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Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of ReadmissionA Randomized Clinical Trial

Educational Objective
To determine whether a multifaceted pharmacist intervention based on medication review, patient interview, and follow-up can reduce the number of readmissions and emergency department visits.
1 Credit CME
Key Points

Question  Can a multifaceted pharmacist intervention prevent hospital readmissions and emergency department visits?

Findings  In a randomized clinical trial of 1467 Danish participants receiving at least 5 medications, a statistically significant reduced rate of readmissions within 30 and 180 days after inclusion was observed in patients randomized to receive an extended pharmacist intervention compared with those who received usual care or a basic pharmacist intervention.

Meaning  The proposed multifaceted pharmacist intervention can reduce the number of hospital readmissions and emergency department visits.

Abstract

Importance  Hospital readmissions are common among patients receiving multiple medications, with considerable costs to the patients and society.

Objective  To determine whether a multifaceted pharmacist intervention based on medication review, patient interview, and follow-up can reduce the number of readmissions and emergency department (ED) visits.

Design, Setting, and Participants  This randomized clinical multicenter study (Odense Pharmacist Trial Investigating Medication Interventions at Sector Transfer [OPTIMIST]) enrolled patients from September 1, 2013, through April 23, 2015, with a follow-up of 6 months completed on October 31, 2015. Consecutive medical patients in an acute admission ward who were 18 years or older and who used 5 or more medications were invited to participate. Of 1873 patients invited to participate, 1499 (80.0%) accepted. The medication review and patient interview were conducted in the hospital and followed up in collaboration with primary care. Analysis was based on intention to treat.

Interventions  The patients were randomized into 3 groups receiving usual care (no intervention), a basic intervention (medication review), and an extended intervention (medication review, 3 motivational interviews, and follow-up with the primary care physician, pharmacy, and nursing home).

Main Outcomes and Measures  The prespecified primary outcomes were readmission within 30 or 180 days and ED visits within 180 days. The primary composite end point was readmission or an ED visit within 180 days. Secondary outcomes were drug-related readmissions within 30 and 180 days after inclusion, and all-cause mortality and drug-related mortality.

Results  A total of 1467 patients (679 men [46.3%] and 788 women [53.7%]; median age, 72 years; interquartile range, 63-80 years) were part of the primary analysis, including 498 randomized to usual care, 493 randomized to the basic intervention, and 476 randomized to the extended intervention. The extended intervention had a significant effect on the numbers of patients who were readmitted within 30 days (hazard ratio [HR], 0.62; 95% CI, 0.46-0.84) or within 180 days (HR, 0.75; 95% CI, 0.62-0.90) after inclusion and on the number of patients who experienced the primary composite end point (HR, 0.77; 95% CI, 0.64-0.93). The study showed a nonsignificant reduction in drug-related readmissions within 30 days (HR, 0.65; 95% CI, 0.39-1.09) and within 180 days (HR, 0.80; 95% CI, 0.59-1.08) after inclusion and in deaths (HR, 0.83; 95% CI, 0.22-3.11). The number needed to treat to achieve the primary composite outcome for the extended intervention (vs usual care) was 12.

Conclusions and Relevance  A multifaceted clinical pharmacist intervention may reduce the number of ED visits and hospital readmissions.

Trial Registration  clinicaltrials.gov Identifier: NCT03079375

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Article Information

Accepted for Publication: December 2, 2017.

Corresponding Author: Lene Vestergaard Ravn-Nielsen, MSc(Pharm), Hospital Pharmacy of Funen, Clinical Pharmacy Department, Odense University Hospital, Solfaldsvej 38, DK-5000 Odense C, Denmark (leneravn.nielsen@gmail.com).

Published Online: January 29, 2018. doi:10.1001/jamainternmed.2017.8274

Author Contributions: Ms Ravn-Nielsen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ravn-Nielsen, Eriksen, Buck, Hansen, Hallas.

Acquisition, analysis, or interpretation of data: Ravn-Nielsen, Duckert, Lund, Henriksen, Nielsen, Eriksen, Pottegård, Hansen, Hallas.

