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Transition of care: A set of pharmaceutical interventions improves hospital discharge prescriptions from an internal medicine ward

  • Marine Neeman
    Affiliations
    Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland
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  • Maria Dobrinas
    Affiliations
    Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland
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  • Sophie Maurer
    Affiliations
    Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland

    Pharmacie du Marché, Vevey, Switzerland
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  • Damien Tagan
    Affiliations
    Hôpital Riviera-Chablais, Vaud-Valais (HRC), Vevey, Switzerland
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  • Annelore Sautebin
    Affiliations
    Hôpital Riviera-Chablais, Vaud-Valais (HRC), Vevey, Switzerland
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  • Author Footnotes
    1 Anne-Laure Blanc and Nicolas Widmer contributed equally to the supervision of this work.
    Anne-Laure Blanc
    Correspondence
    Corresponding author at: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Hôpital Riviera-Chablais, Vaud-Valais (HRC), site du Samaritain, Boulevard Paderewski 3, 1800 Vevey, Switzerland.
    Footnotes
    1 Anne-Laure Blanc and Nicolas Widmer contributed equally to the supervision of this work.
    Affiliations
    Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland
    Search for articles by this author
  • Author Footnotes
    1 Anne-Laure Blanc and Nicolas Widmer contributed equally to the supervision of this work.
    Nicolas Widmer
    Footnotes
    1 Anne-Laure Blanc and Nicolas Widmer contributed equally to the supervision of this work.
    Affiliations
    Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland

    Division of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland
    Search for articles by this author
  • Author Footnotes
    1 Anne-Laure Blanc and Nicolas Widmer contributed equally to the supervision of this work.
Published:November 25, 2016DOI:https://doi.org/10.1016/j.ejim.2016.11.004

      Highlights

      • Pharmaceutical interventions performed during hospital stay ensure continuity of care.
      • Pharmaceutical interventions lower treatment changes at different steps of transition of care.
      • Interventions at hospital lower the number of community pharmacy interventions needed on discharge prescriptions.
      • Pharmacists' hospital interventions lower phone calls to the hospital physician.

      Abstract

      Background

      Continuity of care between hospitals and community pharmacies needs to be improved to ensure medication safety. This study aimed to evaluate whether a set of pharmaceutical interventions to prepare hospital discharge facilitates the transition of care.

      Methods

      This study took place in the internal medicine ward and in surrounding community pharmacies. The intervention group's patients underwent a set of pharmaceutical interventions during their hospital stay: medication reconciliation at admission, medication review, and discharge planning. The two groups were compared with regards to: number of community pharmacist interventions, time spent on discharge prescriptions, and number of treatment changes.

      Results

      Comparison between the groups showed a much lower (77% lower) number of community pharmacist interventions per discharge prescription in the intervention (n = 54 patients) compared to the control group (n = 64 patients): 6.9 versus 1.6 interventions, respectively (p < 0.0001); less time working on discharge prescriptions; less interventions requiring a telephone call to a hospital physician.
      The number of medication changes at different steps was also significantly lower in the intervention group: 40% fewer (p < 0.0001) changes between hospital admission and discharge, 66% fewer (p < 0.0001) between hospital discharge and community pharmacy care, and 25% fewer (p = 0.002) between community pharmacy care and care by a general practitioner.

      Conclusion

      An intervention group underwent significantly fewer medication changes in subsequent steps in the transition of care after a set of interventions performed during their hospital stay. Community pharmacists had to perform fewer interventions on discharge prescriptions. Altogether, this improves continuity of care.

