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Introduction: Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge.Methods: A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders.Results: In total, 369 patients were included (control: n = 195, intervention: n = 174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, ORadj 0.70 [95% CI 0.38–1.31], university hospital: 63% vs 50%, OR adj 1.76 [95% CI 0.75–4.13]).Conclusion: The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.

Background after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. Design single-blind, randomised clinical trial. Setting the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. Subjects cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. Methods the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. Results in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care. Conclusion in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months. Trial registration Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Knowledge regarding preventable hospital readmissions is scarce. Our aim was to compare the clinical characteristics of potentially preventable readmissions (PPRs) with non-PPRs. Additionally, we aimed to identify risk factors for PPRs. Our study included readmissions within 30 days after discharge from 1 of 7 hospital departments. Preventability was assessed by multidisciplinary meetings. Characteristics of the readmissions were collected and 23 risk factors were analyzed. Of the 1120 readmissions, 125 (11%) were PPRs. PPRs occurred equally among different departments (p = 0.21). 29.6% of PPRs were readmitted by a practitioner of a different medical specialty than the initial admission (IA) specialist. The PPR group had more readmissions within 7 days (PPR 54% vs. non-PPR 44%, p = 0.03). The median LOS was 1 day longer for PPRs (p = 0.16). Factors associated with PPR were higher age (p = 0.004), higher socio-economic status (p = 0.049), fewer prior hospital admissions (p = 0.004), and no outpatient visit prior to readmission (p = 0.025). This study found that PPRs can occur at any department in the hospital. There is not a single type of patient that can easily be pinpointed to be at risk of a PPR, probably due to the multifactorial nature of PPRs.

Background Drug-related problems after discharge are common among older adults with polypharmacy. Medication review during hospitalization has been proposed as one solution. Inpatient medication review is often based on clinical records only. An obstacle is the lack of insight into the outpatient history. Therefore, a geriatric stewardship was designed and involved an inpatient medication review by a hospital pharmacist and geriatrician based on (I) clinical records to draft initial recommendations, (II) consultations with primary care providers (general practitioner and community pharmacist) to discuss the hospital-based recommendations, (III) patient interviews to assess their needs, and (IV) a multidisciplinary evaluation of all previous steps to draft final recommendations. Objective To assess the effect of the geriatric stewardship on drug-related problems reported by patients after discharge. Setting General teaching hospital. Methods An implementation study (pre–post design) was performed. Orthopaedic and surgical patients (≥ 65 years) with polypharmacy and a frailty risk factor were included. The pre-group received usual care, the post-group received the geriatric stewardship intervention. Two weeks post-discharge, patient-reported drug-related problems were assessed using a validated questionnaire. Drug-related problems were classified into drug-related complaints, practical problems, and questions about medication. Outcomes The outcomes were the number and type of drug-related problems per patient (primary) and the number of initial recommendations that were altered due to primary care provider and patient input (secondary). Results In total, 127 patients were analysed (usual care n = 74, intervention n = 53). Intervention patients reported fewer drug-related problems compared to usual care: 2.8 versus 3.3 per patient (Adjusted relative risk 0.83, 95% confidence interval 0.66–1.05). This difference resulted from a halving in drug-related complaints (p

BackgroundHarm due to medications is common during the transition from hospital to home. Approaches that seek to prevent harm often involve isolated medication-related interventions and show conflicting results. However, until now, no review has focused on the effect of intervention components delivered both in hospital and following discharge from hospital to home.ObjectiveTo examine effects of medication-related interventions on hospital readmissions, medication-related problems (MRPs), medication adherence and mortality.MethodsFor this systematic review and meta-analysis, we searched the PubMed, Embase, CINAHL and CENTRAL databases without language restrictions. Citations of included articles were checked through Web of Science and Scopus from inception to 20 June 2019. We included prospective studies that examined effects of medication-related interventions delivered both in hospital and following discharge from hospital to home compared with usual care. Three authors independently extracted data and assessed study quality in pairs.ResultsFourteen original studies were included, comprising 8182 patients. Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Nine studies were included in the meta-analysis; compared with usual care (n=3376 patients), medication-related interventions (n=1820 patients) reduced hospital readmissions by 3.8 percentage points within 30 days of discharge (number needed to treat=27, risk ratio (RR) 0.79 (95% CI 0.65 to 0.96)). Meta-regression analysis suggested that readmission rates were reduced by 17% per additional intervention component (RR 0.83 (95% Cl 0.75 to 0.91)). Medication adherence and MRPs may be improved. Effects on mortality were unclear.ConclusionsStudied medication-related interventions reduce all-cause hospital readmissions within 30 days. The treatment effect appears to increase with higher intervention intensities. More evidence is needed for recommendations on adherence, mortality and MRPs.

Aims: Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge. Methods: We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group. Results: For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (Pinteraction = .085). In total, 77.0% of the patients had at least one MRP post-discharge. Conclusions: Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

BACKGROUND: Polypharmacy may result in medication-related readmissions (MRRs). Identifying MRRs is time consuming. Screening of readmissions by students could increase efficiency for healthcare professionals. Recently, two screening tools have been published: the Assessment Tool for identifying Hospital Admissions Related to Medications (AT-HARM10) tool and the Drug-Related Admission (DRA) adjudication guide. It is unknown whether pharmacy students could identify MRRs with these tools. OBJECTIVE: To compare the agreement between two pharmacy students applying the AT-HARM10 tool and DRA adjudication guide in identifying MRRs vs a multidisciplinary panel. METHODS: A retrospective study was conducted from February to July 2020 at OLVG hospital. Readmissions within 30 days after discharge from seven departments were reviewed by a multidisciplinary panel (pharmacists and physicians). MRRs were defined as readmission where medication was the main cause or medication significantly contributed to the readmission. Two 5th year pharmacy-students volunteered to blindly apply both tools individually on all MRRs and a random sample of non-MRRs. The consensus results of the students and the multidisciplinary panel were compared and displayed as a percentage and Cohen's kappa (κ). RESULTS: Three hundred sixty-six readmission cases were selected in total, consisting of 181 MRRs and 185 non-MRRs. The agreement between the students using the AT-HARM10 tool vs the multidisciplinary panel was moderate (80%, κ = 0.60 (95% confidence interval (CI): 0.52-0.68)). The DRA adjudication guide had a moderate agreement (81%, κ = 0.62 (CI: 0.54-0.70)). Students misclassified MRRs mainly because the multidisciplinary panel found disease progression more profound than a contribution of medication. CONCLUSIONS: Two students have an overall agreement of 80% in comparison with the multidisciplinary panel with a moderate Cohen's kappa. Students are more often overestimated, but they may be a good option to preselect potential MRRs to save time for healthcare professionals. However, some MRRs will be missed.

Background: Hospital readmission rates are increasingly used as a measure of healthcare quality. Medicines are the most common therapeutic intervention but estimating the contribution of adverse drug events as a cause of readmissions is difficult.Objectives: To assess the prevalence and preventability of medication-related readmissions within 30 days after hospital discharge and to describe the risk factors, type of medication errors and types of medication involved in these preventable readmissions.Design: A cross-sectional observational study.Setting: The study took place across the cardiology, gastroenterology, internal medicine, neurology, psychiatry, pulmonology and general surgery departments in the OLVG teaching hospital, Netherlands.Participants: Patients with an unplanned readmission within 30 days after discharge from an earlier hospitalization (index hospitalization: IH) were reviewed.Measurements: The prevalence and preventability of medication-related readmissions were assessed by residents in multidisciplinary meetings. A senior internist and hospital pharmacist reassessed the prevalence and preventability of identified cases. Generalized estimating equation with logistic regression was performed to identify risk factors of potentially preventable medication-related readmissions.Results: Of 1,111 included readmissions, 181 (16%) were medication-related, of which 72 (40%) were potentially preventable. The number of medication changes at IH (Adjusted odds ratio [ORadj]: 1.14; 95% CI: 1.05–1.24) and having ≥3 hospitalizations 6 months before IH (ORadj: 2.11; 95% CI: 1.12–3.98) were risk factors of a preventable medication-related readmission. Of these preventable readmissions, 35% were due to prescribing errors, 35% by non-adherence and 30% by transition errors. Medications most frequently involved were diuretics and antidiabetics.Conclusion: This study shows that 16% of readmissions are medication-related, of which 40% are potentially preventable. If the results are confirmed in larger multicentre studies, this may indicate that more attention should be paid to medication-related harm in order to lower the overall readmission rates.

