Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial

Maria Gustafsson, Maria Sjölander, Bettina Pfister, Jeanette Jonsson, Jörn Schneede, Hugo Lövheim, Maria Gustafsson, Maria Sjölander, Bettina Pfister, Jeanette Jonsson, Jörn Schneede, Hugo Lövheim

Abstract

Purpose: To assess whether comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team reduce drug-related hospital readmission rates among people with dementia or cognitive impairment.

Methods: This randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. Patients aged ≥65 years with dementia or cognitive impairment admitted to three wards at two hospitals located in Northern Sweden were included.

Results: Of the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization. The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis. During the 180 days of follow-up, 18.9% (40/212) of patients in the intervention group and 23.0% (50/217) of those in the control group were readmitted for drug-related reasons (HR = 0.80, 95% CI = 0.53-1.21, p = 0.28, univariable Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder and an interaction term, multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR = 0.49, 95% CI = 0.27-0.90, p = 0.02). A post-hoc analysis showed a significantly reduced risk of 30-day readmissions due to drug-related problems in the total sample (without adjustment for heart failure).

Conclusion: Participation of clinical pharmacists in healthcare team conducting comprehensive medication reviews did not significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment; however, post-hoc and subgroup analyses indicated significant effects favoring the intervention. More research is needed.

Trial registration: Clinical trials NCT01504672.

Keywords: Clinical pharmacists; Dementia; Drug-related readmissions; Medication reviews; Old people.

Conflict of interest statement

Description of authors’roles

All authors were involved in the study concept and design. Maria Gustafsson, Bettina Pfister, Jeanette Jonsson, and Hugo Lövheim were involved in the acquisition, analysis, and interpretation of data. Maria Gustafsson and Hugo Lövheim did the statistical analysis. All authors participated in the critical revision of the manuscript, contributed comments, and approved the final version.

Conflict of interest

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Patient flow chart throughout the study
Fig. 2
Fig. 2
Kaplan-Meier plots for drug-related readmissions within 180 days in the total sample. HR and CI according to univariable Cox regression analysis and p value from log rank test
Fig. 3
Fig. 3
Kaplan-Meier plots for drug-related readmissions within 180 days in the subgroup of people without heart failure. HR and CI according to univariable Cox regression analysis and p value from log rank test
Fig. 4
Fig. 4
Kaplan-Meier plots for drug-related readmissions within 30 days in the total sample. HR and CI according to univariable Cox regression analysis and p value from log rank test
Fig. 5
Fig. 5
Kaplan-Meier plots for drug-related readmissions within 30 days in the subgroup of people without heart failure. HR and CI according to univariable Cox regression analysis and p value from log rank test

