Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older

Emma Bajeux, Lilian Alix, Lucie Cornée, Camille Barbazan, Marion Mercerolle, Jennifer Howlett, Vincent Cruveilhier, Charlotte Liné-Iehl, Bérangère Cador, Patrick Jego, Vincent Gicquel, François-Xavier Schweyer, Vanessa Marie, Stéphanie Hamonic, Jean-Michel Josselin, Dominique Somme, Benoit Hue, Emma Bajeux, Lilian Alix, Lucie Cornée, Camille Barbazan, Marion Mercerolle, Jennifer Howlett, Vincent Cruveilhier, Charlotte Liné-Iehl, Bérangère Cador, Patrick Jego, Vincent Gicquel, François-Xavier Schweyer, Vanessa Marie, Stéphanie Hamonic, Jean-Michel Josselin, Dominique Somme, Benoit Hue

Abstract

Background: Older patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients' experience of discharge and their knowledge of their medication.

Methods: An observational multicenter prospective study was conducted in 5 hospitals in Brittany, France.

Results: Patients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036).

Conclusions: This study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients' experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients' ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness.

Trial registration: NCT04018781 July 15, 2019.

Keywords: Adverse Drug Event; Discharge; Experience; Medication Reconciliation; Older people.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
a Description of the steps in the Medication Reconciliation procedure on admission. b Description of the steps in the Medication Reconciliation procedure on discharge
Fig. 2
Fig. 2
Flowchart. MRa Medication Reconciliation on admission, MRd Medication Reconciliation on discharge

