The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine

Systematic Review of Risk Factors Assessed in Predictive Scoring Tools for Drug-Related Problems in Inpatients

Drug-related problems (DRP, defined as adverse drug events/reactions and medication errors) are a common threat for patient safety. With the aim to aid improved allocation of specialist resources and to improve detection and prevention of DRP, numerous predictive scoring tools have been proposed. The external validation and evidence for the transferability of these tools still faces limitations. However, the proposed scoring tools include partly overlapping sets of similar factors, which may allow a new approach to estimate the external usability and validity of individual risk factors. Therefore, we conducted this systematic review and analysis. We identified 14 key studies that assessed 844 candidate risk factors for inclusion into predictive scoring tools. After consolidation to account for overlapping terminology and variable definitions, we assessed each risk factor in the number of studies it was assessed, and, if it was found to be a significant predictor of DRP, whether it was included in a final scoring tool. The latter included intake of ≥ 8 drugs, drugs of the Anatomical Therapeutic Chemical (ATC) class N, ≥1 comorbidity, an estimated glomerular filtration rate (eGFR) <30 mL/min and age ≥60 years. The methodological approach and the individual risk factors presented in this review may provide a new starting point for improved risk assessment.

Factors affecting physician implementation of hospital pharmacists' medication appropriateness recommendations in older adults

AIMS

Non-implementation of pharmacist recommendations by physician prescribers may prolong potentially inappropriate prescribing in hospitalised older adults, increasing the risk of adverse clinical outcomes. The aim of this study was to ascertain the key factors affecting physician prescriber implementation of pharmacists' medication appropriateness recommendations in hospitalised older adults.

METHODS

Semi-structured interviews were conducted with hospital pharmacists and physicians who provided care to older adults (≥65 years) in 2 acute university teaching hospitals in Ireland. Content analysis was employed to identify the key themes that influence physician prescriber implementation of pharmacist recommendations.

RESULTS

Fourteen interviews were conducted with 6 hospital pharmacists and 8 hospital physicians between August 2018 and August 2019. Five key factors were found to affect physician implementation of pharmacist recommendations: (i) the clinical relevance and complexity of the recommendation-recommendations of higher priority and those that do not require complex decision-making are implemented more readily; (ii) interprofessional communication-recommendations provided verbally, particularly those communicated face to face with confidence and assertion, are more likely to be implemented than written recommendations; (iii) physician role and identity-the grade, specialty, and personality of the physician significantly affect implementation; (iv) knowing each other and developing trusting relationships-personal acquaintance and the development of interprofessional trust and rapport greatly facilitate recommendation implementation; and (v) the hospital environment-organisational issues such as documentation in the patient notes, having the opportunity to intervene, and the clinical pharmacy model all affect implementation.

CONCLUSION

This study provides a deeper understanding of the underlying behavioural determinants affecting physician prescriber implementation of pharmacist recommendations and will aid in the development of theoretically-informed interventions to improve medication appropriateness in hospitalised older adults.

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 Collaborative Deprescribing Intervention in a Subacute Medical Outpatient Clinic: A Pilot Randomized Controlled Trial

Medication deprescribing is essential to prevent inappropriate medication use in multimorbid patients. However, experience of deprescribing in Danish Subacute Medical Outpatient Clinics (SMOCs) is limited. The objective of our pilot study was to evaluate the feasibility and sustainability of a collaborative deprescribing intervention by a pharmacist and a physician to multimorbid patients in a SMOC. A randomized controlled pilot study was conducted, with phone follow-up at 30 and 365+ days. A senior pharmacist performed a systematic deprescribing intervention using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, the Danish deprescribing list, and patient interviews. A senior physician received the proposed recommendations and decided which should be implemented. The main outcome was the number of patients having ≥1 medication where deprescribing status was sustained 30 days after inclusion. Out of 76 eligible patients, 72 (95%) were included and 67 (93%) completed the study (57% male; mean age 73 years; mean number of 10 prescribed medications). Nineteen patients (56%) in the intervention group and four (12%) in the control group had ≥1 medication where deprescribing status was sustained 30 days after inclusion (p = 0.015). In total, 37 medications were deprescribed in the intervention group and five in the control group. At 365+ days after inclusion, 97% and 100% of the deprescribed medications were sustained in the intervention and control groups, respectively. The three most frequently deprescribed medication groups were analgesics, cardiovascular, and gastrointestinal medications. In conclusion, a collaborative deprescribing intervention for multimorbid patients was feasible and resulted in sustainable deprescribing of medication in a SMOC.

