Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions?
BACKGROUND: Although medication reconciliation (Med Rec) has demonstrated a reduction in potential adverse drug events, its effect on hospital readmissions remains inconclusive.
OBJECTIVE: To evaluate the impact of an interprofessional Med Rec bundle from admission to discharge on patient emergency department visits and hospital readmissions (hospital visits).
METHODS: The design was a retrospective, cohort study. Patients discharged from general internal medicine over a 57-month interval were identified through administrative databases. Patients who received an enhanced, Gold level, Med Rec bundle (including both admission Med Rec and interprofessional pharmacist-prescriber collaboration on discharge Med Rec) were assigned to the intervention group. Patients who received partial Med Rec services, Silver and Bronze level, comprised the control group. The primary outcome was hospital visits within 30 days of discharge.
RESULTS: Over a 57-month period, 9931 unique patient visits (n = 8678 patients) met the study criteria. The main analysis did not detect a difference in 30-day hospital visits between the intervention (Gold level bundle) and control (21.25% vs 19.26%; adjusted odds ratio, 1.06; 95% confidence interval [CI], 0.95-1.19). Propensity score adjustment also did not detect an effect (16.7% vs18.9%; relative risk of readmission, 0.88; 95% CI, 0.59-1.32).
CONCLUSION: A long-term, observational evaluation of interprofessional Med Rec did not detect a difference in 30-day postdischarge patient hospital visits between patients who received enhanced versus partial Med Rec patient care bundles. In future prospective studies, researchers could focus on evaluating high-risk populations and specific elements of Med Rec services on avoidable, medication-related hospital admissions and postdischarge adverse drug events.
© 2018 Society of Hospital Medicine
Healthcare systems are targeting effective strategies to improve patient safety and reduce hospital readmissions. Hospital readmissions can be detrimental to patients’ health, a source of avoidable healthcare costs, and are frequently a reflection of the quality of patient care during transitions of care. Medication reconciliation (Med Rec) was identified as 1 of 12 interventions that may reduce 30-day readmissions; however, rigorously designed studies are scarce.1,2 Published systematic reviews and meta-analyses have produced mixed conclusions regarding the impact of Med Rec on unplanned 30-day readmissions.2-4
In several studies, researchers have established the positive impact of Med Rec on reducing patient medication discrepancies and potential adverse drug events.4-8 Pharmacy-led Med Rec interventions have been shown to easily identify more clinically relevant and higher impact medication discrepancies when compared to usual care.8 In a systematic review, Mueller et al.2 suggest that there are several interrelated elements that determine if a Med Rec intervention will influence hospital readmissions. These elements form a multicomponent “bundle” of interventions, including a systematic medication history process, admission reconciliation, patient education on discharge, discharge reconciliation, and communication to outpatient providers.9 Several prospective randomized controlled studies have demonstrated lower readmission rates and fewer visits to the emergency department (ED) after implementing a comprehensive, interprofessional, bundled intervention (including Med Rec) from admission to discharge.10-13 A 2016 systematic review and meta-analysis specifically evaluated pharmacy-led Med Rec programs (the majority of which included interventions involving multicomponent bundles) and demonstrated a significant reduction in posthospital healthcare utilization.14
Although comprehensive, interprofessional, bundled interventions have been shown to reduce readmission rates and ED visits in randomized controlled trials (RCTs), limited resources often prevent hospitals from consistently implementing all aspects of these multicomponent interventions. In practice, clinicians may provide varying components of the bundle, such as the combination of admission medication history by the pharmacist and discharge Med Rec completed by the physician alone. The unique impact of combined pharmacist and prescriber Med Rec interventions from admission to discharge on readmissions remains inconclusive. Further, it is unclear which high-risk patient groups will benefit the most from these interventions. We set out to evaluate the impact of an enhanced, interprofessional Med Rec process from admission to discharge (characterized within the context of a novel taxonomy continuum that specifies clinician involvement and intensity of services) on readmissions to hospital and ED visits within 30 days of discharge.
