Research Article: The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before—After prospective study

Date Published: March 12, 2019

Publisher: Public Library of Science

Author(s): Sara Daliri, Jacqueline G. Hugtenburg, Gerben ter Riet, Bart J. F. van den Bemt, Bianca M. Buurman, Wilma J. M. Scholte op Reimer, Marie-Christine van Buul-Gast, Fatma Karapinar-Çarkit, Meagen Rosenthal.


Medication-related problems are common after hospitalization, for example when changes in patients’ medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge. We investigated the effect of a pharmacy-led transitional care program on the occurrence of medication-related problems four weeks post-discharge.

A prospective multi-center before-after study was conducted in six departments in total of two hospitals and 50 community pharmacies in the Netherlands. We tested a pharmacy-led program incorporating (i) usual care (medication reconciliation at hospital admission and discharge) combined with, (ii) teach-back at hospital discharge, (iii) improved transfer of medication information to primary healthcare providers and (iv) post-discharge home visit by the patient’s own community pharmacist, compared with usual care alone. The difference in medication-related problems four weeks post-discharge, measured by means of a validated telephone-interview protocol, was the primary outcome. Multiple logistic regression analysis was used, adjusting for potential confounders after multiple imputation to deal with missing data.

We included 234 (January-April 2016) and 222 (July-November 2016) patients in the usual care and intervention group, respectively. Complete data on the primary outcome was available for 400 patients. The proportion of patients with any medication-related problem was 65.9% (211/400) in the usual care group compared to 52.4% (189/400) in the intervention group (p = 0.01). After multiple imputation, the proportion of patients with any medication-related problem remained lower in the intervention group (unadjusted odds ratio 0.57; 95% CI 0.38–0.86, adjusted odds ratio 0.50; 95% CI 0.31–0.79).

A pharmacy-led transitional care program reduced medication-related problems after discharge. Implementation research is needed to determine how best to embed these interventions in existing processes.

Partial Text

The incidence of medication-related problems (MRPs) ranges from 18.4% two weeks post-discharge to 37.5% four weeks post-discharge [1]. MRPs are defined as events or circumstances related to a patient’s medication [2] that can adversely affect patients’ health status [3–5]. A recent study showed that a median of 21% of hospital readmissions are due to MRPs, of which a median of 69% are regarded as preventable [6]. Examples of MRPs are the continued use of medication that had been discontinued in the hospital, side effects due to medication changes in the hospital, interactions caused by the use of home medications which were unknown during hospitalization (e.g. over-the-counter medication) or problems in implementing an altered medication regimen at home [7].

The present pharmacy-led transitional care program was designed to reduce MRPs post-discharge. The results show that the proportion of patients with at least one MRP four weeks post-discharge was indeed 13.5% lower in the group who received a combination of hospital discharge interventions with a home follow-up visit of the community pharmacist as compared to the group who received usual care. Intervention group patients also reported less symptoms caused by their medication. These symptoms could be potential adverse drug events (ADEs) which are known to increase healthcare use [5, 44] and costs [45].

Application of a pharmacy-led transitional care program resulted in a reduction in the proportion of patients with any self-reported MRPs, and the number of MRPs per patient, four weeks post-discharge. Follow-up care after hospitalization and close collaboration among healthcare providers across health care institutions is needed to identify, resolve and prevent MRPs and to improve the continuity of medication use. Implementation research is needed to determine how best to embed these interventions in existing processes and to determine the effect on clinical outcomes.




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