Contains fulltext : 218225.pdf (Publisher’s version ) (Open Access) BACKGROUND: Hospital readmissions are increasingly used as an indicator of quality in health care. One potential risk factor of readmissions is polypharmacy. No studies have explored the patients' perspectives on the medication relatedness and potential preventability of their readmissions. OBJECTIVE: To compare the patients' perspectives on the medication relatedness and potential preventability of their readmissions with the providers' perspectives. METHODS: Patients unplanned readmitted within 30 days after discharge at one of the participating departments of OLVG Hospital in Amsterdam were interviewed during their readmission. Patients' perspectives regarding medication relatedness of their readmissions, the potential preventability, possible preventable interventions, and satisfaction with medication information were examined. Health-care providers also reviewed files of these readmitted patients. Primary outcome was the percentage of medication-related and potentially preventable readmissions according to the patient vs the provider. Descriptive data analysis was used. RESULTS: According to patients, 36 of 172 (21%) readmissions were medication-related, and of these, 21 (58%) were potentially preventable. According to providers, 26 (15%) readmissions were medication-related and 6 (23%) of these were potentially preventable. Patients and providers agreed on the medication relatedness in 11 of the 172 readmissions, and in two of these, agreement on the potential preventability existed. According to patients, preventive interventions belonged mostly to the hospital level, followed by the primary care level and patient level. CONCLUSION: Patients and providers differ substantially on their perspectives regarding the medication relatedness and preventability of readmissions. Patients were more likely to view medication-related readmissions as preventable.

Contains fulltext : 220997.pdf (Publisher’s version ) (Open Access) OBJECTIVES: To identify the preventability, determinants and causes of unplanned hospital readmissions within 30 days of discharge using a multidisciplinary approach and including patients' perspectives. DESIGN: A prospective cross-sectional single-center study. SETTING: Urban teaching hospital in Amsterdam, the Netherlands. PARTICIPANTS: 430 patients were included. Inclusion criteria were: age ≥ 18 years, discharged from one of seven participating clinical departments and an unplanned readmission within 30 days. METHODS: Residents from the participating departments individually assessed whether the readmission was caused by healthcare, the preventability and possible causes of readmissions using a tool. Thereafter, the preventability of the cases was discussed in a multidisciplinary meeting with residents of all participating departments and clinical pharmacists. The primary outcome was the proportion of readmissions that were potentially preventable. Secondary outcomes were the determinants for a readmission, causes for preventable readmissions, the change in the final decision on preventability after the multidisciplinary meeting and the value of patient interviews in assessing preventability. Differences in characteristics of potentially preventable readmissions (PPRs) and non-PPRs were analyzed using multivariable logistic regression. RESULTS: Of 430 readmissions, 56 (13%) were assessed as PPRs. Age was significantly associated with a PPR (adjusted OR: 2.42; 95%, CI 1.23-4.74; p = 0.01). The main causes for PPRs were diagnostic (30%), medication (27%) and management problems (27%). During the multidisciplinary meeting, the final decision on preventability changed in 11% of the cases. When a patient interview was available, it was used as a source of information to assess preventability in 26% of readmissions. In 7% of cases, the patient interview was mentioned as the most important source. CONCLUSION AND IMPLICATIONS: 13% of readmissions were potentially preventable with diagnostic, medication or management problems being main causes. A multidisciplinary review approach and including the patient's perspective could contribute to a better understanding of the complexity of readmissions and possible improvements.

