The impact of community pharmacist involvement on transitions of care: A systematic review and meta-analysis

ObjectivesTo evaluate the impact of community pharmacist involvement on transitions of care, specifically on 30-day hospital readmissions.Data SourcesWe searched the following databases from inception to August 2018: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, ProQuest Health and Medical Collection, ProQuest Nursing and Allied Health Database, and Web of Science. We also searched clinical trials registries and personal files to identify additional studies.Study SelectionStudies were eligible if the intervention included community pharmacists and patients were being discharged from the hospital to home. We included reports of randomized controlled trials, nonrandomized controlled trials, controlled before-and-after studies, and interrupted time series published in English.Data ExtractionWe extracted intervention characteristics from each study and 30-day readmissions when present.ResultsFrom 744 abstracts that met our inclusion criteria, we included 39 articles describing 36 unique studies, 10 which contributed to the primary outcome of 30-day readmissions. Overall, community pharmacist involvement in transitions of care was associated with a non–statistically significant 28% reduction in 30-day readmissions (relative risk [RR], 0.72; 95% CI 0.50-1.02; I² = 82%). When using per protocol data, community pharmacist involvement in transitions of care was associated with a statistically significant 40% reduction in 30-day readmissions (RR, 0.60; 95% CI 0.41-0.88; I² = 77%). Studies with more active involvement of community pharmacists had a greater effect on 30-day readmissions (RR, 0.55; 95% CI 0.32-0.95; I² = 88%) than those with less active involvement did (RR, 1.02; 95% CI 0.80-1.31; I² = 0%).ConclusionOur review shows that community pharmacists can have a beneficial effect on patients’ transitions of care; however, the body of evidence is limited by the heterogeneity and imprecision. Future studies should test interventions in which community pharmacists play an integral part and ensure that interventions are completed with fidelity.     

Effects of pharmacist interventions on pain intensity: Systematic review and meta-analysis of randomized controlled trials

BackgroundPharmacists can play an important role in pain management.Objective(s)This review aims to summarize the effects of any type of pharmacist intervention, whether led by a pharmacist or in a supportive role, on pain intensity over time in individuals with pain of any etiology.MethodsThree electronic databases (MEDLINE, Embase, and Cochrane Central Register of Controlled Trials) were searched from inception to the end of May 2021 to identify randomized controlled trials (RCTs) that reported the effect of pharmacist interventions on pain intensity. Two reviewers independently extracted data and evaluated study quality. The analyses used a random-effects models and the Grading of Recommendations, Assessment, Development and Evaluation to rate the certainty of the evidence. The primary outcome was reduction in pain intensity and presented as standardized mean differences (SMD).ResultsTwelve RCTs including 1710 participants were included. Pooled estimate of 12 studies demonstrated a statistically significant reduction in pain intensity compared with control (SMD ?0.22 [95% CI ?0.31 to ?0.12], I² = 0%, low certainty). The intervention was more effective when a pharmacist delivered a combination of services comprising educational interventions, medication review, and pharmaceutical care services (SMD ?0.24 [95% CI ?0.35 to ?0.13], I² = 0%, moderate certainty). For educational interventions alone, no statistically significant difference was observed (SMD ?0.15 [95% CI ?0.45 to 0.15], I² = 47.6%, low certainty). Pharmacist intervention was also effective in reducing pain intensity for patients with cancer-related pain (SMD ?0.76 [95% CI ?1.17 to ?0.36], I² = 0%, moderate certainty).ConclusionThere is some promising evidence to suggest that multicomponent pharmacist interventions including medication review or any other pharmaceutical care services, rather than merely educational interventions, are beneficial in reducing pain intensity, particularly in patients with chronic pain. High-quality RCTs are required to confirm the clinical significance of this findings before advocating for its widespread implication in clinical practice.     

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

AimsAdverse 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.MethodsWe 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.ResultsWe 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.ConclusionsWide 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.     

Can the LACE index help identify uninsured patients at risk of loss to follow-up during a pharmacist-led transitions of care program?