References

    1. Beijer HJM, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci. 2002;24(2):46–54. doi: 10.1023/A:1015570104121.
    1. El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt PMLA, Janssen MJA, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc. 2018;66(3):602–608. doi: 10.1111/jgs.15244.
    1. Schwab C, Korb-Savoldelli V, Escudie JB, Fernandez C, Durieux P, Saint-Jean O, et al. Iatrogenic risk factors associated with hospital readmission of elderly patients: A matched case-control study using a clinical data warehouse. J Clin Pharm Ther. 2018;43(3):393–400. doi: 10.1111/jcpt.12670.
    1. Roughead EE, Semple SJ, Rosenfeld E. The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia. Int J Evid Based Healthc. 2016;14(3):113–122. doi: 10.1097/XEB.0000000000000075.
    1. Rottenkolber D, Hasford J, Stausberg J. Costs of adverse drug events in German hospitals–a microcosting study. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2012;15(6):868–875. doi: 10.1016/j.jval.2012.05.007.
    1. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ Can Med Assoc J J Assoc Medicale Can. 2004;170(3):345–349.
    1. Davies EC, Green CF, Mottram DR, Rowe PH, Pirmohamed M. Emergency re-admissions to hospital due to adverse drug reactions within 1 year of the index admission. Br J Clin Pharmacol. 2010;70(5):749–755. doi: 10.1111/j.1365-2125.2010.03751.x.
    1. Ruiz B, García M, Aguirre U, Aguirre C. Factors predicting hospital readmissions related to adverse drug reactions. Eur J Clin Pharmacol. 2008;64(7):715–722. doi: 10.1007/s00228-008-0473-y.
    1. Davies EA, O’Mahony MS. Adverse drug reactions in special populations - the elderly. Br J Clin Pharmacol. 2015;80(4):796–807. doi: 10.1111/bcp.12596.
    1. Koronkowski MJ, Semla TP, Schmader KE, Hanlon JT. Recent Literature Update on Medication Risk in Older Adults, 2015–2016. J Am Geriatr Soc. 2017;65(7):1401–1405. doi: 10.1111/jgs.14887.
    1. Harris CM, Sridharan A, Landis R, Howell E, Wright S. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):150–153. doi: 10.1097/PTS.0b013e318286f87d.
    1. Haute Autorité de Santé. Mettre en œuvre la conciliation des traitements médicamenteux en établissement de santé. Sécuriser la prise en charge médicamenteuse du patient lors de son parcours de soins. Guide version février 2018. [Internet]. 2018 Feb. Available from:
    1. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565–571. doi: 10.1001/archinte.166.5.565.
    1. Chiewchantanakit D, Meakchai A, Pituchaturont N, Dilokthornsakul P, Dhippayom T. The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Res Soc Adm Pharm RSAP. 2020;16(7):886–894. doi: 10.1016/j.sapharm.2019.10.004.
    1. Mekonnen AB, McLachlan AJ, E Brien J anne. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open. 2016;6(2):e010003. doi: 10.1136/bmjopen-2015-010003.
    1. Daliri S, Boujarfi S, El Mokaddam A, Scholte Op Reimer WJM, Ter Riet G, den Haan C, et al. Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis. BMJ Qual Saf. 2020;30(2):146–56. doi: 10.1136/bmjqs-2020-010927.
    1. Renaudin P, Boyer L, Esteve MA, Bertault-Peres P, Auquier P, Honore S. Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis: Pharmacist-led medication reviews and hospital readmissions. Br J Clin Pharmacol. 2016;82(6):1660–1673. doi: 10.1111/bcp.13085.
    1. Cheema E, Alhomoud FK, Kinsara ASAD, Alsiddik J, Barnawi MH, Al-Muwallad MA, et al. The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2018;13(3):e0193510. doi: 10.1371/journal.pone.0193510.
    1. Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T. Impact of medication reconciliation for improving transitions of care. Cochrane Database Syst Rev. 2018;8:CD010791.
    1. Kwan JL, Lo L, Sampson M, Shojania KG. Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158(5_Part_2):397. doi: 10.7326/0003-4819-158-5-201303051-00006.
    1. Guisado-Gil AB, Mejías-Trueba M, Alfaro-Lara ER, Sánchez-Hidalgo M, Ramírez-Duque N, Santos-Rubio MD. Impact of medication reconciliation on health outcomes: An overview of systematic reviews. Res Soc Adm Pharm RSAP. 2020;16(8):995–1002. doi: 10.1016/j.sapharm.2019.10.011.
    1. Anderson LJ, Schnipper JL, Nuckols TK, Shane R, Le MM, Robbins K, et al. Effect of medication reconciliation interventions on outcomes: A systematic overview of systematic reviews. Am J Health Syst Pharm. 2019;76(24):2028–2040. doi: 10.1093/ajhp/zxz236.
    1. Dawoud DM, Smyth M, Ashe J, Strong T, Wonderling D, Hill J, et al. Effectiveness and cost effectiveness of pharmacist input at the ward level: a systematic review and meta-analysis. Res Soc Adm Pharm. 2019;15(10):1212–1222. doi: 10.1016/j.sapharm.2018.10.006.
    1. Al-Hashar A, Al-Zakwani I, Eriksson T, Sarakbi A, Al-Zadjali B, Al Mubaihsi S, et al. Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use. Int J Clin Pharm. 2018;40(5):1154–1164. doi: 10.1007/s11096-018-0650-8.
    1. Chiarelli MT, Antoniazzi S, Cortesi L, Pasina L, Novella A, Venturini F, et al. Pharmacist-driven medication recognition/ reconciliation in older medical patients. Eur J Intern Med. 2021;83:39–44. doi: 10.1016/j.ejim.2020.07.011.
    1. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894–900. doi: 10.1001/archinternmed.2009.71.
    1. Bonnet-Zamponi D, d’Arailh L, Konrat C, Delpierre S, Lieberherr D, Lemaire A, et al. Drug-Related Readmissions to Medical Units of Older Adults Discharged from Acute Geriatric Units: Results of the Optimization of Medication in AGEd Multicenter Randomized Controlled Trial. J Am Geriatr Soc. 2013;61(1):113–121. doi: 10.1111/jgs.12037.