Purpose The need for information for patients and caregivers at the point of hospital discharge is paramount and potentially extensive. Objective The objective of this study was to assess patients' informational needs at hospital discharge, patients' recall of medication changes implemented in the hospital and patients' medication related problems experienced one week after hospital discharge. Methods The study was conducted in a teaching hospital where patients received structured discharge counseling. Patients were interviewed at hospital discharge regarding their informational needs. One week post-discharge, patients were interviewed by phone to assess any changes in informational needs, their recall regarding in-hospital medication changes and the medication related problems. Descriptive analysis and logistic regression were used to address study objectives. Results The 124 patients in the study regarded the following topics as most relevant for counseling: what the medicine is for (57%), side effects (52%), drug-drug interactions (45%), action of the drug (37%) and reimbursement (31%). In 9% of patients the informational needs changed post-discharge, e.g. the topic side effects increased in importance. Forty-nine percent could recall whether and which medication was changed during hospitalization. Medication-related problems and side effects were reported by respectively 27% and 15% of patients, whereas only 7% contacted their doctor or pharmacist. Conclusions Patients' informational needs are very individual and can change post-discharge. Despite structured counseling, only half of the patients were able to recall the medication changes implemented in the hospital. Furthermore, patients reported several problems for which they did not consult a healthcare provider. This insight could help in smoothing the transition from hospital to the primary care setting.

Item does not contain fulltext OBJECTIVES: To summarize the evidence on the prevalence and preventability of drug-related hospital readmissions. DESIGN: A systematic review was performed of studies that examined drug-related hospital readmissions. PubMed, EMBASE, and the Cochrane Library were searched from inception through August 2016. Reference lists and a citation analysis on Web of Science and Scopus were also consulted. Two reviewers extracted study data with dual assessment of risk of bias. Prevalence and preventability of readmission due to drugs were calculated. Data were qualitatively summarized according to outcome. RESULTS: Nineteen studies met the eligibility criteria. Nine measured readmissions due to drug-related problems, seven due to adverse drug reactions, two due to adverse drug events, and one due to drug-drug interactions. Rates of readmissions due to drugs varied from 3% to 64% (median 21%, interquartile range (IQR) 14-23%). Readmissions were deemed preventable in 5% to 87% of cases (median 69%, IQR 19-84%). Evidence regarding the risk factors for drug-related readmissions and drugs causing these readmissions was inconsistent. CONCLUSION: Although studies show high variability in prevalence and preventability of drug-related hospital readmissions, readmissions due to drugs seem to occur often, especially in older adults. Further research is needed to specify the causes of preventable readmissions and implement effective interventions to reduce medication-related hospital admissions.

Item does not contain fulltext INTRODUCTION: Patients with Parkinson disease (PD) use multiple drugs. This pill burden with consequent poor adherence may cause worsening of motor symptoms and drug-related problems. Therefore, a multifaceted pharmacist-led intervention program was designed to improve adherence, motor-functioning, and quality of life (QoL) in PD patients. METHODS: This prospective pilot study was performed in an outpatient PD clinic, where usual care was compared with stepwise introduction of 3 interventions: unit dose packaging (UDP), Parkinson KinetiGraph (PKG), and pharmacist-led medication review (MR).The study analyzed endpoints at 6 weeks (stage 1, usual care), 10 weeks (stage 2, UDP), 14 weeks (stage 3, UDP + PKG), and 26 weeks (UDP + PKG + MR) on motor symptoms, medication adherence, and QoL. RESULTS: Medication adherence improved significantly after the combined UDP, PKG, and MR intervention in nonadherent patients. On time significantly increased from 56% (+/-30) at stage 1, to 64% (+/-25) at stage 3, and to 68% (+/-27) at stage 4, which correlated with an increase of 1.4 and 2.2 hours in stage 3 and 4, respectively. Quality of life only improved significantly after MR (Parkinson's Disease Questionnaire with 8 domains, 21.0 +/- 3.5 in stage 3 vs 19.5 +/- 5.3 in stage 4, P = 0.01). CONCLUSIONS: Our data did not support the added value of UDP alone or in combination with PKG. Only the combined intervention of UDP, PKG, and MR showed significant improvements in medication adherence, on time, and QoL. This supports the effectiveness of MR by a clinical pharmacist for PD patients in an outpatient setting. Therefore, this small scale study should be followed by larger-scale trials on this topic.