BackgroundUninsured patients are susceptible to being lost to follow-up (LTFU). In addition to being uninsured, follow-up is especially critical among this population during transitions of care when patients are discharged from the hospital setting back to home because follow-up care after discharge has been proven to prevent readmissions. The LACE tool has historically been used to predict readmissions, but the LACE tool has not been used to evaluate patients’ risk of LTFU.ObjectiveTo understand the potential translation of the LACE tool for use in uninsured patients’ follow-up care, we assessed the association between LACE index scores and patients’ risk of LTFU during a pharmacist-led transitions of care program for uninsured patients.MethodsData were extracted from a randomized controlled trial implementing a pharmacist-led transitions of care program at an indigent care clinic. The study population included uninsured adult patients (>18 years old) who spoke English and attended a clinical visit with a pharmacist within 16 days after discharge from a community hospital. Analyses sought to determine factors associated with the patients' LTFU status.ResultsAmong 88 enrolled participants, 29 participants (32.95%) were LTFU. Thirty-two patients (36.4%) had a high LACE index score at baseline, indicating an increased risk of 30-day readmission. Of the remaining 56 patients (63.6%) with low-to-moderate LACE index scores, 54 (61.4%) had a moderate LACE index score, and only 2 (2.3%) had a low LACE index score. Uninsured patients with high LACE index scores had 70% lower odds of being LTFU than uninsured patients with low-to-moderate LACE index scores (exact odds ratio 0.297 [95% CI 0.081–0.947]).ConclusionThe LACE index score was inversely related to the risk of LTFU during a pharmacist-led transitions of care program. Pharmacists may use the LACE tool to identify patients at high risk of LTFU.     

Association of pharmacist counseling with adherence, 30-day readmission,and mortality: A systematic review and meta-analysis of randomized trials

Objective(s)To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.MethodsThe initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.ResultsThe participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.ConclusionThe evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.     

Evaluating provider acceptance of pharmacist interventions in the Discharge Companion Program and its association with readmission reduction

ObjectiveTo evaluate provider acceptance of pharmacist interventions within the Discharge Companion Program (DCP) and its association with hospital readmissions.MethodsThis retrospective record review included patients referred to the DCP between January and October 2018. DCP pharmacists’ interventions were assessed for provider acceptance on follow-up consultation or readmission. A chi-square test assessed the association between provider acceptance, communication modality, and technology used. A logistic regression model assessed the association between readmission risk and variables of interest. An a priori alpha level of 0.05 was used.ResultsOf the 197 patients referred to the DCP, 102 met inclusion criteria. DCP pharmacists made a total of 271 interventions; 185 (68.7%) required provider action. The most common intervention type was medication addition or discontinuation (n = 74, 40%); the communication mode was between DCP nurses and primary care provider offices or skilled nursing facilities (n = 56, 54.9%); and the preferred technology was the telephone (n = 58, 56.9%). Provider acceptance rate was 30.8% (n = 57) of actionable interventions, although it was not significantly associated with 30-day readmission reductions (P = 0.833) and did not differ significantly when interventions were communicated to other health care professionals (P = 0.53). The specific intervention communication mode (i.e., telephone, facsimile, or both) of pharmacist interventions did not significantly affect provider acceptance (P = 0.133). The overall readmission rate was 22.5% (n = 23), and the only significant predictor of 30-day readmission was the number of comorbidities (odds ratio 1.28 [95% CI 1.03–1.58], P = 0.024).ConclusionProvider acceptance of pharmacists’ interventions did not significantly affect 30-day readmission rates, regardless of communication mode (telephone or facsimile) or technology used. However, the DCP successfully identified numerous medication-related problems. Further study is warranted regarding provider acceptance of pharmacist recommendations on 30-day readmission reduction.     

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BackgroundPharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.ObjectiveThis study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.MethodsWe identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence.The review protocol was published on PROSPERO (CRD42020167994).ResultsTwenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.ConclusionThe findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.     

Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review

BackgroundMany older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications.ObjectivesWe sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults.MethodsWe conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded.ResultsWe screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement.ConclusionsWe identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.     

Efficacy and safety of dendritic cell vaccines for patients with glioblastoma: A meta-analysis of randomized controlled trials

BackgroundDendritic cell (DC)-based vaccination has been suggested to be promising for glioblastoma. However, the evidence in randomized controlled trials (RCTs) is inconsistent. We aimed to systematically evaluate the efficacy and safety of DC vaccine for glioblastoma via a meta-analysis of RCTs.MethodsRelated randomized controlled trials (RCTs) were identified via a search of PubMed, Embase, and Cochrane’s Library. We used a random-effect model to pool the results.ResultsSix phase II RCTs with 347 patients with newly diagnosed or recurrent glioblastoma that underwent conventional treatments were included. Compared to the control group with placebo or blank treatment, DC vaccine was associated with significantly improved overall survival in patients with glioblastoma (hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.49 to 0.97, p = 0.03) with moderate heterogeneity (p for Cochrane’s Q test = 0.07, I² = 51%). A trend of improved progression-free survival was also detected in patients allocated to the DC vaccine group compared to those in the control group (HR: 0.76, 95% CI: 0.56 to 1.02, p = 0.07), with no significant heterogeneity (I² = 0%). Moreover, the incidence of adverse events was not significant between patients treated with DC vaccine or control (odds ratio = 1.52, 95% CI: 0.88 to 2.62, p = 0.14; I² = 0%).ConclusionsEvidence based on phase II RCTs suggests that DC vaccine may improve the survival of patients with glioblastoma. Large-scale RCTs are needed to validate the findings and determine the optimal regimens for DC vaccine.     

Quality of care indicators in the MAnageMent of BlOOdstream infections caused by Enterobacteriaceae (MAMBOO-E study): state of the art and research agenda

ObjectivesThe impact on outcome of five interventions was reviewed in order to investigate the state of the art for management of Enterobacteriaceae bloodstream infection (E-BSI).MethodsWe searched for randomised controlled trials (RCTs) and observational studies published from January 2008 to March 2019 in PubMed, EMBASE and Cochrane Library. Populations consisted of patients with E-BSI. Interventions were as follows: (i) performance of imaging to assess BSI source and/or complications; (ii) follow-up blood cultures (FU-BCs); (iii) use of loading dose followed by extended/continuous infusion (E/CI) of β-lactams; (iv) duration of treatment (short- versus long-term); and (v) infectious diseases (ID) consultation. Patients without intervention were considered as controls. The main outcome was 30-day mortality. RoB 2.0 and ROBINS-I tools were used for bias assessment.ResultsNo study was eligible for interventions i, iii and v. For FU-BCs, one observational study including 901 patients with E-BSI was considered. Intervention consisted of repeating BCs within 2–7 days after index BCs. All-cause 30-day mortality was 14.2% (35/247) in the intervention group versus 14.7% (96/654) in the control group. For short treatment duration, two RCTs and six observational studies were included comprising 4473 patients with E-BSI. All-cause mortality was similar in the short and long treatment groups (OR = 1.10, 95% CI 0.83–1.44).ConclusionOf the assessed interventions, only short treatment duration in non-immunocompromised patients with E-BSI is supported by current data. Studies investigating the use of systematic imaging, FU-BCs, E/CI β-lactams and ID consultation in patients with E-BSI are needed.     

An inpatient multidisciplinary educational approach to reduce 30-day heart failure readmissions

BackgroundDespite dramatic improvements in the management of heart failure (HF), hospital readmissions due to HF exacerbation remain high. To improve quality of care, many hospitals have developed interventions to reduce HF readmission rates. The aim of this study was to evaluate the impact of an inpatient multidisciplinary educational approach utilizing pharmacist to reduce 30-day HF readmissions.MethodsRetrospective observational study conducted at a tertiary-hospital in Tucson-Arizona, USA. It included adult patients admitted with a documented diagnosis of HF and excluded patients discharged to hospice. Patents were divided into two groups: intervention and control group. Intervention components included: (1) pharmacy student counseling; (2) HF education provided jointly by a pharmacist and a nurse as a group class to patients and caregivers and/or one-on-one education with a nurse; and (3) follow-up phone calls 1–3 days post-discharge reinforcing HF education. The main outcome was the rate of hospital readmission within 30 days post HF discharge.ResultsA total of 221 patients were identified in the intervention and 183 in the control groups. Of the patients in the intervention group, 44.8% received pharmacy student counseling, 47.1% received HF education, 25.3% were contacted 1–3 days post-discharge; and 5% received all intervention components. The difference in the primary outcome was not statistically different, with 3.8% readmission rate in the control group compared to 4.5% in the intervention group (p = 0.73). It is worth to notice that none of the 11 patients who received all components of the interventions were readmitted. Univariate analysis demonstrated a significant association between pharmacy student counseling and 30-day HF readmissions (p = 0.03); however, no difference was observed after adjusting for all variables.ConclusionThe readmission rate in both groups was below national rate, and neither the intervention nor components were associated with a significant reduction in the primary outcome. Another study is needed to assess the rate of HF readmission in patients receiving all components of the multidisciplinary interventions.     

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BackgroundMinimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.ObjectiveWe assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.MethodsIn this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).ResultsAfter the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.ConclusionsThe implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.     

Pharmacist-led transitions of care for older adults at risk of drug-related problems: A feasibility study

BackgroundTransitions of care (TOC) is one of three key action areas identified in the World Health Organization (WHO)'s third Global Patient Safety Challenge, Medication Without Harm, released in 2017. Systematic reviews have shown that TOC interventions can improve health outcomes, although few studies have evaluated the role of the community pharmacist.ObjectiveTo evaluate the feasibility of a pharmacist-led TOC intervention for older adults at risk of drug-related problems.MethodsPragmatic feasibility study conducted in hospital and community pharmacies in a health region of Quebec, Canada. The interventions consisted of a pharmaceutical care plan developed by the hospital pharmacist and transferred at hospital discharge to the patients’ community pharmacist, who completed patient consultations in the week following discharge and monthly for six months thereafter. Feasibility evaluations included recruitment, retention, time required, types of interventions, and modified classes of medications, based on clinical data entered in an electronic health record accessible to clinicians in all settings.ResultsOf the 90 recruited patients, 76 were discharged with a pharmaceutical care plan. The mean age of these 76 subjects was 79.5 years, and 52.6% were female. The most frequent inclusion criteria were 15 or more medications (57.9%), two or more emergency department visits (past three months), or one or more hospitalization (past twelve months) (42.1%). The hospital pharmacist interventions took a mean time of 222 min. The community pharmacist interventions took a mean time of 52 min and 32 min for the first and subsequent visits, respectively. Therapeutic goals were documented for 60.5% of patients.ConclusionsThis study shows the feasibility of implementing a pharmacist-led TOC intervention in the Canadian context. Development of the TOC model in three health regions is currently being pursued along with the inclusion of primary care clinics who recently added pharmacists to their interdisciplinary teams.     

Improving 30-day readmissions: Student pharmacists’ role in transitions of care

BackgroundPharmacists have reduced 30-day hospital readmissions when involved with transitions of care (TOC). The impact of student pharmacists on readmissions is more limited.ObjectiveThe goal of this study was to describe student pharmacists’ role in a new TOC service and determine their impact on 30-day hospital readmissions.MethodsWe designed a 3-step TOC service spanning inpatient, discharge, and follow-up led by student pharmacists and involving both inpatient and ambulatory care pharmacy preceptors. The student pharmacists followed inpatient care and discussed medications with the patients. Discharge orders were reviewed, and the student pharmacists provided discharge education. On discharge, the student pharmacists wrote a handoff to the ambulatory care pharmacist describing inpatient care, discharge medication list, follow-up, and unresolved medication issues. Finally, the student pharmacists participated in the outpatient follow-up at the primary care provider office with the provider and an ambulatory care pharmacist. Readmissions were compared between this process and a standard-of-care historical control group using chi-square analysis.ResultsThe student pharmacist–led TOC service reduced 30-day hospital readmissions by 13.1% (P = 0.018) compared with standard of care.ConclusionStudent pharmacists are effective members of the health care team in reducing readmissions. Student pharmacists are cost-effective, appropriately trained, and well positioned to assist with these services.     