Developing an Integrated Electronic Medication Reconciliation Platform and Evaluating its Effects on Preventing Potential Duplicated Medications and Reducing 30-Day Medication-Related Hospital Revisits for Inpatients

The aims were to develop an integrated electronic medication reconciliation (ieMR) platform, evaluate its effects on preventing potential duplicated medications, analyze the distribution of the potential duplicated medications by the Anatomical Therapeutic and Chemical (ATC) code for all inpatients, and determine the rate of 30-day medication-related hospital revisits for a geriatric unit. The study was conducted in a tertiary medical center in Taiwan and involved a retrospective quasi pre-intervention (July 1-November 30, 2015) and post-intervention (October 1-December 31, 2016) study design. A multidisciplinary team developed the ieMR platform covering the process from admission to discharge. The ieMR platform included six modules of an enhanced computer physician order entry system (eCPOE), Pharmaceutical-care, Holistic Care, Bedside Display, Personalized Best Possible Medication Discharge Plan, and Pharmaceutical Care Registration System. The ieMR platform prevented the number of potential duplicated medications from pre (25,196 medications, 2.3%) to post (23,413 medications, 3.8%) phases (OR 1.71, 95% CI, 1.68-1.74; p < .001). The most common potential duplicated medications classified by the ATC codes were cardiovascular system (28.4%), alimentary tract and metabolism (26.4%), and nervous system (14.9%), and by chemical substances were sennoside (12.5%), amlodipine (7.5%), and alprazolam (7.4%). The rate of medication-related 30-day hospital revisits for the geriatric unit was significantly decreased in post-intervention compared with that in pre-intervention (OR = 0.12; 95% CI, 0.03-0.53; p < .01). This study indicated that the ieMR platform significantly prevented the number of potential duplicated medications for inpatients and reduced the rate of 30-day medication-related hospital revisits for the patients on the geriatric unit.

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.

Effects of stratified medication review in high-risk patients at admission to hospital: a randomised controlled trial

Background:

Patients at high risk of medication errors will potentially benefit most from medication reviews. An algorithm, MERIS, can identify the patients who are at highest risk of medication errors. The aim of this study was to examine the effects of performing stratified medication reviews on patients who according to MERIS were at highest risk of medication errors.

Methods:

A randomised controlled trial was performed at the Acute Admissions Unit, Aarhus University Hospital, Denmark. Patients were included at admission to the hospital and were randomised to control or intervention. The intervention consisted of stratified medication review at admission on patients with a high MERIS score. Clinical pharmacists and clinical pharmacologists performed the medication reviews; the clinical pharmacologists performed the reviews on patients with the highest MERIS score. The primary outcome measure was the number of prescribing errors during the hospitalisation. Secondary outcomes included self-experienced quality of life, health-care utilisation and mortality measured at follow-up 90 days after discharge.

Results:

A total of 375 patients were included, of which medication reviews were performed in 64 patients. The medication reviews addressed 63 prescribing errors in 37 patients and 60 other drug-related problems. No difference in the number of prescribing errors during hospitalisation between the intervention group (n = 165) and control group (n = 153) was found, corresponding to 0.11 prescribing errors per drug (95% confidence interval (CI): 0.08–0.14) versus 0.13 per drug (95% CI: 0.09–0.16), respectively. No differences in secondary outcomes were observed.

Conclusion:

A stratified medication review approach based on the individual patient’s risk of medication errors did not show impact on the chosen outcomes.

Plain language summary

How does a medication review at admission affect patients who are in high risk of medication errors?

Patients are at risk of medication errors at admission to hospital. Medication reviews aim to detect and solve these. Yet, due to limited resources in healthcare, it would be beneficial to detect the patients who are most at risk of medication errors and perform medication reviews on those patients.

In this study we investigated whether an algorithm, MERIS, could detect patients who are at highest risk of medication errors; we also studied whether performing medication reviews on patients at highest risk of medication errors would have an effect on, for example, the number of medication errors during hospitalisation, qualify of life and number of readmissions. We included 375 patients in a Danish acute admission unit and they were divided into control group and intervention group. Patients in the intervention group received a medication review at admission if they were considered at high risk of medication errors, assessed with the aid of MERIS. In summary, 64 patients in the intervention group were most at risk of medication errors and therefore received a medication review.

We conclude in the study that MERIS was useful in identifying relevant patients for medication reviews. Yet, the medication reviews performed at admission did not impact on the chosen outcomes.

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.

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.

Emergency department-based medication review on outpatient health services utilization: interrupted time series

Background

One in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication reviews on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization.

Methods

Data included information from 10,783 patients who were part of a prospective, multi-centre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners (GP); medical specialists; surgical specialists; and imaging and laboratory specialists. During triage, patients deemed high-risk based on their medical history, were systematically allocated to receive either a medication review (n = 6403) or the standard of care (n = 4380). Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization.

Results

ED-based pharmacist-led medication review did not result in a significant level or trend change in the primary outcome of total outpatient health services utilization. There were also no differences in the secondary outcomes of primary care physician visits or ED visits relative to the standard of care in the 12 months following the intervention. Our findings were consistent when stratified by age, hospital site, and whether patients were discharged on their index visit.

Conclusion

This was the first study to measure long-term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community-based providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate physician acceptance of pharmacist recommendations and should encourage patient follow-up to community providers.