Patients play an important role in achieving the desired therapeutic outcomes, as they are frequently responsible for their own medication management. To facilitate drug administration and overcome medication issues, the patients’ needs and preferences should be considered in the pharmaceutical drug product design. With the aim to evaluate the current state of evidence for patient appropriateness, acceptability, usability and preference for aspects of this design, a literature search was performed. Comparative clinical studies that assessed such endpoints for different patient populations were included and summarized descriptively. The search identified 45 publications that met the inclusion criteria. A detailed analysis of the studies identified two main areas investigating either packaging design ( n = 10) or dosage form design ( n = 35). Studies on packaging design showed preferences for wing top and screw cap openings, push-through blisters and suppositories with slide system. Additionally, child-resistant containers should be avoided concerning specific patient populations. Regarding dosage form design, sprinkles and minitablets were the most preferred in studies involving young patients, while preferences varied considerably depending on route of administration and geographical region in studies with adult patients. Review of the methodology used in the studies revealed that ten studies had used well-defined protocols and observational endpoints to investigate patient appropriateness. Studies focusing on methodology for testing the appropriateness and usability of drug products by patients were not found. In conclusion, more interdisciplinary scientific efforts are required to develop and increase research in understanding patient needs and preferences.

Background Medication reconciliation (MR) is a widely recognised method to promote patient safety. However, its implementation is generally limited to an interaction at a single transition point. Objectives To examine the rates and types of changes implemented in patient's medication regimens when MR is performed longitudinally at hospital admission, discharge and post-discharge, and to assess the clinical impact. Methods A prospective multicentre cohort study was conducted in two hospitals. Patients received MR at admission, discharge and within five days post-discharge at home. Data was collected on rates and types of changes implemented in their medication regimens, due to MR, at all three transition points. These changes entailed corrections of unintentional discrepancies, e.g., between patients’ actual medication use and physician prescriptions, and optimisations of pharmacotherapy, e.g., adding laxatives when opioids are prescribed. Using a validated instrument, the clinical impact of all medication changes were scored. Data were analysed using descriptive statistics. Results In total, 197 patients with a median age of 73 years were included. In 86.3% of patients at least one change was implemented in the medication regimen due to longitudinal MR. At admission, discharge and post-discharge, changes in medication regimens were necessary in 66.5%, 62.9% and 52.8% of patients, respectively. At admission and post-discharge, mainly unintentional discrepancies were corrected, and at discharge mainly optimisations were implemented. Implemented medication changes, due to longitudinal MR, prevented potential harm in 161 patients (81.7%). Potentially serious medication errors were most often prevented at hospital discharge, and predominantly involved optimising antithrombotic agents. Conclusions Changes in medication regimens were implemented in 86.3% of patients due to longitudinal MR at admission, discharge and post-discharge. The rates and types of medication changes vary over time. Hospital discharge is an important moment for optimising pharmacotherapy.

