clinicians. Medline, EMBASE, Centre for Reviews and Dissemination, The Cochrane Library, NHS Economic Evaluations, Health Technology Assessment and Health Economic Evaluations databases were searched. Inclusion criteria specified the population as adults and young people (age >16 years) who are admitted to hospital with suspected or confirmed acute or emergent illness. Only randomised controlled trials (RCTs) published in English were eligible for inclusion in the effectiveness review. Economic studies were limited to full economic evaluations and comparative cost analysis. Included studies were quality-assessed. Data were extracted, summarised. and meta-analysed, where appropriate.

RESULTS

Eighteen RCTs and 7 economic studies were included. The RCTs were from USA (n = 3), Sweden (n = 2), Belgium (n = 2), China (n = 2), Australia (n = 2), Denmark (n = 2), Northern Ireland, Norway, Canada, UK and Netherlands. The economic studies were from UK (n = 2), Sweden (n = 2), Belgium and Netherlands. The results showed that regular pharmacist input was most cost effective. It reduced length-of-stay (mean = -1.74 days [95% CI: 2.76, -0.72], and increased patient and/or carer satisfaction (Relative Risk (RR) = 1.49 [1.09, 2.03] at discharge). At £20,000 per quality-adjusted life-year (QALY)-gained cost-effectiveness threshold, it was either cost-saving or cost-effective (Incremental Cost Effectiveness Ratio (ICER) = £632/QALY-gained). No evidence was found for 7-day pharmacist presence.

CONCLUSIONS

Pharmacist inclusion in the ward multidisciplinary team improves patient safety and satisfaction and is cost-effective when regularly provided throughout the ward stay. Research is needed to determine whether the provision of 7-day service is cost-effective.