Drafting of the manuscript: Ravn-Nielsen, Duckert, Nielsen, Pottegård, Hallas.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Pottegård.

Obtained funding: Ravn-Nielsen, Buck, Hallas.

Administrative, technical, or material support: Duckert, Henriksen, Nielsen, Buck, Hansen, Hallas.

Study supervision: Lund, Pottegård, Hansen, Hallas.

Conflict of Interest Disclosures: Ms Ravn-Nielsen reported receiving grants from the Hospitals Pharmacies’ and Amgros’ Research Development Foundation, 2 public regional foundations, and the Actavis Foundation during the conduct of the study. Dr Hansen reported receiving grants from Menarini and Pfizer unrelated to this project and personally receiving fees from the Danish Association of Pharmaceutical Manufacturers. Dr Hallas reported participating in research projects funded by Novartis, Pfizer, Menarini, MSD, Nycomed, Leo Pharmaceuticals, Astellas, and Alk-Abelló with grants paid to the institution where he was employed and personally receiving fees from the Danish Association of Pharmaceutical Manufacturers, Pfizer, and Menarini unrelated to this project. No other disclosures were reported.

Funding/Support: This study was supported by unrestricted grants from The Hospitals Pharmacies’ and Amgros’ Research Development Foundation, public regional research foundations for Southern Denmark and Zealand, and the Actavis Foundation.

Role of the Funder/Sponsor: The funding organizations had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Lisbeth Muurholm, MSc(Pharm), Hospital Pharmacy of Funen, Odense, Denmark, ensured the organizational base for this study. We thank the intervention pharmacists from Odense University Hospital, Odense and Svendborg; the personnel involved from the Hospital Pharmacy of Funen; the clinical pharmacists from Viborg Regional Hospital, Viborg, Denmark, and Holbæk Hospital, Holbæk, Denmark; and all the participating wards, patients, physicians, nurses, general practitioners, nursing homes, and pharmacy personnel from primary care and the impartial clinical pharmacologist.