Background A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used. To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review. Methods A literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods. Results Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information. Conclusion A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

BackgroundMedication-related problems are common after hospitalization, for example when changes in patients' medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge. We investigated the effect of a pharmacy-led transitional care program on the occurrence of medication-related problems four weeks post-discharge.MethodsA prospective multi-center before-after study was conducted in six departments in total of two hospitals and 50 community pharmacies in the Netherlands. We tested a pharmacy-led program incorporating (i) usual care (medication reconciliation at hospital admission and discharge) combined with, (ii) teach-back at hospital discharge, (iii) improved transfer of medication information to primary healthcare providers and (iv) post-discharge home visit by the patient's own community pharmacist, compared with usual care alone. The difference in medication-related problems four weeks post-discharge, measured by means of a validated telephone-interview protocol, was the primary outcome. Multiple logistic regression analysis was used, adjusting for potential confounders after multiple imputation to deal with missing data.ResultsWe included 234 (January-April 2016) and 222 (July-November 2016) patients in the usual care and intervention group, respectively. Complete data on the primary outcome was available for 400 patients. The proportion of patients with any medication-related problem was 65.9% (211/400) in the usual care group compared to 52.4% (189/400) in the intervention group (p = 0.01). After multiple imputation, the proportion of patients with any medicationrelated problem remained lower in the intervention group (unadjusted odds ratio 0.57; 95% CI 0.38-0.86, adjusted odds ratio 0.50; 95% CI 0.31-0.79).ConclusionsA pharmacy-led transitional care program reduced medication-related problems after discharge. Implementation research is needed to determine how best to embed these interventions in existing processes.

Background A main obstacle of inpatient medication review is the lack of insight into patient needs and the outpatient’s medical history. Purpose To establish whether drug-related problems (DRPs) after discharge can be reduced via geriatric stewardship, which entails inpatient medication reviews based on patient interviews and consultations with primary care providers. Material and methods This implementation study with a pre-post design included hospitalised elderly patients with polypharmacy and a risk factor for frailty who were admitted to orthopaedic or surgical wards. The pre-cohort received the usual care; and the after-cohort received an extended medication review based on: 1) a review of the clinical records; 2) a consultation with the general practitioner and community pharmacist; 3) a patient interview; and 4) a multidisciplinary evaluation of all the recommendations of steps 1 to 3. Two weeks after discharge, patient-reported DRPs were assessed by telephone using a validated questionnaire. DRPs (i.e. an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes) were classified into drug-related complaints, practical problems and questions about medication. The primary outcome was the number of DRPs per patient in each group. A Poisson regression was performed to compare the groups, adjusted for potential confounders. Second, we assessed the number of altered recommendations by patient interviews and consultations of primary care providers. Results Of 127 included patients (control: 74, intervention: 53), intervention patients reported fewer DRPs after discharge than patients in usual care, 2.8 vs. 3.3 per patient (RRadjusted 0.83, 95% CI: 0.66 to 1.05). The difference was mainly due to a 50% reduction in drug-related complaints. In the intervention group, nearly 30% of the medication review recommendations based on the clinical records changed after consulting the patient and primary care providers. Conclusion The implementation of geriatric stewardship reduced DRPs after discharge in this cohort. Significance was not reached but further research with larger patient numbers may confirm this effect and determine the effect on clinical outcomes. The importance of patient interviews is consistent with the findings of Viktil et al1 on the value of patient interviews in an inpatient setting. No previous study considered consultations of primary care providers. References and/or acknowledgements 1. Viktil, et al. Pharmacoepidemiol Drug Saf2006;15:667–74. No conflict of interest.

Background After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. Methods In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15–23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. Discussion This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. Trial registration NTR6316. Date of registration: April 6, 2017. Electronic supplementary material The online version of this article (10.1186/s12913-018-3301-9) contains supplementary material, which is available to authorized users.