    1. Tomlinson J, Cheong VL, Fylan B, Silcock J, Smith H, Karban K, et al. Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity. Age Ageing. 2020;49(4):558–569. doi: 10.1093/ageing/afaa002.
    1. Eggink RN, Lenderink AW, Widdershoven JWMG, van den Bemt PMLA. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure. Pharm World Sci PWS. 2010;32(6):759–766. doi: 10.1007/s11096-010-9433-6.
    1. Ibrahim OHM. Impact of Clinical Pharmacist Intervention on Decreasing Incidence of Preventable Adverse Drug Events after Hospital Discharge. Adv Pharmacoepidemiol Drug Saf [Internet]. 2012 [cited 2021 Jan 7];01(02). Available from:
    1. Singh D, Fahim G, Ghin HL, Mathis S. Effects of Pharmacist-Conducted Medication Reconciliation at Discharge on 30-Day Readmission Rates of Patients With Chronic Obstructive Pulmonary Disease. J Pharm Pract. 2021;34(3):354–359. doi: 10.1177/0897190019867241.
    1. Nickerson D, Smith N, Hunter P. New developments in a strongly coupled cardiac electromechanical model. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2005;7(Suppl 2):118–127.
    1. Ford I, Norrie J. Pragmatic Trials. Drazen JM, Harrington DP, McMurray JJV, Ware JH, Woodcock J, editors. N Engl J Med. 2016 Aug 4;375(5):454–63.
    1. Barnish MS, Turner S. The value of pragmatic and observational studies in health care and public health. Pragmatic Obs Res. 2017;8:49–55. doi: 10.2147/POR.S137701.
    1. Ware JH, Hamel MB. Pragmatic Trials — Guides to Better Patient Care? N Engl J Med. 2011;364(18):1685–1687. doi: 10.1056/NEJMp1103502.
    1. Décret n° 2016–524 du 27 avril 2016 relatif aux groupements hospitaliers de territoire [Internet]. Available from:
    1. Alix L, Bajeux E, Hubert J, Cador B, Josselin JM, Tuffier S, et al. Medication reconciliation in hospital patients over the age of 65: How long does it take and how much does it cost? A time-motion study in an internal medicine ward. Eur J Intern Med. 2020;73:100–102. doi: 10.1016/j.ejim.2019.12.003.
    1. Expert Group on Safe Medication Practices. Creation of a better medication safety culture in Europe: Building up safe medication practices [Internet]. Conseil de l’Europe; 2006. Available from:
    1. VA Center for Medication Safety, VHA Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel. Adverse drug events, adverse drug reactions and medication errors frequently asked questions [Internet]. 2006 Nov. Available from:
    1. Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician’s guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140(10):795–801. doi: 10.7326/0003-4819-140-10-200405180-00009.
    1. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44(2):213–218. doi: 10.1093/ageing/afu145.
    1. Gusmano M, Rodwin V, Weisz D, Cottenet J, Quantin C. Comparison of rehospitalization rates in France and the United States. J Health Serv Res Policy. 2015;20(1):18–25. doi: 10.1177/1355819614551849.
    1. Urban R, Armitage G, Morgan J, Marshall K, Blenkinsopp A, Scally A. Custom and practice: A multi-center study of medicines reconciliation following admission in four acute hospitals in the UK. Res Soc Adm Pharm. 2014;10(2):355–368. doi: 10.1016/j.sapharm.2013.06.009.
    1. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–187. doi: 10.7326/0003-4819-150-3-200902030-00007.
    1. Fernandes BD, Almeida PHRF, Foppa AA, Sousa CT, Ayres LR, Chemello C. Pharmacist-led medication reconciliation at patient discharge: A scoping review. Res Soc Adm Pharm. 2020;16(5):605–613. doi: 10.1016/j.sapharm.2019.08.001.
    1. Lindquist LA, Go L, Fleisher J, Jain N, Baker D. Improvements in Cognition Following Hospital Discharge of Community Dwelling Seniors. J Gen Intern Med. 2011;26(7):765–770. doi: 10.1007/s11606-011-1681-1.
    1. Phatak A, Prusi R, Ward B, Hansen LO, Williams MV, Vetter E, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study) J Hosp Med. 2016;11(1):39–44. doi: 10.1002/jhm.2493.
    1. Flanagan P, Kainth S, Nissen L. Satisfaction survey for a medication management program: satisfaction guaranteed? Can J Hosp Pharm. 2013;66(6):355–360.
    1. Karapinar-Çarkıt F, Borgsteede SD, Janssen MJA, Mak M, Yildirim N, Siegert CEH, et al. The effect of a pharmaceutical transitional care program on rehospitalisations in internal medicine patients: an interrupted-time-series study. BMC Health Serv Res. 2019;19(1):717–729. doi: 10.1186/s12913-019-4617-9.
    1. Pellegrin KL, Krenk L, Oakes SJ, Ciarleglio A, Lynn J, McInnis T, et al. Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study. J Am Geriatr Soc. 2017;65(1):212–219. doi: 10.1111/jgs.14518.
    1. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11):1817–1825. doi: 10.1111/j.1532-5415.2004.52504.x.
    1. Vervloet M, van Dijk L, Rademakers JJDJM, Bouvy ML, De Smet PAGM, Philbert D, et al. Recognizing and Addressing Limited PHarmaceutical literacy: Development of the RALPH interview guide. Res Soc Adm Pharm RSAP. 2018;14(9):805–11. doi: 10.1016/j.sapharm.2018.04.031.
    1. Bajeux E, Corvol A, Somme D. Integrated Care for Older People in France in 2020: Findings, Challenges, and Prospects. Int J Integr Care. 2021;21(4):16. doi: 10.5334/ijic.5643.
    1. Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008;11(337):a2390. doi: 10.1136/bmj.a2390.
    1. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. BMJ. 2015;8(350):h2147. doi: 10.1136/bmj.h2147.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere