Could pharmacists really help reduce emergency visits?


hospital pharmacist medication chart

A study has found pharmacist intervention may potentially lead to reduced risk of ED visits and hospital readmissions

Danish researchers have looked at the role of pharmacists in reducing hospital readmissions and emergency department visits.

Their study included 1467 participants, all of whom used five or more prescribed drugs daily.

Patients, who were enrolled from September 2013 to April 2015 and followed up for six months, were randomised 1:1:1 to either:

  • Usual care – standard care with no intervention
  • Basic intervention – a structured, patient-centred medication review conducted by a clinical pharmacist
  • Extended intervention – medication review conducted by clinical pharmacist, with medication reconciliation and patient interview (motivational interviewing) provided on discharge, with follow-up calls to patient, doctor and pharmacy, and further motivational interviewing both one week and six months after discharge.

Participating pharmacists were not authorised to implement changes in patients’ medication after performing a review, but had to document proposed changes in the patient record and communicate with the doctor-in-charge, who could then follow or reject the advice.

During the medication reviews, pharmacists proposed 946 interventions to hospital physicians, of which 61% were accepted and implemented.

And 183 interventions were directed to primary care physicians, of which 66% were implemented.

Results showed the extended intervention in particular had a statistically significant effect on the number of patients who experienced readmission within 30 days after inclusion (HR, 0.62, 95% CI, 0.46-0.84), or within 180 days (HR, 0.75, 95% CI, 0.62-0.90).

Extended intervention by pharmacists also had a statistically significant effect on the number of patients who had a composite of readmissions or ED visits within 180 days after inclusion.

The authors observed a non-significant decrease in the number of drug-related readmissions within 30 days or 180 days, drug-related deaths within 180 days, and ED visits.

Counterintuitive results?

It may seem counterintuitive that the effect on non-drug-related readmissions was stronger than that on drug-related readmissions, the authors concede.

However they suggest interventions could be effective against non-adherence, which “to a large extent could prevent readmissions that are not obviously drug related”.

“If a patient is readmitted because of non-adherence, this will typically manifest itself as a worsening of his or her underlying disease,” they say.

“Unless the patient confesses to being non-adherent, the readmission is unlikely to be recognised as drug related.”

While previous analyses have concluded that medication reviews do not reduce hospital readmissions, the researchers point out that their study is larger than previous ones.

“In this randomised clinical trial, we established that a multi-faceted pharmaceutical intervention based on medication review, motivational review, and postdischarge follow-up for hospitalised patients with polypharmacy can reduce the short- and long-term rates of readmissions,” they conclude, adding that barriers to actual implementation of such interventions include cost, training, and politics.

Pharmacists in the hospital

Recent studies have looked at the role of pharmacists in the hospital team, with positive results.

For example, a recent Australian trial found pharmacist involvement in medication charting lowered inaccuracies from 41.1% to just 1.4%.

During the one-month trial held in a Sydney teaching hospital, preadmission clinic pharmacists completed 72 medication charts as part of an intervention to find out the impact they would have on chart accuracy and completeness.

The study results, published in the October issue of the Journal of Pharmacy Practice and Research, also found that pharmacist involvement led to completeness of charts significantly improving, from 5.4% to 80.6% (p < 0.001).

Another trial evaluated patient discharge summaries from Melbourne’s Alfred Hospital between March and July in 2015.

General medical patients were randomised to either receive medication management plans completed by a pharmacist (intervention), or standard medical discharge summaries (control).

The results, published in the Medical Journal of Australia in early 2017, found at least one medication error for 61.5% of patients in the control arm, compared with 15% in the intervention arm.

The absolute risk reduction for at least one medication error was 46.5%, while the absolute risk reduction for a high or extreme risk error was 9.6%.

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3 Comments

  1. Deirdre Criddle
    04/02/2018

    Collaborative, patient-centered handover from hospital to the primary care team. Hospital-Initiated medicines review for ‘at-risk’ patients makes as much sense now as it did in 2008 when the first statement of priorities from the Campbell review into Home Medicines Review highlighted the importance of this for our most vulnerable patients. Pharmacists can lead “Care across transitions” . How many studies are needed? How many patients being harmed from a lack of coordinated care and handover for medication management will it take to mandate investment in these roles. Pharmacists at the Exit point of hospital changing Discharge to Handover. 10 years on, and our patients are still waiting, and hurting from a lack of progress.

    • Big Pharma
      05/02/2018

      SPOT ON DEIRDRE!

      It is disappointing that programs like HMRs have been capped rather than expanded. Hospital referred HMRs were touted as the future of clinical pharmacy in the community however outside the SHPA, no other pharmacy body is interested. PSA and PGA are happy to accept registration fees from members of AACP however offer no positive stance or progression in this field (instead quite the opposite). Avenues for referral cannot be expanded whilst caps remain.

      Lengthy delays are frequent after discharge for high-risk patients. Delays in medication review occurs at the point of referral, as the patient waits to be reviewed by their GP, as well as delays created by inappropriate caps once the referral is received. Many of the country’s best clinicians are walking away from the archaic system. Patients are often readmitted before an intervention can occur. High-risk rural patients are even more disadvantaged. Their services have been stripped completely as a result of the caps with no one qualified locally to conduct the review.

      I note recent increases in the number of medschecks that can be conducted as well as an increase in the vague criteria which qualifies a patient for the service. Including “taking a medication that is high-risk of an adverse effect”….whatever that means (anyone could qualify). Whilst high-risk complex discharges miss out on a thorough collaborative medication review, low-risk cherry-picked KPI “services” completed in isolation are being encouraged.

      • United we stand
        05/02/2018

        Pharmacy is a tightly regulated system with significant legislative red tape. We don’t operate in a free market economy, and as such improvements and efficiencies are always too slow to come by.

        To overcome this issue would require a new community pharmacy system based on free market economy which may produce worse outcomes or it may not.

        Who’s willing to risk it all? Say aye

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