      Keywords

      1. Introduction

      Continuity of care is defined as “a set of actions designed to ensure the coordination and continuity of healthcare, as patients transfer between different locations or different levels of care within the same location” [
      • Coleman E.A.
      • Boult C.
      • American Geriatrics Society Health Care Systems C
      Improving the quality of transitional care for persons with complex care needs.
      ]. The main goals of continuity of care are optimal patient safety and quality of care [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ]. Transitions between hospital and community setting can be a major issue and need improvements to ensure medication safety. Indeed, discrepancies which happen after hospital discharge can lead to adverse medical events, increase the length of hospital stays or even lead to hospital readmissions [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ,
      • Michalsen A.
      • Konig G.
      • Thimme W.
      Preventable causative factors leading to hospital admission with decompensated heart failure.
      ,
      • Fluitman K.S.
      • van Galen L.S.
      • Merten H.
      • Rombach S.M.
      • Brabrand M.
      • Cooksley T.
      • et al.
      Exploring the preventable causes of unplanned readmissions using root cause analysis: coordination of care is the weakest link.
      ,
      • Mekonnen A.B.
      • McLachlan A.J.
      • Brien J.A.
      Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.
      ]. Different solutions have been shown to improve patient safety during transitions between care providers, such as: discharge planning and written discharge support notes, medication reconciliation, and increasing patient awareness and empowerment [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ]. The earlier interventions to prepare for hospital discharge start during hospitalisation, the greater the benefits to patients; those interventions can continue throughout and after hospitalisation [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ].
      Various studies have shown that clinical pharmacists performing these interventions can improve transition of care by reducing medication discrepancies and thus lower rates of adverse drug events and readmission [
      • Mekonnen A.B.
      • McLachlan A.J.
      • Brien J.A.
      Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.
      ,
      • Kaboli P.J.
      • Hoth A.B.
      • McClimon B.J.
      • Schnipper J.L.
      Clinical pharmacists and inpatient medical care: a systematic review.
      ,
      • Mekonnen A.B.
      • McLachlan A.J.
      • Brien J.A.
      Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
      ].
      Medication reconciliation performed at hospital admission allows several limitations in medication history to be identified. Incomplete medication histories at admission are the causes of hospital prescribing errors in almost 30% of cases [
      • Tam V.C.
      • Knowles S.R.
      • Cornish P.L.
      • Fine N.
      • Marchesano R.
      • Etchells E.E.
      Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.
      ]. Patients cannot always remember or understand their medication, indications or doses. Language and health literacy can be a barrier to this understanding, as can the short amount of time spent by physicians on a complete medication reconciliation [
      • Gleason K.M.
      • McDaniel M.R.
      • Feinglass J.
      • Baker D.W.
      • Lindquist L.
      • Liss D.
      • et al.
      Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
      ,
      • De Winter S.
      • Spriet I.
      • Indevuyst C.
      • Vanbrabant P.
      • Desruelles D.
      • Sabbe M.
      • et al.
      Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.
      ]. Moreover, over-the-counter drugs, herbal medicines, eye drops, vitamins and nutritional supplements are often omitted. Several different types of healthcare professionals (physicians, clinical pharmacists, nurse, etc.) may be able to carry out medication reconciliation, but a reconciliation carried out as part of a clinical pharmacist's routine practice is seldom possible, often due to financial constraints.
      Besides medication reconciliation, clinical pharmacists can reduce drug-related problems during hospitalisation by performing medication reviews and informing physicians about adverse drug events, drug interactions, therapeutic drug monitoring, pharmacoeconomic issues, etc. [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ,
      • Kaboli P.J.
      • Hoth A.B.
      • McClimon B.J.
      • Schnipper J.L.
      Clinical pharmacists and inpatient medical care: a systematic review.
      ].
      Another aspect of the transition between hospital and community care concerns treatment changes at each step; these changes occur for more than 95% of hospitalised patients [
      • von Kluchtzner W.
      • Grandt D.
      Influence of hospitalization on prescribing safety across the continuum of care: an exploratory study.
      ]. They can induce misunderstandings for patients, incomplete information and communication at transition steps, and thus induce medication errors and decreases in medication safety [
      • Kripalani S.
      • Henderson L.E.
      • Jacobson T.A.
      • Vaccarino V.
      Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions.
      ,
      • Frydenberg K.
      • Brekke M.
      Poor communication on patients' medication across health care levels leads to potentially harmful medication errors.
      ]. Community pharmacists are also concerned by this issue and play an important role after hospital discharge. They perform medication reconciliations between hospital discharge prescriptions and patients' medication histories in order to ensure complete and optimal treatments. One of the most common community pharmacist interventions is contacting a hospital physician to clarify whether a treatment change is intended or not [
      • Wüthrich R.
      Intervention pharmaceutique lors de la validation d'ordonnance.
      ]. Telephone calls to hospital physicians may induce disruptions to their work routines that can negatively affect patient safety [
      • Weigl M.
      • Muller A.
      • Zupanc A.
      • Glaser J.
      • Angerer P.
      Hospital doctors' workflow interruptions and activities: an observation study.
      ].

      2. Aim of the study

      This study aimed to evaluate whether a set of pharmaceutical interventions to prepare hospital discharge, in close collaboration with the medical staff involved in patient care, facilitates the transition of care, reduces interventions by community pharmacists and decreases the number of medication changes at different phases of the transition.

      3. Ethical approval

      This study was reviewed and approved by the Human Research Ethics Committee of the Canton Vaud (approval ID: 358/15). Oral informed consent was obtained from each participant included in the study.

      4. Material and methods

      4.1 Setting and participants

      The present prospective, interventional, monocentric study with an interrupted time series analysis included a control group followed by an intervention group. It took place in a 70-bed internal medicine ward of a Swiss hospital (the Hôpital Riviera–Chablais Vaud-Valais) and in community pharmacies surrounding it. Patients in the two groups were enrolled and monitored from October 2015 to May 2016.
      Patients in the control group were recruited consecutively from October to December 2015 by community pharmacists using the following study inclusion criteria: taking more than 4 drugs for chronic complaints; discharged from the hospital's internal medicine ward (whether followed by a stay in a rehabilitation centre or not); proficient in French; aged 18 years old or above; being followed-up by one of the participating community pharmacies; a hospital stay of at least 3 days; capable of discernment; and patient approval.
      Patients in the intervention group were recruited consecutively by the hospital's clinical pharmacist, between January and March 2016, by screening all the patients admitted to the hospital's internal medicine ward and using the same study inclusion criteria.