References
1.
Beijer  HJM, de Blaey  CJ.  Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies.  Pharm World Sci. 2002;24(2):46-54.PubMedGoogle ScholarCrossref
2.
Kongkaew  C, Noyce  PR, Ashcroft  DM.  Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies.  Ann Pharmacother. 2008;42(7):1017-1025.PubMedGoogle ScholarCrossref
3.
Hallas  J, Gram  LF, Grodum  E,  et al.  Drug related admissions to medical wards: a population based survey.  Br J Clin Pharmacol. 1992;33(1):61-68.PubMedGoogle ScholarCrossref
4.
Cunningham  G, Dodd  TR, Grant  DJ, McMurdo  ME, Richards  RM.  Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassessment.  Age Ageing. 1997;26(5):375-382.PubMedGoogle ScholarCrossref
5.
Mannesse  CK, Derkx  FH, de Ridder  MA, Man in ’t Veld  AJ, van der Cammen  TJ.  Contribution of adverse drug reactions to hospital admission of older patients.  Age Ageing. 2000;29(1):35-39.PubMedGoogle ScholarCrossref
6.
Patel  NS, Patel  TK, Patel  PB, Naik  VN, Tripathi  CB.  Hospitalizations due to preventable adverse reactions: a systematic review.  Eur J Clin Pharmacol. 2017;73(4):385-398.PubMedGoogle ScholarCrossref
7.
Christensen  HR, Krølner  BK.  Medication problems in connection with transferral between sectors [in Danish].  Ugeskr Laeger. 2009;171(10):808-811.PubMedGoogle Scholar
8.
Karapinar-Carkit  F, Borgsteede  SD, Zoer  J,  et al.  The effect of the COACH program (Continuity of Appropriate Pharmacotherapy, Patient Counselling and Information Transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients.  BMC Health Serv Res. 2010;10:39.PubMedGoogle ScholarCrossref
9.
Midlöv  P, Bergkvist  A, Bondesson  A, Eriksson  T, Höglund  P.  Medication errors when transferring elderly patients between primary health care and hospital care.  Pharm World Sci. 2005;27(2):116-120.PubMedGoogle ScholarCrossref
10.
Knez  L, Suskovic  S, Rezonja  R, Laaksonen  R, Mrhar  A.  The need for medication reconciliation: a cross-sectional observational study in adult patients.  Respir Med. 2011;105(suppl 1):S60-S66.PubMedGoogle ScholarCrossref
11.
Uitvlugt  EB, Suijker  R, Janssen  MJA, Siegert  CEH, Karapinar-Çarkit  F.  Quality of medication related information in discharge letters: A prospective cohort study.  [published online October 7, 2017].  Eur J Intern Med. 2017;46:e23-e25. doi:10.1016/j.ejim.2017.09.015PubMedGoogle ScholarCrossref
12.
Carter  BL, Farris  KB, Abramowitz  PW,  et al.  The Iowa Continuity of Care study: background and methods.  Am J Health Syst Pharm. 2008;65(17):1631-1642.PubMedGoogle ScholarCrossref
13.
Graabaek  T, Kjeldsen  LJ.  Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review.  Basic Clin Pharmacol Toxicol. 2013;112(6):359-373.PubMedGoogle ScholarCrossref
14.
Bergkvist  A, Midlöv  P, Höglund  P, Larsson  L, Bondesson  A, Eriksson  T.  Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management.  Eur J Clin Pharmacol. 2009;65(10):1037-1046.PubMedGoogle ScholarCrossref
15.
Midlöv  P, Holmdahl  L, Eriksson  T,  et al.  Medication report reduces number of medication errors when elderly patients are discharged from hospital.  Pharm World Sci. 2008;30(1):92-98.PubMedGoogle ScholarCrossref
16.
Midlöv  P, Deierborg  E, Holmdahl  L, Höglund  P, Eriksson  T.  Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital.  Pharm World Sci. 2008;30(6):840-845.PubMedGoogle ScholarCrossref
17.
Holland  R, Desborough  J, Goodyer  L, Hall  S, Wright  D, Loke  YK.  Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? a systematic review and meta-analysis.  Br J Clin Pharmacol. 2008;65(3):303-316.PubMedGoogle ScholarCrossref
18.
Mekonnen  AB, McLachlan  AJ, Brien  J-AE.  Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.  BMJ Open. 2016;6(2):e010003.PubMedGoogle ScholarCrossref
19.
Grimes  TC, Breslin  N, Deasy  E,  et al.  Comment on: pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.  J Clin Pharm Ther. 2016;41(6):739-740.PubMedGoogle ScholarCrossref
20.
Nieuwlaat  R, Wilczynski  N, Navarro  T,  et al.  Interventions for enhancing medication adherence.  Cochrane Database Syst Rev. 2014;(11):CD000011.PubMedGoogle Scholar
21.
Christensen  M, Lundh  A.  Medication review in hospitalised patients to reduce morbidity and mortality.  Cochrane Database Syst Rev. 2016;2(2):CD008986.PubMedGoogle Scholar
