Evaluation of Pharmacist Involvement in Outpatient Transitions of Care
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KEY WORDStransitions of care pharmacy medication reconciliation outpatient general medicine
Approximately 20% of patients will experience an adverse event during the transition from hospital to home, with two thirds of the events due to medications.1 Medication reconciliation at transitions can minimize and/or eliminate the risk of medication errors by ensuring each patient’s regimen is accurate and updated.2 Pharmacists are uniquely qualified to complete this task due to their expertise in assessing patients’ medication profiles, identifying medication errors, and providing recommendations for resolution. Studies have consistently found that pharmacist involvement in medication reconciliation in the inpatient setting reduces medication errors.3, 4 However, few have examined the integration of a pharmacist in the outpatient setting, following a patient’s discharge to home.
UConn Health’s academic hospital (JDH) utilizes trained pharmacy technicians to conduct comprehensive medication history taking. At discharge, medication reconciliation is performed by a physician, with any changes noted in the discharge summary. General Medicine Associates (GMA) is a primary care clinic within the UConn Health system that includes 49 general medicine providers, 34 of whom are medical residents, and a pharmacy team (faculty, residents, and students). While the facilities utilize separate medical records, providers have access to both.
Our objective was to assess the impact of pharmacist involvement on the identification and resolution of medication discrepancies during post-discharge follow-up appointments at GMA. The institution’s investigational review board (IRB) granted exemption to this project, as it was determined to be a quality improvement project.
A retrospective and prospective analysis was completed to determine the impact of pharmacist integration into an outpatient transition of care process. The retrospective review included 31 patients discharged from JDH who had a Medicare transition of care management (TCM) visit between February 2016 and September 2016. The prospective review included 14 patients discharged from hospital to home with a scheduled follow-up/TCM appointment between October 2016 and March 2017.
In both cohorts, a medical assistant (MA) called the patient prior to the scheduled appointment to review the discharge summary and conduct medication reconciliation. Following, a pharmacist reviewed the discharge instructions, medication list, and the MA’s medication reconciliation and compared this with the outpatient medication profile to identify medication discrepancies and provide recommendations to the primary care provider (PCP).
Types of medication discrepancies identified
Medications active in outpatient profile not included in discharge instructions
Medications included in discharge instructions not currently active in outpatient profile
Medications active in outpatient profile and included in discharge instruction, but with a change in dose, frequency, or directions
Drug interaction deemed potentially significant
Includes duplicate active orders, direction/dose optimization, and all other discrepancies not included in above categories
The patient population was similar between the two cohorts with respect to age (p = 0.74), gender (p = 0.45), and number of medications at discharge (12.8 ± 5.4 vs. 13.1 ± 7.1; p = 0.9). The number of medication discrepancies identified was not significantly different (p = 0.09) between the retrospective (11.3, SD 5.8) and prospective (12, SD 7.8) cohorts. Of the identified medication discrepancies, 21% involved cardiac medications, 18% involved over the counter medications or dietary supplements, and 13% involved gastrointestinal medications. Omissions, additions, and dose changes accounted for greater than 75% of all discrepancies identified in both cohorts with no significant differences between the two cohorts.
Pharmacist involvement in outpatient-based transitions of care significantly increased medication discrepancies addressed by the patient’s PCP following discharge from hospital to home. Furthermore, pharmacist involvement led to a significant increase in the percentage of moderate and major discrepancies addressed by the physician. This project’s demonstration of an improved medication reconciliation process with pharmacist involvement within a general medicine practice expands the body of evidence that pharmacists improve transitions of care management to include outpatient settings.
The authors wish to thank and recognize Jeffery Aeschlimann, PharmD, for his assistance with data analysis and statistical testing.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 2.Schuldt LM. Joint Commission resources: medication reconciliation handbook. 2nd rev. ed. Oakbrook Terrace, IL: Department of Publication Joint Commission Resources; 2009:2–3Google Scholar