Effectiveness of medication review on the number of drug-related problems in patients visiting the outpatient cardiology clinic: A randomized controlled trial

AIMS

To assess the effectiveness of medication review on the number of drug-related problems (DRPs) in outpatient cardiology patients.

METHODS

In this randomized controlled trial, a computer-assisted and pharmacist-led medication review with patient involvement (questionnaire and telephone call with pharmacist) was conducted in intervention patients prior to their visit to the cardiologist. The control group received usual care. Adult outpatient cardiology patients without support concerning the administration of medication, without a medication review in the past 6 months and who gave permission to access their electronic medication record were included. The primary outcome measure was the number of DRPs 1 month after the visit. Secondary outcome measures concerned the type of DRP and the type of medication involved in the DRPs.

RESULTS

In total, 75 patients (mean [standard deviation, SD] age 66.0 [12.5] years, 41% female) were included. Intervention (n = 90) and control group (n = 85) were comparable at baseline. The mean (SD) number of drugs used per patient was 7.9 (3.9). After 1 month, the mean (SD) number of DRPs was 0.3 (0.7) and 0.8 (1.0) and the median (range) number of DRPs was 0 (0-4) and 0 (0-4) in the intervention group and control group, respectively (P < .001). In the intervention group, 74% of the DRPs identified at T0 were solved at T1 vs 14% in the control group.

CONCLUSION

This randomized controlled trial suggests that a pharmacist-led medication review in patients with a scheduled visit to the outpatient cardiology clinic decreases the number of DRPs.

Study protocol for a single-centre, prospective, non-blinded, randomised, 12-month, parallel-group superiority study to compare the efficacy of pharmacist intervention versus usual care for elderly patients hospitalised in orthopaedic wards

INTRODUCTION

Given that polypharmacy and potentially inappropriate prescribing are common in elderly orthopaedic patients, pharmacist interventions to improve medication practices among this population are important. However, past studies have reported mixed results regarding the effectiveness of pharmacist-led interventions in inpatient elderly care. Furthermore, few randomised controlled trials have evaluated patient-relevant outcomes as a primary endpoint. Therefore, we will evaluate whether a pharmacist-led intervention could reduce readmission of hospitalised elderly orthopaedic patients with polypharmacy or potentially inappropriate prescribing.

METHODS AND ANALYSIS

This is an ongoing single-centre, prospective, non-blinded, randomised controlled trial designed to evaluate the superiority of a pharmacist-led intervention for hospitalised elderly patients compared with usual care. The trial will include newly admitted orthopaedic patients 70 years of age and older with polypharmacy or at least one potentially inappropriate prescription, as identified by the screening tool of older people's prescriptions (STOPP) criteria. Usual care includes medication reconciliation, patient education and monitoring, as well as providing information about discharge medications. Pharmacist interventions, in addition to usual care, include advising the patient's physician to stop unnecessary or inappropriate medications and start necessary medications. The primary outcome is the 1-year readmission rate. Secondary outcomes are the proportion of patients who undergo emergency department visits and the occurrences of all-cause death, a new fracture, myocardial infarction and ischaemic stroke. The study started in November 2017, and up to approximately 220 patients will be enrolled.

ETHICS AND DISSEMINATION

The protocol was approved by the Medical Ethics Committee of the National Hospital Organization Tochigi Medical Center (No. 29-22). The trial was registered at the University Hospital Medical Information Network (UMIN) clinical registry. The results of this trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000029404.

The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: A systematic review and meta-analysis of randomized controlled trials

Background

Adverse drug events (ADEs) impose a major clinical and cost burden on acute hospital services. It has been reported that medicines reconciliation provided by pharmacists is effective in minimizing the chances of hospital admissions related to adverse drug events.

Objective

To update the previous assessment of pharmacist-led medication reconciliation by restricting the review to randomized controlled trials (RCTs) only.

Methods

Six major online databases were sifted up to 30 December 2016, without inception date (Embase, Medline Ovid, PubMed, BioMed Central, Web of Science and Scopus) to assess the effect of pharmacist-led interventions on medication discrepancies, preventable adverse drug events, potential adverse drug events and healthcare utilization. The Cochrane tool was applied to evaluate the chances of bias. Meta-analysis was carried out using a random effects model.

Results

From 720 articles identified on initial searching, 18 RCTs (6,038 patients) were included. The quality of the included studies was variable. Pharmacists-led interventions led to an important decrease in favour of the intervention group, with a pooled risk ratio of 42% RR 0.58 (95% CI 0.49 to 0.67) P<0.00001 in medication discrepancy. Reductions in healthcare utilization by 22% RR 0.78 (95% CI 0.61 to 1.00) P = 0.05, potential ADEs by10% RR 0.90 (95% CI 0.78 to 1.03) P = 0.65 and preventable ADEs by 27% RR 0.73 (0.22 to 2.40) P = 0.60 were not considerable.

Conclusion

Pharmacists-led interventions were effective in reducing medication discrepancies. However, these interventions did not lead to a significant reduction in potential and preventable ADEs and healthcare utilization.

