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

Effectiveness of hospital-to-home transitional care interventions and consultation for implementation in Sudan: a scoping review of systematic reviews

Background

Hospital discharge is often associated with a lack of continuity resulting in fragmented care, particularly in low-income countries. As there is limited information about interventions in these countries and no study evaluating the effectiveness of hospital discharge interventions, we conducted a scoping review to identify effective hospital-to-home transitional care interventions and explore their applicability in a low-income country (Sudan).

Methods

Our scoping review of systematic reviews and meta-analyses classed interventions as effective, ineffective, undesirable, or uncertain, based on the quality of their evidence and their estimated effects on the following outcomes: readmission rates, mortality, costs, quality of life, and adverse outcomes) and certainty of evidence. Our authors from Sudan used the SUPPORT summary tool to determine if three effective interventions could be implemented in Sudan.

Results

Out of 3,276 articles that were identified, and 72 articles were reviewed, 10 articles has been included in the review. Seven interventions were classified as effective, one as ineffective, and none with undesirable effects. Eight interventions were classified as having an uncertain effect. The effective interventions were composed of home visits, information and communication technology (ICT), case manager models, multidisciplinary teams, and self-management support.

Conclusions

The finding of this study suggested that a combining two to four interventions can improve enhance hospital-to-home transitional care. Effective interventions are composed of home visits, ICT, case manager models, multidisciplinary teams, and self-management support. The implementation of these interventions in Sudan was found to be undermined by contextual factors such as inadequate human resources, telecommunication instability, and inequality in accessibility. These interventions could be tailored based on an in-depth understanding of the contextual factors in low-income countries that influence implementation.

Systematic Review Registration

https://osf.io/9eqvr/, doi: 10.17605/OSF.IO/9EQVR.

Developing a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients: A collaboration between hospital and community pharmacists

Background

Patients who transfer from the hospital back to the community are at risk of experiencing problems related to their medications. Hospital pharmacists (HPs) and community pharmacists (CPs) may play an important role and provide transitional pharmaceutical care in transition of care interventions.

Objective

To describe how a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients was developed, utilizing already existing pharmacist interventions in the hospital and community pharmacy.

Methods

A mixed-method approach to intervention development was applied. Existing evidence was identified through a literature review of effective transitional care interventions and existing services in the hospital and community pharmacy. Focus group interviews and a workshop were carried out with HPs and CPs to identify their perceived facilitators and uncertainties in relation to intervention development. The final intervention and the expected outcomes were developed in an expert group workshop. Finally, the hospital part of the intervention was tested in a small-scale feasibility study to assess what type of information the HP would transfer to the CP for follow up.

Results

Five components were identified through the 209 systematic reviews: pharmacist-led medication reconciliation, pharmacist-led medication review, collaboration with general practitioners (GPs), post discharge pharmacist follow up and patient counseling or education. HPs and CPs identified uncertainties related to the relevance of the information sent from the HP to the CP, identification of patients at the community pharmacy and communication. The expected outcomes for the patients receiving the intervention were an experience of increased safety and satisfaction and less use of healthcare resources. The feasibility study led to optimization of language and structure of the pharmacist referrals that were used to transfer information from the HP to the CP.

Conclusion

A patient centered intervention to provide transitional pharmaceutical care for hospital discharged patients was developed using existing evidence in transition of care, HPs and CPs, an expert group, and a small-scale feasibility study. A full-scale feasibility test of the intervention should be carried out for it to be further refined.

Pharmacist Intervention to Improve Medication Adherence in Patients with Acute Coronary Syndrome: The PRIMA-ACS Study

Background

Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge.

Objective

To determine whether a standardized counselling intervention at hospital discharge significantly improved patients' adherence to cardiovascular medications following ACS.

Methods

This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed.

Results

Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year.

Conclusions

Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS.

Development of a Theory-Informed Behavior Change Intervention to Reduce Inappropriate Prescribing of Nephrotoxins and Renally Eliminated Drugs

BACKGROUND

Goals of managing patients with acute kidney injury (AKI) are mitigating disease progression and ensuring safety while providing supportive care because no effective treatment exists. One strategy recommended in guidelines to meet these goals is optimizing medication management. Unfortunately, guideline implementation appears to be lacking as observed by the frequent occurrence of medication errors and adverse drug events.

OBJECTIVE

To address this performance gap in the care of hospitalized patients receiving nephrotoxins and renally eliminated drugs, we sought to provide a potential intervention based on theory-informed behavior change.

METHODS

Formative research with a qualitative analysis identifying what needs to change in patient care was completed by obtaining clinician opinion and expert opinion and reviewing the published literature. Frontline providers, including 8 physicians, 4 pharmacists, and a multiprofessional group of authors, provided insight into possible barriers to appropriate prescribing. Capability, Opportunity, Motivation and Behavior model and Theoretical Domain Framework were applied to characterize behavior change interventions and inform a potential implementation intervention for changing inappropriate prescribing behaviors.

RESULTS

Lack of knowledge about appropriate drug management in patients at risk for adverse outcomes was provided as a major barrier. Other reported barriers included a lack of: (1) tools to assist with drug management, (2) motivation to make changes, (3) routinization, and (4) an accountable clinician.

CONCLUSIONS AND RELEVANCE

Assigning a designated clinician to execute a stepwise, routine care process following the checklist provided is a recommended intervention to overcome barriers. The intended impact is behavior change that reduces inappropriate prescribing.

Impact of pharmacist-conducted anticoagulation patient education and telephone follow-up on transitions of care: a randomized controlled trial

Background

There is limited published data in Lebanon evaluating the impact of supplemental education for anticoagulants use, especially DOACs, on clinical outcomes such as bleeding. The study aims to assess the impact of pharmacist-conducted anticoagulation education and follow-up on bleeding and readmission rates.

Methods

This study was a randomized, non-blinded interventional study conducted between August 2017 and July 2019 in a tertiary care teaching Lebanese hospital. Participants were inpatients ≥18 years discharged on an oral anticoagulant for treatment. Block randomization was used. The control group received the standard nursing counseling while the intervention group additionally received pharmacy counseling. Phone call follow-ups were done on day 3 and 30 post-discharge. Primary outcomes included readmission rates and any bleeding event at day 3 and 30 post-discharge. Secondary outcomes included documented elements of education in the medical records and reported mortality upon day 30 post-discharge.

Results

Two hundred patients were recruited in the study (100 patients in each study arm) with a mean age of 73.9 years. In the pharmacist-counseled group, more patients contacted their physician within 3 days (14% versus 4%; p = 0.010), received explicit elements of education (p < 0.001) and documentation in the chart was better (p < 0.05). In the standard of care group, patients were more aware of their next physician appointment date (52% versus 31%, p < 0.001). No difference in bleeding rates at day 3 and 30 post-discharge was observed between the groups.

Conclusions

Although pharmacist-conducted anticoagulation education did not appear to reduce bleeding or readmission rates at day 30, pharmacist education significantly increased patient communication with their providers in the early days post-discharge.

Trial registration

Lebanon Clinical Trial Registry LBCTR2020033424. Retrospectively registered. Date of registration: 06/03/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06156-2.

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.