Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial

Abstract

Background: Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.

Objective: The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.

Design: Randomized, controlled trial with concealed allocation and blinded outcome assessors

Setting: Two tertiary care academic medical centers

Participants: Adults hospitalized with a diagnosis of ACS and/or ADHF.

Intervention: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge

Main measures: The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported.

Key results: A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition.

Conclusion: A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

Trial registration: ClinicalTrials.gov NCT00632021.

Keywords: Acute coronary syndrome; Health literacy; Heart failure; Pharmacist; Readmissions.

Conflict of interest statement

Funders

This study was funded by grants R01 HL989755 (SK), K23 HL077597 (SK), and K08 HL072806 (JS) 2K24 HL077506 (VV) from the National Heart, Lung, and Blood Institute. Dr. Bell is supported by K12HD043483-11 from NIH/NICHD and by the Eisenstein Women’s Heart Fund.

Prior Presentations

Health Literacy Annual Research Conference, Nov 2014 (poster)

Society of General Internal Medicine Annual Conference, Apr 2015

Conflict of Interest

Dr. Kripalani is a consultant to and holds equity in Bioscape Digital/PictureRx, which makes materials for patient engagement and education. The company’s products and services were not used in this study. All other authors declare no potential conflicts of interest

Figures

Fig. 1

Study flow diagram

Fig. 2

Cumulative incidence curve of time to first health care utilization event for intervention and control groups over 30 days following discharge

Fig. 3

Adjusted treatment effect of intervention on health care utilization by pre-specified sub-group analysis: (a) All events (hospital admission and/or ER visit), (b) Hospital admission, (c) ER visits. Values less than 1.0 indicate that the mean outcomes in the treatment group are smaller than in the control group.