Examining the nature of interprofessional practice: An initial framework validation and creation of the InterProfessional Activity Classification Tool (InterPACT)

The practice of, and research on interprofessional working in healthcare, commonly referred to as teamwork, has been growing rapidly. This has attracted international policy support flowing from the growing belief that patient safety and quality of care can only be achieved through the collective effort of the multiple professionals caring for a given patient. Despite the increasing policy support, the evidence for effectiveness lags behind: while there are supporting analytic epidemiological studies, few reliable intervention studies have been published and so we have yet to confirm a causal link. We argue that this lag in evidence development may be because interprofessional terms (e.g. teamwork, collaboration) remain conceptually unclear, with no common terminology or definitions, making it difficult to distinguish interventions from each other. In this paper, we examine published studies from the last decade in order to elicit current usage of terms related to interprofessional working; and, in so doing, undertake an initial empirical validation of an existing conceptual framework by mapping its four categories (teamwork, collaboration, coordination and networking) against the descriptions of interprofessional interventions in the included studies. We searched Medline and Embase for papers describing interprofessional interventions using a standard approach. We independently screened papers and classified these under set categories following a thematic approach. Disagreements were resolved through consensus. Twenty papers met our inclusion criteria. Identified interprofessional work interventions fall into a range, from looser to tighter links between members. Definitions are inconsistently and inadequately applied. We found the framework to be a helpful and practical tool for classifying such interventions more consistently. Our analysis enabled us to scrutinise the original dimensions of the framework, confirm their usefulness and consistency, and reveal new sub-categories. We propose a slightly revised typology and a classification tool (InterPACT) for future validation, with four mutually exclusive categories: teamwork, collaboration, coordination and networking. Consistent use, further examination and refinement of the new typology and tool may lead to greater clarity in definition and design of interventions. This should support the development of a reliable and coherent evidence base on interventions to promote interprofessional working in health and social care.

Important Aspects of Pharmacist-led Medication Reviews in an Acute Medical Ward

In some hospitals, clinical pharmacists review the medication to find drug-related problems (DRPs) in acutely admitted patients. We aimed to identify the nature of identified DRPs and investigate factors of potential importance for the clinical implementation of pharmacist suggestions. In 100 randomly selected medication review (MR) notes, we retrospectively evaluated the clinical implementation and classified (1) timing and communication of the review; (2) DRPs and related suggestions for the physician; and (3) DRPs' potential clinical relevance to patients as 'beneficial', 'somewhat beneficial', 'no relevance' or 'other relevance'. Of 327 DRPs (0-13 DRPs per patient), 42% were implemented. The clinical implementation was higher if the MR note was made prior to (instead of after) the physician's admission, and even higher if the suggestions were communicated verbally (instead of only in writing) to the physicians (44% versus 79%, p < 0.05). The clinical relevance of the DRPs was either 'beneficial' (16%), 'somewhat beneficial' (43%), 'no relevance' (22%) or 'other relevance' (19%). The 'beneficial' DRPs had a higher clinical implementation (53%) than 'no relevance' (34%) (p < 0.05). The most frequently implemented suggestions were based on DRPs concerning 'indication for drug treatment not noticed', 'inappropriate drug form' and 'drug dose too low', with implementation rates of 83%, 67% and 63%, respectively. In our sample, the pharmacist's MR suggestions were only implemented by physicians in 42% of the cases, but review prior to physician contact and verbal communication of the suggestions, higher clinical relevance and specific types of DRPs were associated with a higher implementation rate.

Effects of multidisciplinary teams and an integrated follow-up electronic system on clinical pharmacist interventions in a cancer hospital

Background The aim of drug therapy is to attain distinct therapeutic effects that not only improve patient's quality of life but also reduce the inherent risks associated with the therapeutic use of drugs. Pharmacists play a key role in reducing these risks by developing appropriate interventions. Whether to accept or reject the intervention made by the pharmacist is a relevant consultant's decision. Objective To evaluate the impact of electronic prompts and follow-up of rejected pharmacy interventions by clinical pharmacists in an in-patient setting. Setting Shaukat Khanum Cancer Hospital & Research Center, Lahore, Pakistan. Method The study was conducted in two phases. Data for 3 months were collected for each phase of the study. Systematic and quantifiable consensus validity was developed for rejected interventions in phase 1, based on patient outcome analyses. Severity rating was assigned to assess the significance of interventions. Electronic prompts for follow-on interventions in phase 2 were then developed and implemented, including daily review via a multidisciplinary team (MDT) approach. Main outcome measure Validity of rejected interventions, acceptance of follow-on interventions before and after re-engineering the pharmacy processes, rejection rate and severity rating of follow-on interventions. Result Of a total of 2649 and 3064 interventions that were implemented during phase 1 and phase 2, 238 (9%) and 307 (10%) were rejected, respectively. Additionally, 133 (56%) were inappropriate rejections during phase 1. The estimated reliability between pharmacists regarding rejected interventions was 0.74 (95% CI of 0.69, 0.79, p 0.000). Prospective data were analysed after implementing electronic alerts and an MDT approach. The acceptance rate of follow-on interventions in phase 2 was 60% (184). Conclusion Electronic prompts for follow-on interventions together with an MDT approach enhance the optimization of pharmacotherapy, increase drug rationality and improve patient care.