      4.2 Outcomes and variables

      4.2.1 Control group

      Participating community pharmacists were asked to collect data about all the interventions they performed and the time required to deal with the hospital discharge prescriptions handled in their pharmacies. A data collection questionnaire for the study was adapted from Maes et al. [
      • Maes K.A.
      • Tremp R.M.
      • pharmacy GWgoc
      • Hersberger K.E.
      • Lampert M.L.
      Demonstrating the clinical pharmacist's activity: validation of an intervention oriented classification system.
      ].
      During hospital stay, patients from the control group received usual care, which consisted in hospital admission and discharge prepared by the hospital physician. Medication reviews were not carried out systematically by a clinical pharmacist, but this could happen periodically, during medical ward rounds to which clinical pharmacists from our team participate on a monthly basis.

      4.2.2 Intervention group

      A set of three pharmaceutical interventions was systematically performed in this group: medication reconciliation at hospital admission; medication review during hospitalisation; and discharge planning, including discharge medication reconciliation.
      A pharmacy technician carried out medication reconciliation at admission under the clinical pharmacist's supervision. Three sources of medication history information were used: patients' admission drug regimen, collected from patients' electronic medical records (Soarian® version 4.00 SP08, Cerner Health Services, MO, USA); patient interviews about their medication, using a standard questionnaire; and patient medication histories, obtained from the participating community pharmacies by telephone call. Drugs were recorded by trade name and classified according to the anatomical therapeutic chemical (ATC) classification system (WHO Collaborating Centre for Drug Statistics Methodology) [
      World Health Organization (WHO) Collaborating Centre for Drug Statistics Methodology
      Methodology. Anatomical therapeutic chemical (ATC) classification system - ATC/DDD index 2016.
      ].
      Demographic data (age, sex) and clinical data (diagnoses, comorbidities) were also collected. Diagnoses and comorbidities were subsequently classified into broader categories. A score for the burden of chronic disease, adapted from Charlson et al., was calculated from any chronic comorbidities listed in the medical record [
      • Quan H.
      • Li B.
      • Couris C.M.
      • Fushimi K.
      • Graham P.
      • Hider P.
      • et al.
      Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
      ].
      After comparing the three data sources, medication discrepancies were identified by the pharmacy technician, validated by the clinical pharmacist and then transmitted to the hospital physician.
      Medication discrepancies were classified as omissions, dosing changes and galenic formulation changes. Their impact on patient care was assessed according to the potential to cause patient harm, using the classification developed by Cornish et al. [
      • Cornish P.L.
      • Knowles S.R.
      • Marchesano R.
      • Tam V.
      • Shadowitz S.
      • Juurlink D.N.
      • et al.
      Unintended medication discrepancies at the time of hospital admission.
      ]. According to these criteria, medication discrepancies were classed as: 1) unlikely to cause harm; 2) having potential to cause moderate discomfort or clinical deterioration; and 3) having potential to cause severe discomfort or clinical deterioration. This classification was made by consensus by three clinical pharmacists.
      The clinical pharmacist performed the medication review during the hospital stay, either during medical ward rounds or by informing the physician directly. Patients' medical prescriptions were analysed to identify potential drug-related problems with the following criteria: duplicate or missing therapy, contraindications, adverse events, drug–drug interactions, drug dosage, drug use or others, according to the system for pharmaceutical interventions of the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA) [
      System for pharmaceutical interventions of the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA).
      ]. These criteria were verified using product information, Micromedex® [
      • Truven Health Analytics Inc
      Micromedex solutions.
      ], Lexicomp® [
      • UpToDate drugs' database
      Lexicomp.
      ] and recommendations from available clinical guidelines. Lexi-Interact® [
      • UpToDate drugs' database
      Lexi-interact.
      ] was used to check drug–drug interactions. The clinical pharmacist's interventions were then classified according to the same GSASA classification [
      System for pharmaceutical interventions of the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA).
      ].
      Finally, the clinical pharmacist drew up a discharge plan for every patient at the end of their hospital stay. This consisted of reviewing discharge medication and a reconciliation with the patient's drug regimen at admission, communicating any prescription changes to the physician, informing the patient, and preparing a written summary of the discharge medication for both the patient and the community pharmacist.

      4.3 Comparison between control and intervention groups

      To compare the control and intervention groups, the following outcomes were analysed: number and type of interventions made by community pharmacists; time spent validating hospital discharge prescriptions; number of medication changes between different phases (hospital admission to discharge, hospital discharge to community pharmacy care, and community pharmacy care to care by a general practitioner (GP)).