22.
Levy  HB.  Polypharmacy reduction strategies: tips on incorporating American Geriatrics Society Beers and Screening Tool of Older People’s Prescriptions criteria.  Clin Geriatr Med. 2017;33(2):177-187.PubMedGoogle ScholarCrossref
23.
Graabæk  T, Bonnerup  DK, Kjeldsen  LJ, Rossing  C, Pottegård  A.  Pharmacist-led medication review in an acute admissions unit: a systematic procedure description.  Eur J Hosp Pharm Sci Pract. 2015;22(4):202.Google ScholarCrossref
24.
Pirmohamed  M, James  S, Meakin  S,  et al.  Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients.  BMJ. 2004;329(7456):15-19.PubMedGoogle ScholarCrossref
25.
Cua  YM, Kripalani  S.  Medication use in the transition from hospital to home.  Ann Acad Med Singapore. 2008;37(2):136.PubMedGoogle Scholar
26.
Poole  DL, Chainakul  JN, Pearson  M, Graham  L.  Medication reconciliation: a necessity in promoting a safe hospital discharge.  J Healthc Qual. 2006;28(3):12-19.PubMedGoogle ScholarCrossref
27.
Britt  E, Hudson  SM, Blampied  NM.  Motivational interviewing in health settings: a review.  Patient Educ Couns. 2004;53(2):147-155.PubMedGoogle ScholarCrossref
28.
Rollnick  S, Butler  CC, Kinnersley  P, Gregory  J, Mash  B.  Motivational interviewing.  BMJ. 2010;340:c1900.PubMedGoogle ScholarCrossref
29.
Doucette  WR, Farris  KB, Youland  KM, Newland  BA, Egerton  SJ, Barnes  JM.  Development of the Drug Adherence Work-up (DRAW) tool.  J Am Pharm Assoc (2003). 2012;52(6):e199-e204.PubMedGoogle ScholarCrossref
30.
Ministry of Health. Healthcare in Denmark: an overview. http://www.sum.dk/~/media/Filer%20-%20Publikationer_i_pdf/2016/Healthcare-in-dk-16-dec/Healthcare-english-V16-dec.ashx. 2017. Accessed December 16, 2017.
31.
Schmidt  M, Schmidt  SAJ, Sandegaard  JL, Ehrenstein  V, Pedersen  L, Sørensen  HT.  The Danish National Patient Registry: a review of content, data quality, and research potential.  Clin Epidemiol. 2015;7(Nov):449-490.PubMedGoogle ScholarCrossref
32.
Hallas  J, Harvald  B, Gram  LF,  et al.  Drug related hospital admissions: the role of definitions and intensity of data collection, and the possibility of prevention.  J Intern Med. 1990;228(2):83-90.PubMedGoogle ScholarCrossref
33.
The Uppsala Monitoring Centre. The use of the WHO-UMC system for standardised case causality assessment. 2016http://www.who.int/medicines/areas/quality_safety/safety_efficacy/WHOcausality_assessment.pdf. Accessed December 16, 2017.
34.
Naranjo  CA, Busto  U, Sellers  EM,  et al.  A method for estimating the probability of adverse drug reactions.  Clin Pharmacol Ther. 1981;30(2):239-245.PubMedGoogle ScholarCrossref
35.
Hansen  TG. Medicines Management Among Elderly Patients: Evidence, Procedure, Outcome and a New Approach [thesis]. Odense: University of Southern Denmark; 2016.
36.
Kjeldsen  LJ, Olesen  C, Hansen  MK, Nielsen  TRH.  Clinical outcomes used in clinical pharmacy intervention studies in secondary care.  Pharmacy (Basel). 2017;5(2):E28. doi:10.3390/pharmacy5020028PubMedGoogle ScholarCrossref
37.
Kim  J, Shin  W.  How to do random allocation (randomization).  Clin Orthop Surg. 2014;6(1):103-109.PubMedGoogle ScholarCrossref
38.
Vickers  AJ.  How to randomize.  J Soc Integr Oncol. 2006;4(4):194-198.PubMedGoogle ScholarCrossref
39.
Gillespie  U, Alassaad  A, Henrohn  D,  et al.  A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial.  Arch Intern Med. 2009;169(9):894-900.PubMedGoogle ScholarCrossref
40.
Olesen  C, Harbig  P, Buus  KM, Barat  I, Damsgaard  EM.  Impact of pharmaceutical care on adherence, hospitalisations and mortality in elderly patients.  Int J Clin Pharm. 2014;36(1):163-171.PubMedGoogle ScholarCrossref
41.
Brayne  C, Gao  L, Dewey  M, Matthews  FE; Medical Research Council Cognitive Function and Ageing Study Investigators. Dementia before death in ageing societies— the promise of prevention and the reality. PLoS Med. 2006;3(10):e397.
42.
Saedder  EA, Lisby  M, Nielsen  LP,  et al.  Detection of patients at high risk of medication errors: development and validation of an algorithm.  Basic Clin Pharmacol Toxicol. 2016;118(2):143-149.PubMedGoogle ScholarCrossref
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