Hospital pharmacists working with geriatric patients in Europe: a systematic literature review

Objectives

Multimorbidity of geriatric patients often leads to polypharmacy that increases the risk for drug interactions. Geriatric patients are also more sensitive to adverse drug reactions due to physiological changes resulting from ageing. Hence, the use of medicines should be considered thoroughly. This systematic literature review aimed at identifying and presenting available evidence on the effect of pharmaceutical interventions on geriatric patients, their medications or healthcare costs in a clinical setting in Europe.

Methods

We included all studies on research of pharmaceutical interventions on geriatric inpatients (≥65 years) in Europe since 2001. Database searches were conducted on PubMed, EMBASE, The Cochrane Library and AgeInfo. In addition, the following journals were searched manually: European Journal of Hospital Pharmacy, 'Krankenhauspharmazie', 'Medizinische Monatsschrift für Pharmazeuten' and 'Zeitschrift für Gerontologie und Geriatrie'.

Results

Database screening yielded 8058 hits. After deletion of duplicates, screening of title and abstract, 143 full-text articles were analysed and 17 papers were included. Manual searching added four more papers. Included studies were conducted in Belgium, Denmark, England, Ireland, the Netherlands, Sweden and Spain. They demonstrate that pharmaceutical care on wards leads to more appropriate medication use and might reduce outcomes like drug-related readmissions. Intensified pharmaceutical care showed additional effects, even in countries with established pharmaceutical care in hospitals.

Conclusions

This systematic literature review demonstrates that ward-based pharmacists may improve the appropriateness of medications, seamless care and drug safety for geriatric inpatients while being cost effective.

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Background

Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.

Methods

A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.

Results

Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).

Conclusions

There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Impact of early in-hospital medication review by clinical pharmacists on health services utilization

Background

Adverse drug events are a leading cause of emergency department visits and unplanned admissions, and prolong hospital stays. Medication review interventions aim to identify adverse drug events and optimize medication use. Previous evaluations of in-hospital medication reviews have focused on interventions at discharge, with an unclear effect on health outcomes. We assessed the effect of early in-hospital pharmacist-led medication review on the health outcomes of high-risk patients.

Methods

We used a quasi-randomized design to evaluate a quality improvement project in three hospitals in British Columbia, Canada. We incorporated a clinical decision rule into emergency department triage pathways, allowing nurses to identify patients at high-risk for adverse drug events. After randomly selecting the first eligible patient for participation, clinical pharmacists systematically allocated subsequent high-risk patients to medication review or usual care. Medication review included obtaining a best possible medication history and reviewing the patient’s medications for appropriateness and adverse drug events. The primary outcome was the number of days spent in-hospital over 30 days, and was ascertained using administrative data. We used median and inverse propensity score weighted logistic regression modeling to determine the effect of pharmacist-led medication review on downstream health services use.

Results

Of 10,807 high-risk patients, 6,416 received early pharmacist-led medication review and 4,391 usual care. Their baseline characteristics were balanced. The median number of hospital days was reduced by 0.48 days (95% confidence intervals [CI] = 0.00 to 0.96; p = 0.058) in the medication review group compared to usual care, representing an 8% reduction in the median length of stay. Among patients under 80 years of age, the median number of hospital days was reduced by 0.60 days (95% CI = 0.06 to 1.17; p = 0.03), representing 11% reduction in the median length of stay. There was no significant effect on emergency department revisits, admissions, readmissions, or mortality.

Limitations

We were limited by our inability to conduct a randomized controlled trial, but used quasi-random patient allocation methods and propensity score modeling to ensure balance between treatment groups, and administrative data to ensure blinded outcomes ascertainment. We were unable to account for alternate level of care days, and therefore, may have underestimated the treatment effect in frail elderly patients who are likely to remain in hospital while awaiting long-term care.

Conclusions

Early pharmacist-led medication review was associated with reduced hospital-bed utilization compared to usual care among high-risk patients under 80 years of age, but not among those who were older. The results of our evaluation suggest that medication review by pharmacists in the emergency department may impact the length of hospital stay in select patient populations.

A systematic review of the outcomes reported in trials of medication review in older patients: the need for a core outcome set

AIM

Medication review has been advocated as one of the measures to tackle the challenge of polypharmacy in older patients, yet there is no consensus on how best to evaluate its efficacy. This study aimed to assess outcome reporting in trials of medication review in older patients.

METHODS

Randomized controlled trials (RCTs), prospective studies and RCT protocols involving medication review performed in patients aged 65 years or older in any setting of care were identified from: (1) a recent systematic review; (2) RCT registries of ongoing studies; (3) the Cochrane library. The type, definition, and frequency of all outcomes reported were extracted independently by two researchers.