      4.4 Statistical analysis

      Descriptive statistics (means, proportions, standard deviations, confidence intervals and graphic representations) were calculated using Excel® (version 2010, Microsoft Corp, Redmond, WA, USA). Student's t-test, Mann–Whitney and Kruskal–Wallis tests for the comparison of variables were carried out using STATA® (version 13.1, StataCorp, College Station, TX, USA). p-Values lower than 0.05 were considered statistically significant.

      5. Results

      5.1 Study population

      Fourteen of the 37 community pharmacies invited to participate in the study did so, and they recruited 64 patients for the control group.
      Of the 638 patients assessed for eligibility in the intervention group, 61 were included in the study and 54 completed it (Fig. 1). Table 1 describes the patient characteristics, diagnoses and comorbidities; there were no statistically significant differences in patient characteristics between the two groups.
      Table 1Patient characteristics.
      CharacteristicsControl group (n = 64)Intervention group (n = 54)p-Value
      Age, mean ± SD (range), years78 ± 12 (44–98)75 ± 12 (36–96)0.24
      Student's t-test for comparison.
      Sex, n (%)
       Male26(40)20(37)0.69
      Mann–Whitney comparison test.
       Female38(59)34(63)
      Number of drugs on discharge prescription,

      mean ± SD (range)
      10 ± 4 (3–19)10 ± 4 (5–25)0.95
      Student's t-test for comparison.
      Length of hospital stay,

      mean ± SD (range), days
      18 ± 15 (2–57)15 ± 12 (1–44)0.27
      Student's t-test for comparison.
      Charlson comorbidity score, mean ± SD (range)1.7 ± 1.7 (0–7)1.8 ± 1.6 (0–7)0.64
      Student's t-test for comparison.
      Diagnoses and comorbidities, n (%)
      For the intervention group, the percentages correspond to a number of 61 patients assessed for the intervention.
       Myocardial infarction12(19)11(18)
       Congestive heart failure18(28)16(26)
       Peripheral vascular disease5(8)7(11)
       Cerebrovascular disease8(13)6(10)
       Dementia6(9)3(5)
       Chronic pulmonary disease15(23)19(31)
       Rheumatologic disease4(6)5(8)
       Peptic ulcer disease7(11)3(5)
       Mild liver disease0(0)0(0)
       Diabetes without chronic complications16(25)14(23)
       Diabetes with chronic complications2(3)2(3)
       Hemiplegia or paraplegia0(0)0(0)
       Renal disease11(17)10(16)
       Any malignancy, including leukaemia or lymphoma1(2)2(3)
       Moderate or severe liver disease2(3)1(2)
       Metastatic solid tumour1(2)3(5)
       HIV/AIDs0(0)0(0)
      a Student's t-test for comparison.
      b Mann–Whitney comparison test.
      * For the intervention group, the percentages correspond to a number of 61 patients assessed for the intervention.

      5.2 Medication reconciliation at hospital admission

      Medication discrepancies were recorded in 80% (n = 44) of cases and the mean number of discrepancies per patient was of 2 (SD ± 1.8; range 0–7). A total of 119 discrepancies were identified and 90% (n = 106) of them were classified as omissions of a drug taken by the patient before hospital admission.
      The severity assessment of medication discrepancies revealed that 53% (n = 63) of them were unlikely to cause harm. The most common class of drugs in this category were analgesics. However, 27% (n = 32) of discrepancies had the potential to cause moderate discomfort or clinical deterioration, according to the Cornish classification; these were most commonly psycholeptics (e.g. benzodiazepines). A further 20% (n = 24) had the potential to cause severe discomfort or clinical deterioration; these were most commonly ophthalmic eye drops, medication for obstructive airway diseases and diuretics.
      The mean total time per patient spent on medication reconciliation at hospital admission (data collection, patient interviews, community pharmacy telephone calls) was 48 min (SD ± 18.4; range 20–105 min). Of this, the mean time spent on patient interviews was 16 min (SD ± 6.5; range 5–40 min).

      5.3 Medication review

      The clinical pharmacist performed a medication review for every patient included in the study during their hospital stay. The mean number of interventions per patient was 2.6 (SD ± 1.5; range 1–7) and the total number of interventions made by the clinical pharmacist and communicated to the patients' physicians was 136. Of these, the most frequent interventions were: therapy monitoring, 20% (n = 27); dose adjustment, 18% (n = 25); treatment initiation, 17% (n = 24); treatment discontinuation, 16% (n = 22); clarification of the medical record, 10% (n = 13); treatment substitution, 8% (n = 11); optimisation of administration, 7% (n = 9); and information to the healthcare team, 4% (n = 5). Cardiac medications, such as amiodarone, were the most frequently involved drugs (11%), followed by drugs for acid-related disorders, such as proton pump inhibitors (PPI) (10%), and analgesics (9%). Fig. 2 illustrates the most frequent interventions crossed with the main therapeutic classes, in order to emphasise specific pharmaceutical interventions related to specific medications.
      Fig. 2
      Fig. 2Medication review: most frequent interventions and main therapeutic classes.