Deprescribing potentially inappropriate medications in memory clinic patients (DePIMM): A feasibility study

BackgroundMedication-related problems and inappropriate medication use are prevalent among people attending memory clinics. There have been no deprescribing intervention studies in this setting.ObjectiveTo evaluate the feasibility of a pharmacist-led interdisciplinary deprescribing intervention study in a memory clinic.MethodsA pre-post-intervention study conducted at an outpatient memory clinic of an Australian tertiary care public hospital. Participants were English-speaking, community-dwelling patients identified as being at risk of a medication-related problem, or their carers. Participants received a medication review in their home from a consultant pharmacist who collaborated with the patient/carer, memory clinic, general practitioner and community pharmacist to develop a plan for optimising medication use. The primary outcome was feasibility, based on i) proportion of memory clinic patients eligible for the study, ii) proportion of eligible patients who consented, and iii) proportion of pharmacist-identified inappropriate/unnecessary medications that were deprescribed (reduced or ceased) at six months.ResultsOne-third of memory clinic patient/carers were eligible (n = 82/238), 61% (n = 50/82) consented to participate. The median (IQR) age of participants who received the intervention (n = 46) was 80.5 (71.5–85.0) years and median (IQR) number of medications was 11 (8.0–13.3). Pharmacists recommended deprescribing 124 medications, and 53 (42.7%) had been ceased or dose-reduced at six months.ConclusionIt was feasible to recruit study participants and deliver a pharmacist-led interdisciplinary deprescribing intervention in this memory clinic setting. A larger, multi-centre study with longer follow-up is needed to confirm effectiveness and clinical outcomes.     

Assessing the impact of adding pharmacist management services to an existing discharge planning program on 30-day readmissions

BackgroundAlthough hospital readmission rates are declining nationally, avoidable readmissions remain a public health concern. Effective readmission interventions are multifaceted and include discharge planning and transition-of-care coordination. Clinical pharmacists are effective contributors to these processes, bringing expertise to discharge counseling, medication reconciliation, medication adherence, and postdischarge follow-up counseling.ObjectiveWe evaluated the impact of adding health plan clinical pharmacy management services to an existing discharge program on all-cause readmissions and postdischarge primary physician visits.MethodPharmacy management services by health plan clinical pharmacists of a large regional integrated delivery system were added to an existing optimal discharge planning (ODP) program. Criteria for eligibility for these pharmacists’ services included patients who prescribed a new maintenance medication after discharge, received a therapeutic substitution, had a previous discharge within 30 days, or were taking a high-risk medication. A retrospective, observational analysis of a subgroup of patients, who received the pharmacy management services as part of ODP, was performed using a difference-in-difference model, by comparing propensity-matched discharges from February 22, 2016, to January 31, 2017 (preprogram implementation) with discharges from February 22, 2017, to January 31, 2018 (implementation period), to estimate changes in 30-day readmission rates and postdischarge primary physician visits.ResultsA total of 111 of the propensity matched received the pharmacy management services; of these, 73% (ODP) versus 64% (non-ODP) were ≥58 years, 60% were females, and 62% (ODP) versus 52% (non-ODP) were Medicare beneficiaries. There was a 16.7% (P = 0.022) statistically significant reduction in combined inpatient and observation 30-day readmissions and a 19.7% increase in 5-day postdischarge follow-up physician visits (P = 0.037) for the subgroup who also received the pharmacy management services.ConclusionAddition of pharmacist management services to an existing hospital discharge program for select at-risk patients was associated with reduced inpatient and observation 30-day readmissions.     

Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial

ObjectivesPharmacists’ involvement in the transitions of care has shown the potential to decrease readmissions and increase access to care in many populations; however, the uninsured patient populations have not been studied. The evidence for the feasibility of implementing transitions of care services in indigent care clinics with limited resources also remains limited. The objectives were to implement a pharmacist-led transitions of care program in an indigent care clinic, to demonstrate the feasibility of its implementation, and to evaluate its impact on readmissions and emergency department (ED) visit rates among an uninsured population.MethodsThe study was a single-blind, parallel, randomized controlled trial implemented in an indigent care clinic in the Southeast region of the United States from October 2018 to July 2019. Eligible patients were those older than 18 years, uninsured, English-speaking, diagnosed with any condition, and recently discharged from a local community hospital within the past 16 days. The primary outcome was the hospital readmission rate at 30 days after discharge. The secondary outcomes included 60- and 90-day readmission rates in addition to 30-, 60-, and 90-day ED visit rates.ResultsA total of 88 participants were recruited. The intervention was successfully implemented in the clinic, but patient-level barriers to follow-ups included transportation, accessibility, financial burdens, inconsistent telephone communication, and a lack of knowledge about the importance of follow-ups. At 30 days postdischarge, 13.64% of the patients in the usual care group experienced readmissions compared with 9.30% of the patients in the intervention group. The relative change in the 30-day readmission rates between the usual care and the intervention groups was 1.7 (rate ratio [RR] 1.69 [95% CI 0.47–6.08]). The RRs were insignificant for the 30-, 60-, and 90-day readmission and ED visit rates.ConclusionThis study demonstrated the feasibility of implementing transitions of care services in a clinic with limited resources by pharmacists. The intervention showed promising results by reducing readmission rates.     

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

BackgroundPrescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers.ObjectiveTo evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type.MethodProspective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests.ResultsA total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, ?30.6 to ?16.8), t(75) = ?6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group.ConclusionPharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.     

Pharmacist-led medication reviews in pre-dialysis and dialysis patients

BackgroundPre-dialysis and dialysis patients are at risk for drug related problems (DRPs) due to a high incidence of comorbidities. Pharmacist-led medication reviews might reduce the number of DRPs.ObjectivesThe aim of this study was to evaluate pharmacist-led medication reviews in pre-dialysis and dialysis patients by determining the number and type of DRPs, nephrologist acceptance of pharmacist interventions and time investment.MethodsFrom September 2017 until December 2018, pharmacist-led medication reviews were performed on pre-dialysis and dialysis patients. DRPs (medication discrepancies, prescribing issues related to drug and dose selection, drug use problems) were identified using the pharmacists’ expert opinion and the STOPP/START criteria. Number and type of accepted pharmacist interventions, sustainability of interventions after at least 1 month and time investment were determined. Practical barriers in the process were appraised.ResultsOne-hundred twenty five patients were reviewed: 37 pre-dialysis and 88 dialysis patients. In 100 (80%) patients 277 medication discrepancies were identified of which 224 (81%) were accepted by the nephrologist. Pharmacists suggested 422 interventions concerning drug or dose selection for 115 patients; 106 interventions were accepted by the nephrologist, which resulted in 60 patients having medication changed. Ninety percent of those changes remained implemented on follow-up after at least 1 month. In 46 (37%) patients, the clinical pharmacist detected DRPs concerning the drug use process and performed patient counseling. The average time investment was 85 min per patient for the clinical pharmacist and 15 min for the nephrologist. Besides time investment, unclear responsibility for medication management due to multiple prescribers was an important barrier in the process and the main reason for nephrologists to reject pharmacist interventions.ConclusionPharmacist-led medication reviews in pre-dialysis and dialysis patients led to medication changes in half of the patients. However, efficiency should be improved before adopting pharmacist-led medication reviews into clinical practice.