RESULTS

Forty-seven RCTs or prospective published studies and 32 RCT protocols were identified. A total of 327 distinct outcomes were identified in the 47 published studies. Only one fifth (21%) of the studies evaluated the impact of medication reviews on adverse events such as drug reactions or drug-related hospital admissions. Most of the outcomes were related to medication use (n = 114, 35%) and healthcare use (n = 74, 23%). Very few outcomes were patient-related (n = 24, 7%). A total of 248 distinct outcomes were identified in the 32 RCT protocols. Overall, the number of outcomes and the number and type of health domains covered by the outcomes varied largely.

CONCLUSION

Outcome reporting from RCTs concerning medication review in older patients is heterogeneous. This review highlights the need for a standardized core outcome set for medication review in older patients, to improve outcome reporting and evidence synthesis.

Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Medication review is often recommended to optimize medication use. In clinical practice it is mostly operationalized as an intervention without co-interventions during a short term intervention period. However, most systematic reviews also included co-interventions and prolonged medication optimization interventions. Furthermore, most systematic reviews focused on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). Therefore, the objective of this study is to assess the effectiveness of medication review as an isolated short-term intervention, irrespective of the patient population and the outcome measures used.

METHODS

A literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. Randomized controlled trials (RCTs) with medication review as isolated short term intervention (<3 months) were included. There were no restrictions with regard to patient characteristics and outcome measures. One reviewer extracted and a second checked data. The risk of bias of studies was evaluated independently by two reviewers. A best evidence synthesis was conducted for every outcome measure used in more than one trial. In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect.

RESULTS

Thirty-one RCTs were included in this systematic review (55% low risk of bias). A best evidence synthesis was conducted for 22 outcome measures. No effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning), except a decrease in the number of falls per patient. However, in a sensitivity analysis using a more stringent threshold for risk of bias, the conclusion for the effect on the number of falls changed to inconclusive. Furthermore no effect was found on quality of life and evidence was inconclusive about the effect on economical outcome measures. However, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs.

CONCLUSIONS

An isolated medication review during a short term intervention period has an effect on most drug-related outcomes, minimal effect on clinical outcomes and no effect on quality of life. No conclusion can be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care.

Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis

AIMS

The aim of this meta-analysis is to examine the impact of in-hospital pharmacist-led medication reviews in paediatric and adult patients.

METHODS

Relevant studies were identified from the Medline and Cochrane Library databases. Studies were included if they met the following criteria (without any language or date restrictions): design: randomized controlled trial; intervention: in-hospital pharmacist-led medication review (experimental group) vs. usual care (control group); participants: paediatric or adult population. The primary outcome was all-cause readmissions and/or emergency department (ED) visits at different time points. The secondary outcomes were all-cause readmissions, all-cause ED visits, drug-related readmissions, mortality, length of hospital stay, adherence and quality of life. We calculated the relative risk (RR) or mean differences (MD) with 95% confidence intervals (CIs) for each study. We used fixed and/or random effects models. Heterogeneity was assessed using the I² statistic.

RESULTS

We systematically reviewed 19 randomized controlled trials (4805 participants). The readmission rates did not differ between the experimental group and the control group (RR = 0.97, 95% CI 0.89; 1.05, p = 0.470). The secondary outcomes did not differ between the two groups, except for in drug-related readmissions, which were lower in the experimental group (RR = 0.25, 95% CI 0.14; 0.45, p < 0.001), and all-cause ED visits (RR = 0.70, 95% CI 0.59; 0.85 p = 0.001).

CONCLUSION

The low-quality evidence in this analysis suggests an impact of pharmacist-led medication reviews on drug-related readmissions and all-cause ED visits. Few studies reported on adherence and quality of life. More high-quality randomized clinical trials are needed to assess the impact of pharmacist-led medication reviews on patient-relevant outcomes, including adherence and quality of life.

Risk of prescribing errors in acutely admitted patients: a pilot study

Background Prescribing errors in emergency settings occur frequently. Knowing which patients have the highest risk of errors could improve patient outcomes. Objective The aim of this study was to test an algorithm designed to assess prescribing error risk in individual patients, and to test the feasibility of medication reviews in high-risk patients. Setting The study was performed at the Acute Admissions Unit at Aarhus University Hospital, Denmark. Methods The study was an interventional pilot study. Patients included were assessed according to risk of prescribing errors with the aid of an algorithm called 'Medication Risk Score' (MERIS). Based on the score, high-risk patients were offered a medication review. The clinical relevance of the medication reviews was assessed retrospectively. Main outcome measure The number and nature of prescribing errors during the patients' hospitalisation. Results The study included 103 patients, all of whom could be risk assessed with the algorithm MERIS. MERIS stratified 38 patients as high-risk patients and 65 as low-risk patients. The 103 patients were prescribed a total of 848 drugs in which 88 prescribing errors were found (10.4 %). Sixty-two of these were found in patients in the high-risk group. In general, the medication reviews were found to be clinically relevant and approximately 50 % of recommendations were implemented. Conclusion MERIS was found to be applicable in a clinical setting and stratified most patients with prescribing errors into the high-risk group. The medication reviews were feasible and found to be clinically relevant by most raters.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug-related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.