      5.4 Discharge planning

      The clinical pharmacist communicated 125 discharge interventions to patients' physicians. Of these, the most frequent interventions were: drug substitution, 46% (n = 58); clarification of the medical record, 14% (n = 17); dose adjustment, 13% (n = 16); treatment discontinuation, 12% (n = 15); treatment initiation, 6% (n = 8); optimisation of administration, 6% (n = 8); and information to the healthcare team, 2% (n = 3). The most frequently involved drugs were psycholeptics (14%), drugs for acid-related disorders (9%) and agents acting on the renin-angiotensin system (9%). Fig. 3 presents the most frequent pharmaceutical interventions before discharge and the main therapeutic classes involved in those interventions.
      Fig. 3
      Fig. 3Medication reconciliation at discharge: most frequent interventions and main therapeutic classes.
      The clinical pharmacist spent with the hospital physician a mean time per discharge reconciliation of 14 min (SD ± 7.8; range 5–40 min); the mean time spent with each patient was also 14 min (SD ± 5.7; range 5–30 min).

      5.5 Comparison between control and intervention groups

      Results of the comparison between the control and intervention groups are presented in Table 2.
      Table 2Comparison of control and intervention groups.
      Control groupIntervention groupp-Value
      Number of patients6454
      Total number of interventions performed by community pharmacists on discharge prescriptions43988
      Number of interventions performed by community pharmacists per patient (discharge prescription), mean ± SD (range)6.9 ± 3.5 (1–16)1.6 ± 1.7 (0–6)<0.0001
      Student's t-test for comparison.
      Number of discharge prescriptions with no community pharmacist intervention014
      Number of interventions on discharge prescriptions requiring a telephone call to the patient's hospital physician30362
      Number of interventions requiring a telephone call to the patient's hospital physician per patient (discharge prescription), mean ± SD (range)4.8 ± 3.1 (0–14)1.2 ± 1.4 (0–6)<0.0001
      Student's t-test for comparison.
      Time spent by community pharmacists per discharge prescription, n (%)0.0001
      Kruskal–Wallis comparison test.
       <10 min9 (14)34 (63)
       10–20 min33 (52)15 (28)
       20–40 min18 (28)4 (7)
       >40 min4 (6)1 (2)
      Number of medication changes per patient between hospital admission and discharge, mean ± SD (range)9.6 ± 4.5 (2–23)6.0 ± 3.7 (0–19)<0.0001
      Student's t-test for comparison.
      Number of medication changes per patient between hospital discharge and community pharmacy care, mean ± SD (range)2.6 ± 1.9 (0–9)1.0 ± 1.5 (0–7)<0.0001
      Student's t-test for comparison.
      Number of medication changes per patient between community pharmacy care and GP care, mean ± SD (range)4.2 ± 2.7 (0–12)2.6 ± 1.9 (0–8)0.002
      Student's t-test for comparison.
      a Student's t-test for comparison.
      b Kruskal–Wallis comparison test.
      The mean number of interventions per patient by community pharmacists was of 6.9 in the control group and 1.6 in the intervention group: 77% (4.3 times) fewer interventions than for the control group (p < 0.0001). Every discharge prescription in the control group required a pharmaceutical intervention, but, interestingly, 14 (26%) discharge prescriptions in the intervention group required no pharmaceutical intervention whatsoever.
      The most frequent interventions made by community pharmacists per patient in the control group versus the intervention group were: confirmation of treatment discontinuation to the patients' physician (2.17 vs 0.56); drug substitution (1.41 vs 0.13); dose adjustment according to the patient's usual dosage (1.16 vs 0.15); medication substitution because of a reimbursement issue (0.61 vs 0.04); confirmation of initiation of a medication omitted from the discharge prescription with patient's physician (0.44 vs 0.37); and optimisation of drug formulation (0.45 vs 0.13).
      The time community pharmacists spent dealing with discharge prescriptions was significantly lower in the intervention group than the control group (p = 0.0001). For instance, less than 10 min was spent with 14% (n = 9) of patients in the control group, but with 63% (n = 34) of patients in the intervention group. Moreover, the mean number of interventions requiring telephone calls to patients' hospital physicians to clarify medication was of 4.8 in the control group and 1.2 in the intervention group: 75% (4 times) fewer interventions than for the control group (p < 0.0001).
      Data collected from community pharmacists showed that 32% of patients from the control group and 24% of patients from the intervention group had not seen their GP within 30 days of hospital discharge.
      With regards to treatment changes, there were statistically significant lower numbers of medication changes in the intervention group at different phases in the transition of care. The mean number of medication changes between hospital admission and discharge was 9.6 in the control group versus 6.0 in the intervention group (40% lower, p < 0.0001). The mean number of medication changes between hospital discharge and community pharmacy care was 2.6 versus 1.0 (66% lower, p < 0.0001) and between community pharmacy care and GP care was 4.2 versus 2.6 (25% lower, p = 0.002), for the control and intervention groups, respectively.