References

    1. Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150:841–845. doi: 10.1001/archinte.1990.00390160093019.
    1. Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Intern Med J. 2001;31:199–205. doi: 10.1046/j.1445-5994.2001.00044.x.
    1. Gustafsson M, Sjölander M, Pfister B, Jonsson J, Schneede J, Lövheim H. Drug-related hospital admissions among old people with dementia. Eur J Clin Pharmacol. 2016;72:1143–1153. doi: 10.1007/s00228-016-2084-3.
    1. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, Kettis-Lindblad A, Melhus H, Morlin C. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169:894–900. doi: 10.1001/archinternmed.2009.71.
    1. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205. doi: 10.1001/jama.279.15.1200.
    1. Hajjar ER, Hanlon JT, Artz MB, Lindblad CI, Pieper CF, Sloane RJ, Ruby CM, Schmader KE. Adverse drug reaction risk factors in older outpatients. Am J Geriatr Pharmacother. 2003;1:82–89. doi: 10.1016/S1543-5946(03)90004-3.
    1. Cancelli I, Beltrame M, Gigli G, Valente M. Drugs with anticholinergic properties: cognitive and neuropsychiatric side-effects in elderly patients. Official Journal of the Italian Neurological Society. 2009;30:87–92.
    1. Selbaek G, Kirkevold O, Engedal K. The course of psychiatric and behavioral symptoms and the use of psychotropic medication in patients with dementia in Norwegian nursing homes—a 12-month follow-up study. Am J Geriatr Psychiatry. 2008;16:528–536. doi: 10.1097/JGP.0b013e318167ae76.
    1. Gustafsson M, Karlsson S, Lovheim H. Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units. BMC Pharmacol Toxicol. 2013;14:10. doi: 10.1186/2050-6511-14-10.
    1. Olsson J, Bergman A, Carlsten A, Oke T, Bernsten C, Schmidt IK, Fastbom J. Quality of drug prescribing in elderly people in nursing homes and special care units for dementia: a cross-sectional computerized pharmacy register analysis. Clin Drug Investig. 2010;30:289–300. doi: 10.2165/11534320-000000000-00000.
    1. Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165:68–74. doi: 10.1001/archinte.165.1.68.
    1. Winterstein AG, Sauer BC, Hepler CD, Poole C. Preventable drug-related hospital admissions. Ann Pharmacother. 2002;36:1238–1248. doi: 10.1345/aph.1A225.
    1. Blix H, Viktil K, Moger T, Reikvam Å. Characteristics of drug-related problems discussed by hospital pharmacists in multidisciplinary teams. Pharm World Sci. 2006;28:152–158. doi: 10.1007/s11096-006-9020-z.
    1. Altowaijri A, Phillips CJ, Fitzsimmons D. A systematic review of the clinical and economic effectiveness of clinical pharmacist intervention in secondary prevention of cardiovascular disease. J Manag Care Pharm. 2013;19:408–416.
    1. Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, Bero L (2010) Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev (7):Cd000336
    1. Graabaek T, Kjeldsen LJ. Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review. Basic Clin Pharmacol Toxicol. 2013;112:359–373. doi: 10.1111/bcpt.12062.
    1. Tan EC, Stewart K, Elliott RA, George J. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm. 2014;10:608–622. doi: 10.1016/j.sapharm.2013.08.006.
    1. Christensen M, Lundh A (2013) Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev 2: Cd008986
    1. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48:923–933. doi: 10.1097/MLR.0b013e3181e57962.
    1. Cipolle R, Strand L, Morely P. Pharmaceutical Care Practice. New York: The McGraw-Hill Companies inc; 1998.
    1. WHO. World health organization. Criteria for causality assessment. Available: Accessed 15 January 2015.
    1. Jha AK. Seeking rational approaches to fixing hospital readmissions. JAMA. 2015;314:1681. doi: 10.1001/jama.2015.13254.
    1. Scullin C, Scott MG, Hogg A, McElnay JC. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13:781–788. doi: 10.1111/j.1365-2753.2006.00753.x.
    1. Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med. 2008;168:687–694. doi: 10.1001/archinte.168.7.687.
    1. van der Wal MHL, Jaarsma T, Moser DK, Veeger NJGM, van Gilst WH, van Veldhuisen DJ. Compliance in heart failure patients: the importance of knowledge and beliefs. Eur Heart J. 2006;27:434–440.
    1. Fischer C, Lingsma HF, Marang-van de Mheen PJ, Kringos DS, Klazinga NS, Steyerberg EW. Is the readmission rate a valid quality indicator? A review of the evidence. PLoS One. 2014;9 doi: 10.1371/journal.pone.0112282.
    1. Barnett ML, Hsu J, McWilliams JM. Patient characteristics and differences in hospital readmission rates. JAMA Intern Med. 2015;175:1803. doi: 10.1001/jamainternmed.2015.4660.
    1. Ouslander JG, Lamb G, Perloe M, Givens JH, Kluge L, Rutland T, Atherly A, Saliba D. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58:627–635. doi: 10.1111/j.1532-5415.2010.02768.x.
    1. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370:173–184. doi: 10.1016/S0140-6736(07)61091-5.
    1. Lisby M, Bonnerup DK, Brock B, Gregersen PA, Jensen J, Larsen ML, Rungby J, Sonne J, Mainz J, Nielsen LP (2015) Medication Review and Patient Outcomes in an Orthopedic Department: A Randomized Controlled Study. J Patient Saf

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