OBJECTIVES

We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care.

SEARCH METHODS

We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events.

DATA COLLECTION AND ANALYSIS

Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes.

MAIN RESULTS

We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow-up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low-certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high-certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low-certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low-risk population and 12 for a high-risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results.

AUTHORS' CONCLUSIONS

We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow-up ranging from 30 days to one year, important treatment effects may have been overlooked. High-quality trials with long-term follow-up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long-term follow-up.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of early in-hospital medication review on health outcomes: a systematic review

AIMS

Adverse drug events are an important cause of emergency department visits, unplanned admissions and prolonged hospital stays. Our objective was to synthesize the evidence on the effect of early in-hospital pharmacist-led medication review on patient-oriented outcomes based on observed data.

METHODS

We systematically searched eight bibliographic reference databases, electronic grey literature, medical journals, conference proceedings, trial registries and bibliographies of relevant papers. We included studies that employed random or quasi-random methods to allocate subjects to pharmacist-led medication review or control. Medication review had to include, at a minimum, obtaining a best possible medication history and reviewing medications for appropriateness and adverse drug events. The intervention had to be initiated within 24 h of emergency department presentation or 72 h of admission. We extracted data in duplicate and pooled outcomes from clinically homogeneous studies of the same design using random effects meta-analysis.

RESULTS

We retrieved 4549 titles of which seven were included, reporting the outcomes of 3292 patients. We pooled data from studies of the same design, and found no significant differences in length of hospital admission (weighted mean difference [WMD] -0.04 days, 95% confidence interval [CI] -1.63, 1.55), mortality (odds ratio [OR] 1.09, 95% CI 0.69, 1.72), readmissions (OR 1.15, 95% CI 0.81, 1.63) or emergency department revisits at 3 months (OR 0.60, 95% CI 0.27, 1.32). Two large studies reporting reductions in readmissions could not be included in our pooled estimates due to differences in study design.

CONCLUSIONS

Wide confidence intervals suggest that additional research is likely to influence the effect size estimates and clarify the effect of medication review on patient-oriented outcomes. This systematic review failed to identify an effect of pharmacist-led medication review on health outcomes.

Underutilization of cardiovascular medications: effect of a continuity-of-care program

PURPOSE

The effect of hospital pharmacists' enhanced communication with patients and community providers on the underutilization of key cardiovascular medications was studied.

METHODS

Patients enrolled in the Iowa Continuity of Care study were eligible for inclusion in this study if they had a diagnosis of hypertension, hyperlipidemia, heart failure, coronary artery disease, or a combination of these diagnoses. Eligible patients also had to be admitted to the internal medicine, family medicine, cardiology, or orthopedics services and receive their usual medical care in the community and their prescriptions from a community pharmacy. Patients were randomized to receive minimal intervention, enhanced intervention, or usual care. For the minimal- and enhanced-intervention groups, pharmacy case managers (PCMs) performed comprehensive medication reconciliations and identified drug-related problems within 24 hours of admission. The PCMs made recommendations to the inpatient care team and to patients' community physicians. For patients in the enhanced-intervention group, the PCM developed a discharge care plan containing the patient's discharge medication list. PCMs made specific recommendations to optimize regimens that did not meet current guidelines or medications that were underutilized. Medication underutilization was assessed at admission, discharge, 30 days after discharge, and 90 days after discharge.

RESULTS

A total of 732 patients were enrolled in this study. There were no significant differences among the three study groups. Overall, the rate of underutilization remained constant among all three groups, despite enhanced pharmacist involvement in both intervention groups.

CONCLUSION

Enhanced interventions by PCMs had no effect on the underutilization of key cardiovascular drugs during hospitalization or after hospital discharge.

Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care

STUDY OBJECTIVE

To determine whether recommendations made by pharmacists and accepted by hospital physicians resulted in fewer postdischarge readmissions and urgent care visits compared with recommendations that were not implemented.

DESIGN

Prospective substudy of pharmacist recommendations.

SETTING

Tertiary care academic medical center and private community-based physician practices and community pharmacies.

PATIENTS

A total of 192 patients aged 18 years or older who were a subsample of a randomized, prospective study, who were admitted with a previous diagnosis of one of nine cardiovascular or pulmonary diseases or diabetes mellitus or had received oral anticoagulation therapy and who were discharged to community-based care provided by private physicians and community pharmacists.