      6. Discussion

      The present study showed that a set of pharmaceutical interventions during hospital stay, performed in close collaboration with the medical staff involved in patient care, was associated with a lower number of medication changes at different phases in the transition of care. Furthermore, fewer community pharmaceutical interventions were necessary when validating hospital discharge prescriptions. All these elements can reduce the risk of misunderstanding and confusion related to medication, thus increasing patient safety during these transitions [
      • Frydenberg K.
      • Brekke M.
      Poor communication on patients' medication across health care levels leads to potentially harmful medication errors.
      ].

      6.1 Medication reconciliation at hospital admission

      In our study, 80% of patients had discrepancies in their medication reconciliation at hospital admission, with the omission of a drug previously taken by the patient being the most frequent one.
      Concerning the severity of discrepancies, those considered to have the potential to cause severe discomfort or clinical deterioration, according to the Cornish classification, mainly included medications like ophthalmologic eye drops for glaucoma treatment, for obstructive airway diseases and antidepressants. This is consistent with studies showing that patient self-perception and adherence to galenic formulations other than tablets might be poor and patients' knowledge about these medications might be incomplete or lacking [
      • Rees G.
      • Leong O.
      • Crowston J.G.
      • Lamoureux E.L.
      Intentional and unintentional nonadherence to ocular hypotensive treatment in patients with glaucoma.
      ,
      • Cecere L.M.
      • Slatore C.G.
      • Uman J.E.
      • Evans L.E.
      • Udris E.M.
      • Bryson C.L.
      • et al.
      Adherence to long-acting inhaled therapies among patients with chronic obstructive pulmonary disease (COPD).
      ]. Therefore, when interviewing patients about their medication history, clinicians must emphasise that patients should report on all galenic formulations so that no medicines are missed.
      Pharmacy-led reconciliation appears to improve medication safety by preventing most medication errors and by being the most cost-effective means of reconciliation [
      • Karnon J.
      • Campbell F.
      • Czoski-Murray C.
      Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation).
      ]. Some studies have shown that pharmacy technicians are effective and qualified to carry out medication reconciliation [
      • Mekonnen A.B.
      • McLachlan A.J.
      • Brien J.A.
      Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
      ,
      • Brownlie K.
      • Schneider C.
      • Culliford R.
      • Fox C.
      • Boukouvalas A.
      • Willan C.
      • et al.
      Medication reconciliation by a pharmacy technician in a mental health assessment unit.
      ,
      • Siemianowski L.A.
      • Sen S.
      • George J.M.
      Impact of pharmacy technician-centered medication reconciliation on optimization of antiretroviral therapy and opportunistic infection prophylaxis in hospitalized patients with HIV/AIDS.
      ,
      • Sen S.
      • Siemianowski L.
      • Murphy M.
      • McAllister S.C.
      Implementation of a pharmacy technician-centered medication reconciliation program at an urban teaching medical center.
      ,
      • Mueller S.K.
      • Sponsler K.C.
      • Kripalani S.
      • Schnipper J.L.
      Hospital-based medication reconciliation practices: a systematic review.
      ]. Having pharmacy technicians perform medication reconciliation, instead of a pharmacist, can thus improve this intervention's cost-effectiveness and accessibility [
      • Brownlie K.
      • Schneider C.
      • Culliford R.
      • Fox C.
      • Boukouvalas A.
      • Willan C.
      • et al.
      Medication reconciliation by a pharmacy technician in a mental health assessment unit.
      ]. In several European countries, medication reconciliation performed by pharmacy technicians at hospital admission has been shown to be beneficial [
      • De Winter S.
      • Spriet I.
      • Indevuyst C.
      • Vanbrabant P.
      • Desruelles D.
      • Sabbe M.
      • et al.
      Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.
      ,
      • Brownlie K.
      • Schneider C.
      • Culliford R.
      • Fox C.
      • Boukouvalas A.
      • Willan C.
      • et al.
      Medication reconciliation by a pharmacy technician in a mental health assessment unit.
      ,
      • van den Bemt P.M.
      • van den Broek S.
      • van Nunen A.K.
      • Harbers J.B.
      • Lenderink A.W.
      Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.
      ]. However, to the best of our knowledge, this is the first study in Switzerland to analyse the involvement of a pharmacy technician in medication reconciliation at admission.
      Whether conducted by a physician or a pharmacy technician, this study showed the importance of carrying out a medication reconciliation using a structured patient interview and completing the medication history by using another source of information, such as the patient's community pharmacy.

