Fatma Karapinar-Çarkit

Effect of Medication Reconciliation With and Without Patient Counseling on the Number of Pharmaceutical Interventions Among Patients Discharged from the Hospital

Background Hospital admissions are a risk factor for the occurrence of unintended medication discrepancies between drugs used before admission and after discharge. To diminish such discrepancies and improve quality of care, medication reconciliation has been developed. The exact contribution of patient counseling to the medication reconciliation process is unknown, especially not when compared with community pharmacy medication records, which are considered reliable in the Netherlands. Objective To examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems. Methods A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient. Results Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge. Conclusions Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.

Information needs about medication according to patients discharged from a general hospital

OBJECTIVE Medication regimens change during hospital admission, and these discrepancies can lead to an increased risk of patient harm after hospital discharge. Information about medication according to the patients needs may contribute to patient safety by improvement of knowledge and adherence. The goal of this study is to explore the patients needs on information about medication at hospital discharge. RESEARCH DESIGN AND METHODS Qualitative, semi-structured interviews were performed with 31 patients from the pulmonology, internal medicine and cardiology departments who were discharged with at least one prescribed drug from the hospital to primary care in the Netherlands. Interviews were analysed with content analysis. RESULTS Patients had variable needs concerning information about discharge medication. Most patients wanted to receive basic information about their medication, alternatives for the prescribed medication and side effects. Some patients did not need basic information or explicitly mentioned that information about side effects would negatively influence their attitude towards medication. Patients preferred a combination of oral instructions and written information. CONCLUSIONS Information at discharge should be tailored to the individual needs of the patient. PRACTICE IMPLICATIONS In the process of providing patient information at hospital discharge, the preference of some patients for non-disclosure of information should be recognised.

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

BackgroundMedication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department.Methods/DesignAn experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patients attitude towards medicines, patients satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle.DiscussionThis study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety.Trial registrationDutch trial register: NTR1519

Effect of Medication Reconciliation on Medication Costs After Hospital Discharge in Relation to Hospital Pharmacy Labor Costs

Background: Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs. Objective: To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs. Methods: A prospective observational study was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed medication errors prevented by medication reconciliation. Interventions were classified into 3 categories: correcting hospital formulary-induced medication changes (eg, reinstating less costly generic drugs used before admission), optimizing pharmacotherapy (eg. discontinuing unnecessary laxative), and eliminating discrepancies (eg, restarting omitted preadmission medication). Because eliminating discrepancies does not represent real costs to society (before hospitalization, the patient was also using the medication), these medication costs were not included in the cost calculation. Medication costs at 1 month and 6 months after hospital discharge and the associated tabor costs were assessed using descriptive statistics and scenario analyses. For the 6-month extrapolation, only medication intended for chronic use was included. Results: Two hundred sixty-two patients were included. Correcting hospital formulary changes saved €1 63/patient (exchange rate: EUR 1 = USD 1.3443) in medication costs at 1 month after discharge and €9.79 at 6 months. Optimizing pharmacotherapy saved €20.13/patient in medication costs at 1 month and €86.86 at 6 months. The associated labor costs for performing medication reconciliation were €41.04/patient. Medication cost savings from correcting hospital formulary-induced changes and optimizing of pharmacotherapy (€96.65/patient) outweighed the labor costs at 6 months extrapolation by €55.62/patient (sensitivity analysis €37.25–71.10). Conclusions: Preventing medication errors through medication reconciliation results in higher benefits than the costs related to the net time investment.

Informational needs and recall of in-hospital medication changes of recently discharged patients

Purpose The need for information for patients and caregivers at the point of hospital discharge is paramount and potentially extensive. Objective The objective of this study was to assess patients’ informational needs at hospital discharge, patients’ recall of medication changes implemented in the hospital and patients’ medication related problems experienced one week after hospital discharge. Methods The study was conducted in a teaching hospital where patients received structured discharge counseling. Patients were interviewed at hospital discharge regarding their informational needs. One week post‐discharge, patients were interviewed by phone to assess any changes in informational needs, their recall regarding in‐hospital medication changes and the medication related problems. Descriptive analysis and logistic regression were used to address study objectives. Results The 124 patients in the study regarded the following topics as most relevant for counseling: what the medicine is for (57%), side effects (52%), drug‐drug interactions (45%), action of the drug (37%) and reimbursement (31%). In 9% of patients the informational needs changed post‐discharge, e.g. the topic side effects increased in importance. Forty‐nine percent could recall whether and which medication was changed during hospitalization. Medication‐related problems and side effects were reported by respectively 27% and 15% of patients, whereas only 7% contacted their doctor or pharmacist. Conclusions Patients’ informational needs are very individual and can change post‐discharge. Despite structured counseling, only half of the patients were able to recall the medication changes implemented in the hospital. Furthermore, patients reported several problems for which they did not consult a healthcare provider. This insight could help in smoothing the transition from hospital to the primary care setting.

Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review

To summarize the evidence on the prevalence and preventability of drug‐related hospital readmissions.

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

Background To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective. Methods A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping. Results In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained. Conclusion The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention. Dutch trial register NTR1519