Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions?

Propensity Score Adjustment

Propensity scoring (probability of treatment assignment conditional on observed baseline characteristics) was planned a priori to account for possible factors that would impact whether a patient received the intervention or control care levels. The propensity score for receiving Med Rec was computed from a logistic model using Med Rec as the outcome. A structured iterative approach was used to refine this model to achieve covariate balance within the matched pairs. Covariate balance was measured by the standardized difference, in which an absolute standardized difference >10% represents meaningful imbalance.²⁵ From the original cohort, we attempted to match patients who had the intervention to patients from the control by means of a matching algorithm using the logit of the propensity score for receiving the intervention.²⁶

Subgroup Analysis

We also examined the impact of the intervention on high-risk patient populations such as those ≥65 years of age, with a LACE index score ≥10, on high-alert medications, and on ≥10 medications. A univariate analysis was conducted to identify patient-related risk predictors that may be independently correlated with a higher risk of hospital visits.

Baseline Characteristics

A total of 8678 patients representing 9931 unique visits met the inclusion criteria for analysis. There were 2541 unique visits (approximately 26% of visits) in the intervention group that received Gold level care and 7390 unique visits in the control group. The patients in the control group were largely patients who received the original standard of care at the institution, Silver level care (67% of the control group). Patients who received Bronze level care or less comprised 33% of the control group.

Patients in the intervention group were significantly older (average of 68 years old versus 64 years old) and on more medications. They also notably had a longer duration of stay in hospital, an increased percentage of visits with a LACE index score ≥10, and were more likely to be discharged home on a high-alert medication and with supports (Table 2).

Main Analysis

The main unadjusted analysis of GIM patients (n = 9931 visits) did not detect a difference in 30-day ED visits and readmissions between the intervention group (540 out of 2541; 21.2%) and control (1423 out of 7390; 19.3%; Table 3). By using a multivariate logistic regression model to account for age, sex, LACE index, and number of medications on discharge, the adjusted odds ratio was 1.06 (95% CI, 0.95-1.19; P = 0.33). After propensity score adjustment, the relative risk of readmission was 0.88 (16.7% vs 18.9%; 95% CI, 0.59-1.32; P = 0.54).

Secondary Analyses

In each predefined high-risk patient subgroup (age ≥65, LACE index score ≥10, number of discharge medications ≥10, and the presence of high-alert medications), analyses of our primary endpoint did not detect significant adjusted odds ratios (Table 4). In our univariate analysis, increasing number of medications, LACE index score, and male gender were independently correlated with a higher risk of hospital visits (supplementary Appendix 2).

Med Rec is widely recommended as a patient safety strategy to prevent clinically significant medication discrepancies at transitions in care.^4-9 However, Med Rec varies widely in terms of what it entails and who delivers it, with the preponderance of evidence suggesting an impact on clinically significant medication discrepancies only when interprofessional care delivered includes a central role for pharmacists.²⁷ Furthermore, Med Rec appears to impact short term readmissions only when embedded in a broader, multifaceted, bundled intervention in which pharmacists or other team members educate patients about their medications and deliver postdischarge follow-up phone calls.^10-13

As very few hospitals have the resources to sustainably deliver intensive care bundles that are represented in RCTs (characterized by Platinum and Diamond levels of care in Table 1), in our observational study, we sought to explore whether a resource-attainable, enhanced Med Rec care bundle (Gold level) had an impact on hospital utilization compared to partial Med Rec care bundles (Bronze and Silver levels). In our findings, we did not detect a significant difference on ED visits and readmissions within 30 days between enhanced and partial care bundles. In a secondary analysis of the influence of the intervention on prespecified high-risk patient subgroups, we also did not detect a difference.

As far as we are aware, our long-term, observational study is the largest to date to explore a real-life, enhanced Med Rec intervention and examine its impact on meaningful patient outcomes. We extrapolated that our intervention group received several critical attributes of a successful bundle as discussed by Mueller in a systematic review.² Our intervention included the following: (1) a systematic BPMH process on admission; (2) integrated admission-to-discharge reconciliation processes; (3) discharge delineation of medication changes since admission; (4) pharmacist involvement in reconciliation from admission to discharge; (5) an electronic platform; and (6) formal discharge reconciliation with interprofessional collaboration. Additional components in the bundle described by Mueller included the following: patient education at discharge, postdischarge communication with the patient, and communication with outpatient providers and medication management.

In our results, we did not find a difference in outcomes between the intervention and control groups. Therefore, it is possible that the enhanced bundle’s focus on interprofessional involvement in discharge reconciliation (Gold care level) has no impact on hospital utilization compared to partial care bundles (Silver and Bronze levels). Kwan et al.³ describe similar findings in their systematic review, in which they evaluated the effects of hospital-based Med Rec on unintentional discrepancies with nontrivial risks for harm to patients on 30-day postdischarge hospital visits. Kwan et al.³ concluded that larger well-designed studies are required to further evaluate this outcome, but authors of current published studies suggest that Med Rec alone probably does not reduce postdischarge hospital utilization within 30 days. Med Rec may have a more significant impact on utilization when bundled with other interventions that improve discharge coordination.³

There may be several reasons why we were unable to detect a significant difference between the intervention and control groups. One limitation is that our nonrandomized, retrospective design may have led to unmeasured confounders that impacted allocation into the intervention group versus the control group. It was notable that patients in the intervention group had an increased age, longer duration of hospital stay, more medications, and high-alert medications on discharge compared to the control group and that may have biased our results towards the null hypothesis. Although the propensity score analysis attempted to adjust for this, it also did not detect a significant difference between groups.

In addition, the existing standard of care during the study period allowed for patients in the control group to receive varying levels of Med Rec. Ideally, we would have compared the intervention to a placebo group that did not receive any Med Rec-related care elements. However, as this was a real-life observational study, the majority of patients received some Med Rec services as a part of the standard of care. As a result, 67% of patients in the control group received Silver level Med Rec with a BPMH, admission reconciliation, and prescriber-only discharge reconciliation. This may have made it more difficult to show an incremental benefit on readmissions between the intervention and control.

Also, our primary outcome of all-cause ED or hospital readmissions within 30 days may not have been sensitive enough to detect the effect of Med Rec interventions alone. Only a small proportion of readmissions within 30 days of discharge are preventable and many patient and community level factors responsible for readmissions cannot be controlled by the hospital’s actions.²⁸ Comprehensive pharmacy interventions have demonstrated decreased hospitalizations and emergency visits at 12 months; however, the largest impact was seen on the more specific outcome of medication-related hospitalizations (80% reduction).²⁹ Lastly, another limitation was that we were unable to capture hospital visits to other centres. However, in our region, almost 75% of readmissions are to the same site as the initial hospitalization.³⁰

Overall, our findings in this study and novel characterization of Med Rec services are relevant to many hospital sites that are striving to implement integrated Med Rec with limited healthcare resources. Although interprofessional Med Rec likely reduces clinically significant medication discrepancies, enhanced interprofessional Med Rec on discharge (Gold Med Rec) alone may not be enough to impact hospital utilization compared to partial Med Rec services (Silver and Bronze Med Rec). Further research into practical, targeted Med Rec bundles on more specific outcomes (such as preventable postdischarge adverse events, “avoidable” hospital readmissions, and medication-related readmissions) may detect a significant benefit.