MEASUREMENTS AND MAIN RESULTS

Pharmacy case managers performed evaluations for patients and made recommendations to inpatient physicians. Patients received drug therapy counseling, a drug therapy list, and a wallet card at discharge. Data were collected from patients and private physicians for 90 days after discharge. Pharmacy case managers made 546 recommendations to inpatient physicians for 187 patients (97%). Overall, 260 (48%) of the 546 recommendations were accepted. The acceptance rate was lower for patients who had an urgent care visit compared with the other patients (33.6% vs 52.2%, p=0.033). High acceptance rates were noted for updating the record after medication reconciliation (36 patients [78%]) and when there was an actual allergy (2 [100%] of 2 patients) or medication error (2 [100%] of 2 patients). Physicians were less likely to accept recommendations related to drug indications (p<0.001), drug efficacy (p=0.041), and therapeutic drug and disease state monitoring (p=0.011). Recommendations made for patients with a relatively greater number of drugs were also less likely to be accepted (p=0.003).

CONCLUSION

Recommendations to reconcile medications or address actual drug allergies or medication errors were frequently accepted. However, only 48% of all recommendations were accepted by inpatient physicians, and there was no impact on health care use 90 days after discharge. This study suggests that recommendations by pharmacy case managers were underused, and the low acceptance rate may have reduced the potential to avoid readmissions.

Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review

Suboptimal medication use may lead to morbidity, mortality and increased costs. To reduce unnecessary patient harm, medicines management including medication reviews can be provided by clinical pharmacists. Some recent studies have indicated a positive effect of this service, but the quality and outcomes vary among studies. Hence, there is a need for compiling the evidence within this area. The aim of this systematic MiniReview was to identify, assess and summarize the literature investigating the effect of pharmacist-led medication reviews in hospitalized patients. Five databases (MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library) were searched from their inception to 2011 in addition to citation tracking and hand search. Only original research papers published in English describing pharmacist-led medication reviews in a hospital setting including minimum 100 patients or 100 interventions were included in the final assessment. A total of 836 research papers were identified, and 31 publications were included in the study: 21 descriptive studies and 10 controlled studies, of which 6 were randomized controlled trials. The pharmacist interventions were well implemented with acceptance rates from 39% to 100%. The 10 controlled studies generally show a positive effect on medication use and costs, satisfaction with the service and positive as well as insignificant effects on health service use. Several outcomes were statistically insignificant, but these were predominantly associated with low sample sizes or low acceptance rates. Therefore, future research within this area should be designed using rigorous design, large sample sizes and includes comparable outcome measures for patient health outcomes.

Hospital-based medication reconciliation practices: a systematic review

BACKGROUND

Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk.

OBJECTIVES

To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices.

DATA SOURCES

MEDLINE (1966 through February 2012) and a manual search of article bibliographies.

STUDY SELECTION

Twenty-six controlled studies.

DATA EXTRACTION

Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results.

DATA SYNTHESIS

Studies were grouped by type of medication reconciliation intervention-pharmacist related, information technology (IT), or other-and were assigned quality ratings using US Preventive Services Task Force criteria.

RESULTS

Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population.

CONCLUSIONS

Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

Perceived value of ward-based pharmacists from the perspective of physicians and nurses

BACKGROUND

Clinical pharmacy in a hospital setting is relatively new in Sweden. Its recent introduction at the University Hospital in Uppsala has provided an opportunity for evaluation by other relevant professionals of the integration of clinical pharmacists into the health-care team.

OBJECTIVES

The objectives of this descriptive study were to evaluate the perceived value of wardbased clinical pharmacists from the perspective of hospital based physicians and nurses and to identify potential advantages and disadvantages related to the new inter professional collaboration. Another objective was to evaluate the experiences of general practitioners on receiving medication reports from ward-based clinical pharmacists.

SETTING

Two acute internal medicine wards at the University Hospital in Uppsala, where a previously reported randomized controlled trial investigating the effects of ward based clinical pharmacists on re-visits to hospital was undertaken.

METHODS

Data were collected by questionnaires containing closed- and open-ended questions. The questionnaires were distributed during the nine-month study period of the randomized controlled trial by an independent researcher to 29 hospital-based physicians and 44 nurses on the study wards and to 21 general practitioners who had received two or more medication reports. Answers were analysed descriptively for the closed-ended questions and by content analysis for the open-ended questions.

MAIN OUTCOME MEASURE

The main outcome measure was the physicians' and nurses' level of satisfaction with the new collaboration with clinical pharmacists, from a hospital and primary care perspective.

RESULTS

Seventy-six percent of the hospital-based physicians and 81% of the nurses completed the questionnaire. Ninety-five percent of the physicians and 93% of the nurses were very satisfied with the collaboration. Out of the 17 general practitioners (81%) that completed the questionnaire 71% wanted to continue to receive medication reports in a similar way in the future. Increased patient safety and improvements in patients' drug therapy were the main advantages stated by all three groups of respondents. Eighteen percent of the hospital-based physicians and 21% of the nurses thought that the collaboration had been time-consuming to certain or to a high extent.

CONCLUSIONS

The majority of the respondents, both GPs and hospital based physicians and nurses, were satisfied with the new collaboration with the ward based pharmacists and perceived that the quality of the patients' drug therapy and drug-related patient safety had increased.