The impact of pharmacist-led medication reconciliation and interprofessional ward rounds on drug-related problems at hospital discharge.

BACKGROUND: During transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs). AIM: To investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge. METHOD: In this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital's community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital's community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs. RESULTS: Overall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03). CONCLUSION: Our results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.

Detection and resolution of drug-related problems at hospital discharge focusing on information availability - a retrospective analysis.

BACKGROUND: Hospital stays are often associated with medication changes, which may lead to drug-related problems (DRPs). Medication reconciliation and medication reviews are strategies to detect and resolve DRPs. METHODS: A descriptive cohort study was conducted using DRPs collected during routine pharmacist-led medication reconciliation and medication reviews in the hospital's community pharmacy at discharge (Zug Cantonal Hospital, Switzerland). In a simulation experiment, we retrospectively analysed the detection and resolution possibilities of these DRPs and their dependency on different information sources. RESULTS: Overall, 6,087 prescriptions were filled in the hospital's community pharmacy (between June 2016 and May 2019). Among 1,352 prescriptions (with ≥ 1 documented DRP) a total of 1,876 DRPs were detected. The retrospective assessment showed that 1,115 DRPs could have been detected by performing simple medication reviews (based on the discharge prescription and the medication history), whereas in the remaining cases, additional clinical and/or patient-specific information would have been needed. In 944 (84.7 %) DRPs, which are detectable by simple medication reviews, the pharmacist would need to consult the prescriber for resolution. CONCLUSION: The detection of DRPs is strongly influenced by the information available. These results support models with pre-discharge medication reconciliation and pharmacist-led medication review procedures enabling both comprehensive detection and facilitated resolution of DRPs.

Medication Discrepancies in Community Pharmacies in Switzerland: Identification, Classification, and Their Potential Clinical and Economic Impact.

Background: Transitions of care are high-risk situations for the manifestation of medication discrepancies and, therefore, present threats for potential patient harm. Medication discrepancies can occur at any transition within the healthcare system. Methods: Fifth-year pharmacy students assessed a best possible medication list (BPML) during a medication review (based on medication history and patient interview) in community pharmacies. They documented all discrepancies between the BPML and the latest medication prescription. Discrepancies were classified using the medication discrepancy taxonomy (MedTax) classification system and were assessed for their potential clinical and economic impact. Results: Overall, 116 patients with a mean age and medication prescription of 74 (± 10.3) years and 10.2 (± 4.2), respectively, were analyzed. Of the 317 discrepancies identified, the most frequent type was related to strength and/or frequency and/or number of units of dosage form and/or the total daily dose. Although, the majority of discrepancies were rated as inconsequential (55.2%) on health conditions, the remainder posed a potential moderate (43.2%) or severe impact (1.6%). In 49.5% of the discrepancies, the current patients' medication cost less than the prescribed. Conclusion: Community pharmacies are at a favorable place to identify discrepancies and to counsel patients. To improve patient care, they should systematically perform medication reconciliation whenever prescriptions are renewed or added.

A survey to assess the availability, implementation rate and remuneration of pharmacist-led cognitive services throughout Europe.

BACKGROUND: Pharmacist-led cognitive services (PLCS) are increasingly necessary in primary care as a response to patient-centered care. However, the implementation rate and remuneration models of PLCS are either absent or superficially described in the literature. OBJECTIVE: The aim of this study is to review the implementation of PLCS in primary care across Europe and explore the associated third-party paid remuneration models. METHODS: A cross-sectional study was conducted using an online survey sent to representatives of 44 European countries. The survey listed 21 PLCS and asked respondents to report the availability of the service, the rate of implementation and the existence of remuneration. To ensure credible data, data triangulation was sought using three representatives per country, representing backgrounds of community pharmacy, pharmacy practice research and health policy. Subsequently, data was validated, and consensus sought. RESULTS: Data were collected between November 2016 and October 2017 from 34 different countries across Europe (79%). Provision of medicines' information (94.1%), generic substitution (85.3%), provision of emergency oral contraception (70.6%) and point-of-care testing (67.7%) were the services reported as the most widely disseminated in European primary care. Medication review was the most disseminated among advanced services (55.9%). Medication review, adherence support and monitoring, prescription renewal, opioid substitution and travel medicine had the highest implementation rates reported. Half of the participating countries mentioned models of remuneration, predominantly based on a fee-for-service, with less frequent reports of pay-for-performance or mixed models of remuneration. CONCLUSIONS: The availability of PLCS is increasing and varying in scope across Europe. There is wide variation in the implementation level of services across Europe and a lack of valid data. Remuneration of PLCS is also spreading but no clear pattern was found that relates service provision to payment.

Dispensing of Prescribed Medicines in Swiss Community Pharmacies-Observed Counselling Activities.

BACKGROUND: Patient counselling and addressing drug-related problems are the pharmacist's key activities to ensure the safe and effective use of medicines. This study aimed to describe the dispensing practice of prescribed medicines in daily community pharmacy practice and to identify factors influencing counselling provision; Methods: An observational study was conducted in community pharmacies in Basel, Switzerland. One master student in pharmacy performed non-participatory observations for one day at each of the participating community pharmacies. Patient characteristics, counselling content, additional activities, and pharmaceutical interventions were documented on a structured checklist; Results: 556 prescription encounters (PE) in 18 participating community pharmacies were observed (269 first prescriptions; 287 refill prescriptions). Patients were regular customers (n = 523, 94.1%) and 53.8 ± 23.4 years old. Counselling was provided to 367 (66.0%) customers on 2.9 ± 3.1 themes per PE. Factors influencing counselling were dispensing by the pharmacist, new customer, customer who did not refuse counselling, customer with a first prescription, with a prescription resulting in a pharmaceutical intervention, and a prescription filled by carers. During 144 PEs, 203 interventions were documented. Pharmacists proposed few additional activities and performed no cognitive pharmaceutical service; Conclusions: Our study quantified counselling and additional services at the dispensing of prescribed medicines and identified influencing factors on counselling provision at the patient, prescription, and pharmacy level.