      6.2 Medication review

      Several previous studies have shown that pharmacist-led medication reviews can improve medication safety [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ,
      • Kaboli P.J.
      • Hoth A.B.
      • McClimon B.J.
      • Schnipper J.L.
      Clinical pharmacists and inpatient medical care: a systematic review.
      ,
      • Schnipper J.L.
      • Kirwin J.L.
      • Cotugno M.C.
      • Wahlstrom S.A.
      • Brown B.A.
      • Tarvin E.
      • et al.
      Role of pharmacist counseling in preventing adverse drug events after hospitalization.
      ].
      In the present study, the clinical pharmacist systematically reviewed the medical treatments of patients included in the intervention group and transmitted potential drug-related problems identified to patients' physicians. The drugs most frequently identified by these pharmaceutical interventions were cardiac drugs, such as amiodarone. Because the clinical pharmacist was emphasising amiodarone's potential to cause drug–drug interactions, the precautions linked to its use and possible adverse events, the most frequent follow-up intervention was therapy monitoring. Other drugs involved were for acid-related disorders, such as PPI. Dose adjustment or a discontinuation of PPI treatment were the most common subsequent interventions associated with this therapeutic class. This was confirmed by previous studies showing that the prescription and dosage of PPI are not always appropriate in various hospital settings [
      • Kelly O.B.
      • Dillane C.
      • Patchett S.E.
      • Harewood G.C.
      • Murray F.E.
      The inappropriate prescription of oral proton pump inhibitors in the hospital setting: a prospective cross-sectional study.
      ,
      • Bez C.
      • Perrottet N.
      • Zingg T.
      • Leung Ki E.L.
      • Demartines N.
      • Pannatier A.
      Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department.
      ].

      6.3 Discharge planning

      One of the therapeutic classes most affected by these pharmaceutical interventions before hospital discharge was psycholeptic drugs, such as benzodiazepines. This was consistent with findings from other studies suggesting inappropriate benzodiazepine prescriptions during hospital stays and at discharge [
      • Warie H.
      • Petrovic M.
      • Somers A.
      • Mariman A.
      • Robays H.
      • Pevernagie D.
      The use of hypnosedative drugs in a university hospital setting.
      ,
      • Fagnoni P.
      • Limat S.
      • Haffen E.
      • Henon T.
      • Jacquet M.
      • Sechter D.
      • et al.
      Does hospitalisation affect hypnotic and anxiolytic drug prescribing?.
      ]. Indeed, a recent study conducted in our hospital showed that hospital stay increased the likelihood that a patient was prescribed a hypnotic drug at discharge, making clinical pharmacists' interventions all the more justified [
      • Schumacher L.
      • Blanc A.-L.
      • Tagan D.
      • Sautebin A.
      • Widmer N.
      Prescription of hypnotics during hospital stay: an epidemiological study in a Swiss hospital. In 83. Jahresversammlung der Schweizerischen Gesellschaft für Allgemeine Innere Medizin.
      ].
      In addition to medication reconciliation at discharge, counselling patients about their medication use, each drugs role, dose and frequency, drug interactions, common adverse effects, etc., is an important element of discharge planning [
      • Laugaland K.
      • Aase K.
      • Barach P.
      Interventions to improve patient safety in transitional care—a review of the evidence.
      ,
      • Schnipper J.L.
      • Kirwin J.L.
      • Cotugno M.C.
      • Wahlstrom S.A.
      • Brown B.A.
      • Tarvin E.
      • et al.
      Role of pharmacist counseling in preventing adverse drug events after hospitalization.
      ]. Patients are indeed confused at discharge; most of them are unable to name their medication, diagnoses, drugs role and the main side effects. Patient's awareness of these elements can improve their comprehension and adherence to treatment [
      • Makaryus A.N.
      • Friedman E.A.
      Patients' understanding of their treatment plans and diagnosis at discharge.
      ].

