Pharmacist involvement may lower preventable ADEs rates after discharge

Communication, documentation problems result in meds discrepancies

Pharmacist counseling and follow-up are associated with lower rates of preventable adverse drug events (ADEs) after patient discharge from the hospital, a new study indicates.

Previous studies have shown that counseling patients before discharge reduces medication discrepancies and improves adherence, the researchers say. The effects of pharmacist interventions on ADEs after discharge, however, are more unknown. These researchers wanted to identify drug-related problems (DRPs) during and after medical hospitalization and to evaluate the effects of counseling and follow-up by pharmacists on the rate of preventable ADEs, health care utilization, medication nonadherence, and medication discrepancies 30 days after discharge from an acute care hospital.

The researchers believed that pharmacist interventions might reduce the rate of preventable ADEs after discharge — and that’s the study’s most significant finding, says Jennifer Kirwin, PharmD, BCPS, a researcher in the study and assistant clinical specialist at Northeastern University School of Pharmacy in Boston. Thirty days after discharge, preventable ADEs were detected in 11% of patients in the control group (eight patients) and 1% of patients (one patient) in the intervention group.

"Different parts of our results have been shown in other studies, and we were able to [duplicate them] but bring something new," she says. "That was what was most interesting to us in this study."

Four pharmacists involved in study

The researchers conducted a randomized trial of 178 patients being discharged to home from the general medicine service at Brigham and Women’s Hospital (BWH) in Boston from April 1, 2002, through March 20, 2003. Two patients were excluded, 92 received pharmacist interventions, and 84 received usual care.

Four pharmacists were involved in this study. Two primarily did in-patient counseling on discharge, Kirwin handled most follow-up calls to patients after discharge, and the fourth acted as a floater who stepped in for one of the other three pharmacists when the need arose.

The pharmacist intervention on the day of discharge consisted of several parts, the researchers say. "First, discharge medication regimens were compared with preadmission regimens and all discrepancies were reconciled with the medical team’s help. Patients were screened for previous DRPs, including nonadherence, lack of efficacy, and side effects. The pharmacist reviewed the indications, directions for use, and potential adverse effects of each discharge medication with the patient and discussed significant findings with the medical team."

During the follow-up telephone call to patients three to five days after discharge, Kirwin compared the patient’s self-reported medication list with the discharge list. She also asked about medication adherence, possible ADEs, and adherence with scheduled follow-up and laboratory appointments. Significant findings were entered into the electronic medical record used by all BWH outpatient practices and were communicated to the patient’s primary care physician through a standard e-mail template.

Of the total patients involved in this study, the researchers also were able to contact 152 patients 30 days after discharge to see if a preventable ADE had occurred. Fourteen additional patients visited the emergency department (ED) or were readmitted to the hospital.

More communication uncovers discrepancies

One problem the pharmacists found at discharge counseling is that the medical team had often misunderstood the patient’s preadmission medication regimen and carried through these inaccuracies to the discharge medication orders. These included 34 missing medications, a different dose or frequency of a medication in 12 cases, and a different medication in the same class in 11 cases; 45 patients (49%) had one or more unexplained discrepancies in their discharge medication orders.

The pharmacists also found that 15 patients (16%) admitted to having had problems with their medication regimens before admission, including possible side effects and difficulties with adherence. Pharmacists suggested 23 changes to discharge medications on other clinical grounds. Overall, pharmacists recommended 80 changes in 55 patients (60%).

During follow-up telephone calls three to five days after discharge (79 patients total), pharmacists noted discrepancies between the discharge medication list and the patient’s reported home regimen in 56 patients (71%), according to the study results. In 33 patients (42%), discrepancies represented reported changes by the patients’ physicians or were changes in as-needed or over-the-counter medications only. Twenty-eight of the remaining discrepancies in 23 patients (29%) remained unexplained.

Most discrepancies involved changes in dose or frequency or complete omission of a prescribed medication. In addition, possible medication side effects were noted in 37% (29 patients), medication nonadherence in 23% (18), difficulty obtaining refills in 18% (14), and difficulty with medication costs in 11% (9). (These results were published in the March 13 issue of the Archives of Internal Medicine.

In addition to the larger number of preventable ADEs 30 days after discharge in the intervention group, the rate of preventable, medication-related ED visits or hospital readmissions was 1% in the intervention group and 8% in those assigned to usual care. The groups did not differ significantly with respect to total ADEs, total health care utilization, patient satisfaction, medication adherence, or duration or severity of ameliorable ADEs, the researchers say. Unexplained discrepancies between discharge medication regimens and self-reported medications 30 days after discharge were common in both control and intervention groups (65% and 61%, respectively).

Problems with communication and documentation were commonly related to medication discrepancies, the researchers say. That’s not surprising, Kirwin says. Patients come to the hospital from different geographic regions and then return home after discharge. "It underscored the communications problems we were having."

"Obviously, there are going to be different levels of communication from the hospital physicians to the primary care physicians. [Hospital physicians] don’t have access to all the same information. This was definitely a factor in the study."

Preventable ADEs in the study were due to a number of factors, including discrepancies and inappropriate prescribing before discharge, as well as discrepancies, lack of medication access, nonadherence, and inadequate drug monitoring after discharge. Pharmacists in general should note the different reasons for the preventable ADEs, Kirwin says.

"It wasn’t always adherence, and it wasn’t always a knowledge issue. There were also problems with access to medications. All of these different factors played into it," she says. "When pharmacists work with patients who are recently discharged or transferring settings, they should keep in mind all the potential pitfalls."