Medication review and reconciliation was the primary target of 11 studies.28-38 In the 2 admission interventions, Nester and Hale28 found that medication histories taken by pharmacists, as opposed to nurses, resulted in more accurate medication and allergy information, identified allergy history errors more frequently, and entered allergy information into the computer more quickly, with no difference in drug interactions or ADRs. In a study from Australia, Stowasser et al29 implemented a medication liaison service to improve communication between outpatient physicians and pharmacists and the inpatient team at admission and discharge. The intervention group was more likely to have a pharmacist intervene or change at least 1 medication during hospitalization, with no effect on LOS or mortality. At 30 days, the intervention group had fewer health care visits, nonsignificant reduction in readmissions, and no overall change in health status.
Another 9 studies focused on discharge counseling. Smith et al30 performed home visits and assessed pharmacist discharge counseling on patient medication-taking behavior and found significantly better levels of medication adherence (P<.01), although 75% of patients in the intervention group and 96% of patients in the control group were not taking medications as prescribed. Bolas et al31 compared standard discharge planning with pharmacist discharge counseling coupled with a discharge letter from the inpatient physician to the patient's general practitioner. Significant improvement was noted in the correlation between discharge and home medications 10 to 14 days after discharge, as well as knowledge of drug name, dosage, and frequency, with no difference in readmission rates. In a Veterans Administration hospital discharge counseling intervention, Williford and Johnson32 reported that patients were no more knowledgeable or compliant at the 6-week follow-up.
In a study by Lipton and Bird,33 pharmacists reviewed hospital records, consulted with physicians, provided discharge counseling, and made 4 follow-up telephone calls after discharge. At 2 months, patient medication knowledge was higher in the intervention group. At 3 months, patients in the intervention group compared with those in the control group received fewer medications (5.16 vs 6.75; P<.001) and fewer daily doses (8.30 vs 12.04; P<.001), and reported fewer missed doses (8% vs 22%; P<.001); resource use was not affected. From the same study, Lipton et al34 evaluated a 236-patient sample in 6 domains of medication appropriateness. Patients in the intervention group were less likely to have one or more prescribing problems in any category, in appropriateness or in dosage.
Johnston et al35 evaluated the role of pharmacist discharge counseling on medication knowledge in older patients. An evaluation immediately before discharge and a recall questionnaire found that the percentage of critical items correct for the pharmacist-counseled group was 93% compared with 77% in the control group (P = .02). Nazareth et al36 reported no differences in hospital readmissions, outpatient visits, or mortality at 3 or 6 months for a discharge pharmacist intervention to coordinate care with outpatient pharmacists and providers in patients older than 75 years. In a similar study, Al-Rashed et al37 enrolled 83 elderly patients at discharge and reported improvements in knowledge, compliance, outpatient visits, and hospital readmissions. In the most recent study of pharmacist counseling at discharge with telephone follow-up after 3 to 5 days, Schnipper et al reported fewer
preventable ADEs (1% vs 11%; P = .01) and fewer preventable medication-related emergency department visits or hospital readmissions (1% vs 8%; P = .03) at 30 days in the intervention group compared with the control group, with no difference in medication compliance.
Another 9 studies focused on discharge counseling. Smith et al30 performed home visits and assessed pharmacist discharge counseling on patient medication-taking behavior and found significantly better levels of medication adherence (P<.01), although 75% of patients in the intervention group and 96% of patients in the control group were not taking medications as prescribed. Bolas et al31 compared standard discharge planning with pharmacist discharge counseling coupled with a discharge letter from the inpatient physician to the patient's general practitioner. Significant improvement was noted in the correlation between discharge and home medications 10 to 14 days after discharge, as well as knowledge of drug name, dosage, and frequency, with no difference in readmission rates. In a Veterans Administration hospital discharge counseling intervention, Williford and Johnson32 reported that patients were no more knowledgeable or compliant at the 6-week follow-up.
In a study by Lipton and Bird,33 pharmacists reviewed hospital records, consulted with physicians, provided discharge counseling, and made 4 follow-up telephone calls after discharge. At 2 months, patient medication knowledge was higher in the intervention group. At 3 months, patients in the intervention group compared with those in the control group received fewer medications (5.16 vs 6.75; P<.001) and fewer daily doses (8.30 vs 12.04; P<.001), and reported fewer missed doses (8% vs 22%; P<.001); resource use was not affected. From the same study, Lipton et al34 evaluated a 236-patient sample in 6 domains of medication appropriateness. Patients in the intervention group were less likely to have one or more prescribing problems in any category, in appropriateness or in dosage.
Johnston et al35 evaluated the role of pharmacist discharge counseling on medication knowledge in older patients. An evaluation immediately before discharge and a recall questionnaire found that the percentage of critical items correct for the pharmacist-counseled group was 93% compared with 77% in the control group (P = .02). Nazareth et al36 reported no differences in hospital readmissions, outpatient visits, or mortality at 3 or 6 months for a discharge pharmacist intervention to coordinate care with outpatient pharmacists and providers in patients older than 75 years. In a similar study, Al-Rashed et al37 enrolled 83 elderly patients at discharge and reported improvements in knowledge, compliance, outpatient visits, and hospital readmissions. In the most recent study of pharmacist counseling at discharge with telephone follow-up after 3 to 5 days, Schnipper et al reported fewer
preventable ADEs (1% vs 11%; P = .01) and fewer preventable medication-related emergency department visits or hospital readmissions (1% vs 8%; P = .03) at 30 days in the intervention group compared with the control group, with no difference in medication compliance.
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