      6.4 Comparison between control and intervention groups

      Our study showed a significant improvement in the transition of care. Following a set of pharmaceutical interventions, the number of interventions by community pharmacists was lower, as was the number of medication changes at different phases in the transition of care.
      Both the number of interventions per prescription and the time needed for community pharmacists to validate discharge prescriptions were significantly lower. Moreover, compared to the control group, community pharmacists made 75% fewer interventions requiring telephone calls to patients' physicians in order to clarify discharge prescriptions for the intervention group. This translates into a significant time saving for both community pharmacists and hospital physicians, and there is a decreased risk of errors associated with the frequent interruption of hospital physicians [
      • Weigl M.
      • Muller A.
      • Zupanc A.
      • Glaser J.
      • Angerer P.
      Hospital doctors' workflow interruptions and activities: an observation study.
      ,
      • Méan M.
      • Garnier A.
      • Wenger N.
      • Castioni J.
      • Marques-Vidal P.
      • Waeber G.
      Task-switching during resident's working day: disruption or efficient flexibility.
      ].
      These results show the importance of good coordination between care providers in order to guarantee patient safety. A lack of coordination within healthcare systems, such as failures to transmit the appropriate information to physicians or patients, appears to be a cause of preventable readmissions [
      • Fluitman K.S.
      • van Galen L.S.
      • Merten H.
      • Rombach S.M.
      • Brabrand M.
      • Cooksley T.
      • et al.
      Exploring the preventable causes of unplanned readmissions using root cause analysis: coordination of care is the weakest link.
      ].
      Few studies to date have shown how clinical pharmacists' interventions during hospital stays can have an impact on the amount of work community healthcare professionals must do. This is, to the best of our knowledge, the first study in Switzerland to have addressed this step in the transition of care.
      Changes in medication are made for almost every hospitalised patient [
      • von Kluchtzner W.
      • Grandt D.
      Influence of hospitalization on prescribing safety across the continuum of care: an exploratory study.
      ]. As previously demonstrated, changes in drug regimen during hospitalisation are frequent, as they are during the immediate period after hospital discharge. A particular focus on these changes is needed in order to guarantee medication safety [
      • Viktil K.K.
      • Blix H.S.
      • Eek A.K.
      • Davies M.N.
      • Moger T.A.
      • Reikvam A.
      How are drug regimen changes during hospitalisation handled after discharge: a cohort study.
      ]. The present study demonstrated that the patients in the intervention group had significantly fewer changes in their medication throughout the transition of care than did the control group. By summing all the medication changes during transition of care, patients in the control group had a mean of 17 changes, representing an important source of potential medication errors and safety concerns. In contrast, patients in the intervention group had a mean of 10 changes. This shows that a set of pharmaceutical interventions can reduce medication changes and thus decrease the risk of medication-related errors [
      • Kripalani S.
      • Henderson L.E.
      • Jacobson T.A.
      • Vaccarino V.
      Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions.
      ].
      This lower number of medication changes is consistent with the finding that the most frequent pharmaceutical intervention before hospital discharge was treatment substitution. Medication reconciliation at discharge therefore enabled drugs previously taken by the patient, and possibly changed during the hospital stay, to be included on the discharge prescription once more.
      However, the fact that almost one third of patients from both groups had not consulted their GPs within 30 days of hospital discharge represented a further high risk of medication errors. These consultations are particularly important because the most frequent types of change between hospital admission and discharge were treatment initiation or discontinuation, followed by drug substitution. The validation of the hospital discharge drug regimen by a GP is therefore a crucial step in long-term treatment safety.
      In the present study, most of the patients who did consult their GPs after hospital discharge and then returned to their community pharmacies, had their treatments introduced during hospital stay discontinued.
      Even if there is no data available in the literature on medication changes performed by GPs after hospital discharge, several reasons could explain such changes. Firstly, patients' medication can be changed upon hospital admission, according to drugs' availability in the hospital. Therefore, the GPs often choose to prescribe back the habitual drugs taken by the patient before hospital admission. Moreover, the GPs may prefer to maintain the treatment that has been shown to be the most effective for the patient according to his own medical history, and therefore prefer to prescribe those former medications. Finally, given that GPs might receive hospital discharge documents after patients' appointment, they are thus not aware of the reasons for medication changes during hospital stay, and thus decide to maintain patients' usual medication.

      6.5 Study strengths and limitations

      This study had some limitations. Firstly, this is a non-randomised study with a chronological design, which might have caused a patient selection bias. However, patient characteristics were very similar between the two groups, so we are confident in the interpretation of the study results. Secondly, this study shows the local practices of a regional hospital, and the number of patients included was small. Larger studies with higher numbers of patients and broader outcomes would probably be needed before generalising these results. Finally, this study tested a whole set of pharmaceutical interventions during hospitalisation, so it is not possible to evaluate the chronological impact of each intervention. Moreover, the design of the study and the available resources did not allow a more thorough evaluation of patients' outcomes, in terms of morbidity, mortality, patients' knowledge at discharge and hospital readmission.
      Nevertheless, the significant differences observed between the control and intervention groups allowed us to emphasise the significant role that a clinical pharmacist can play during a hospital stay and at discharge.
      This study's strengths are that, to the best of our knowledge, it is the first in Switzerland to involve collaboration between clinical and community pharmacists, together with the hospital physician, to improve the critical phases of transition of care and to demonstrate that a pharmacy technician can be involved in medication reconciliation.

      7. Conclusion

      This study provides evidence that a set of pharmaceutical interventions carried out during a hospital stay and coordination between different healthcare professionals are significant elements in ensuring patients' medication safety.
      The study demonstrated that it was possible to reduce the number of medication changes at each step in the transition of care and the number of interventions community pharmacists have to perform on hospital discharge prescriptions. All these elements contribute to improvements in the continuity of care and to patient safety.

      Ethical approval

      Yes.

      Conflict of interests

      The authors declare no conflicts of interest related to this study.

      Acknowledgements

      The authors are thankful to the medical teams from the internal medicine ward of the Hôpital Riviera-Chablais Vaud-Valais (Vevey, Switzerland), to the community pharmacies of the Riviera region of Switzerland for their valuable work and collaboration, and to the patients who participated in this study. Finally, D. Hart is thanked for proofreading the English.

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