Objective: Medication regimens change during hospital admission, and these discrepancies can lead to an increased risk of patient harm after hospital discharge. Information about medication according to the patient's needs may contribute to patient safety by improvement of knowledge and adherence. The goal of this study is to explore the patient's needs on information about medication at hospital discharge. Research design and methods: Qualitative, semi-structured interviews were performed with 31 patients from the pulmonology, internal medicine and cardiology departments who were discharged with at least one prescribed drug from the hospital to primary care in the Netherlands. Interviews were analysed with content analysis. Results: Patients had variable needs concerning information about discharge medication. Most patients wanted to receive basic information about their medication, alternatives for the prescribed medication and side effects. Some patients did not need basic information or explicitly mentioned that information about side effects would negatively influence their attitude towards medication. Patients preferred a combination of oral instructions and written information. Conclusions: Information at discharge should be tailored to the individual needs of the patient. Practice implications: In the process of providing patient information at hospital discharge, the preference of some patients for non-disclosure of information should be recognised. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

BackgroundHospital admissions are a risk factor for the occurrence of unintended medication discrepancies between drugs used before admission and after discharge. To diminish such discrepancies and improve quality of care, medication reconciliation has been developed. The exact contribution of patient counseling to the medication reconciliation process is unknown, especially not when compared with community pharmacy medication records, which are considered reliable in the Netherlands.ObjectiveTo examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems.MethodsA prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient.ResultsTwo hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge.ConclusionsSignificantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.

Background Communication and documentation of medication-related information are needed to improve continuity of care. Objective To assess the completeness of medication-related information in discharge letters and post-discharge general practitioner (GP)-overviews. Setting A general teaching hospital in Amsterdam, the Netherlands. Method An observational study was performed. Patients from several departments were included after medication reconciliation at hospital discharge. In liaison with the resident and patient, a pharmacy team prepared a Transitional Pharmaceutical Care (TPC)-overview of current medications, including changes and allergies. The resident was instructed to download the TPC-overview into the discharge letter instead of typing a self-made medication list. Medication overviews were gathered from the GP 2 weeks after the handover of the discharge letter. The TPC-overview (gold standard) was compared with the information in the discharge letter and post-discharge GP-overviews regarding correct medications and allergies. Descriptive data analysis was used. Main outcome measure The number and percentage of complete medication-related information in the discharge letter and the GP-overview were compared to the TPC-overview. Results Ninety-nine patients were included. Medication-related information was complete in 62 (63 %) of 99 discharge letters. Sixteen of 99 GP-overviews (16 %) were complete. Communication of medication-related information increased documentation by the GP, but the medication history could still be incomplete, mainly regarding medication changes and allergies. Conclusions Medication-related information is lost in discharge letters and GP-overviews post-discharge despite in-hospital medication reconciliation. This could result in discontinuity of care.

Background: Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs. Objective: To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs. Methods: A prospective observational study was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed medication errors prevented by medication reconciliation. Interventions were classified into 3 categories: correcting hospital formulary-induced medication changes (eg, reinstating less costly generic drugs used before admission), optimizing pharmacotherapy (eg. discontinuing unnecessary laxative), and eliminating discrepancies (eg, restarting omitted preadmission medication). Because eliminating discrepancies does not represent real costs to society (before hospitalization, the patient was also using the medication), these medication costs were not included in the cost calculation. Medication costs at 1 month and 6 months after hospital discharge and the associated tabor costs were assessed using descriptive statistics and scenario analyses. For the 6-month extrapolation, only medication intended for chronic use was included. Results: Two hundred sixty-two patients were included. Correcting hospital formulary changes saved €1 63/patient (exchange rate: EUR 1 = USD 1.3443) in medication costs at 1 month after discharge and €9.79 at 6 months. Optimizing pharmacotherapy saved €20.13/patient in medication costs at 1 month and €86.86 at 6 months. The associated labor costs for performing medication reconciliation were €41.04/patient. Medication cost savings from correcting hospital formulary-induced changes and optimizing of pharmacotherapy (€96.65/patient) outweighed the labor costs at 6 months extrapolation by €55.62/patient (sensitivity analysis €37.25–71.10). Conclusions: Preventing medication errors through medication reconciliation results in higher benefits than the costs related to the net time investment.

Background Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department. Methods/Design An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient. The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers. The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists. Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle. Discussion This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety. Trial registration Dutch trial register: NTR1519