Transitional pharmaceutical care for patients discharged from the hospital

Abstract

Patients visit multiple healthcare providers, obtain medications from multiple pharmacies and transition between settings, all of which can lead to inaccurate medication information and thus medication errors. To improve continuity of care, transitional pharmaceutical care programs are needed. These programs incorporate medication reconciliation (i.e. obtaining and evaluating a complete medication overview), patient counselling regarding medication changes and information transfer between healthcare providers. Continuity of pharmaceutical care is especially important at hospital discharge as the patient needs to resume responsibility for his medication and other healthcare providers, e.g. general practitioner and community pharmacist, need to guide the patient after hospital discharge. The objective of this thesis was to summarise existing evidence on interventions regarding discharge medication and to develop and evaluate a transitional pharmaceutical care program, developed by the hospital pharmacy, with respect to effects and costs. Existing evidence was summarised in a systematic review. Various discharge medication related interventions were reported to be mainly effective for process measures; 75% of studies were effective for the outcome knowledge, 70% for adherence and 93% for DRPs. A limited number of studies reported effectiveness on morbidity; 18% for readmission and 40% for health services use. For the development of a transitional pharmaceutical care program the informational needs of general practitioners and patients regarding discharge medication, the additional contribution of patient participation in medication reconciliation, the labour costs versus the medication costs and the documentation of relevant discharge medication information by community pharmacies was assessed. General practitioners stated that discharge medication information was delayed. They desired information regarding the reasons for changes in the pharmacotherapy. Patients also expressed this need. Furthermore, patients expressed variable needs, e.g. regarding side-effects, so information at discharge should be tailored to individual needs. Patient participation was essential during medication reconciliation as discharge prescriptions were adjusted frequently after patient counselling due to discrepancies in use or need of drug therapy. The adjustments made by the hospital pharmacy resulted in higher medication cost savings after hospital discharge than the costs related to the net time investment (€56 savings per patient). However, continuity of pharmaceutical care after hospital discharge was shown to fail in the majority of community pharmacies as relevant discharge medication information (e.g. allergies/medication changes) was not documented in computer systems. The transitional pharmaceutical care program COACH (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) was evaluated in 365 patients versus 341 usual care patients. For all patients in the COACH program, interventions were performed to prevent drug-related problems (mean number of interventions: 10 per patient). Examples of interventions included re-starting of pre-admission prescribed medication, adjusting dosing schemes due to kidney malfunction and discontinuing redundant medication. Patients were significantly more satisfied with counselling provided by a hospital pharmacy member compared to the resident (69% resident versus 87% pharmacy). The COACH program did not decrease all-cause unplanned rehospitalisations. Further research will show whether medication-related rehospitalisations are decreased. A cost-effectiveness study showed that the COACH program was not considered cost-effective, although costs were 1000 euro less per patient for the COACH program.