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Discharge mEdication reconciliation by Pharmacists to improve Transitions following Hospitalization ( DEPTH )

Background: Study objectives were to evaluate readmission rates and cost avoidance associated with pharmacist-led discharge medication reconciliation. Methods: This prospective, cohort pilot study was conducted from September through October 2012. Patients eligible were adults with more than 1 discharge medication. During this pilot phase, only patients seen by hospitalist physicians on the pulmonary unit and discharged between 8:00 am and 4:00 pm on Monday through Friday received pharmacist-led medication reconciliation. The primary outcomes included the number and type of pharmacist intervention and the potential cost avoidance associated with the intervention. Secondary outcomes included change in 30-day readmission rates and change in HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Results: Fifty-eight patients were included for receiving pharmacy-led discharge medication reconciliation. Sixty patients discharged from the same unit during the study period did not meet inclusion criteria and served as the comparison group. There were 116 recommendations across the 58 patients in the intervention population. Seventy-four of 116 recommendations (63.7%) were accepted by the physician. The total cost avoidance of all the recommendations was estimated to be $66 192. Seventeen percent of patients receiving pharmacy-led discharge medication reconciliation were readmitted to our institution within 30 days of hospital discharge, which was not statistically different from the comparison group. No significant difference was seen between HCAHPS scores in the 2 groups. Conclusions: Pharmacists have a valuable role in the discharge medication reconciliation process. Pharmacists’ interventions at discharge can contribute to more interdisciplinary collaboration and prevent unnecessary medication costs. Several studies have linked poor medication reconciliation to increased adverse drug events (ADEs) and a rise in hospital and emergency department (ED) readmissions. Unplanned hospital readmissions continue to be an outcome measure used to evaluate the quality of hospital care. One in 5 hospitalized Medicare beneficiaries is readmitted within 30 days of discharge, leading to increased healthcare costs, averaging $17.4 billion in 2004.1 Both the Joint Commission and Centers for Medicare & Medicaid Services (CMS) have focused on reducing readmission rates and have included medication reconciliation as an important component in achieving that goal. The Joint Commission has outlined the following 5 steps as essential elements to completing medication reconciliation: 1) obtain a home medication list, 2) obtain a list of medications to be prescribed during the hospitalization, 3) compare the 2 lists, 4) identify and resolve discrepancies, and 5) communicate any changes to the patient or caregivers.2 The importance of admission medication reconciliation is well documented in the literature. Previous studies have indicated that more than GHS Proc. May 2016; 1 (1): 32-37