Introduction
Methods
Study design
Ethics
Quantitative part
Setting
Hospital | A | B | C | D | E | F |
---|---|---|---|---|---|---|
County (region) | Capital (West) | Drenthe (North) | Gelderland (East) | Zuid Holland (West) | Utrecht (Centre) | Limburg (South) |
surrounding | Urban | Rural | Rural | Urban | Urban | Urban |
Type | Teaching | General | Specialized | General | Teaching | Teaching |
Number of beds 2012 | 551 | 284 | 317 | 722 | 1102 | 536 |
Wards with MR activities by pharmacies in 2012 | Lung diseases Internal medicine Cardiology Neurology | All wards including ICU, paediatrics | All wards | 75% all admissions covered; discharge counselling if patient passes by outpatient pharmacy or on request physician | All wards except ICUs | All wards except ED |
Study wards and number of patients included (n) | Lung diseases (150) | Internal medicines (27) Cardiology (50) Surgery (73) | Orthopaedics (150) | Internal medicines (23) Gastroenterology (4) Surgery (114) Lung diseases (8) | Internal medicines (107) Gastroenterology (12) Surgery (28) Lung diseases (3) | Internal medicines (85) Lung disease (65) |
length of stay, median (range) | 9.0 (3–48) | 4.0 (1–60) | 6.0 (1–115) | 6.0 (1–21) | 7.0 (2–32) | 7.0 (2–37) |
number admission medications, mean (SD) | 9.1 (4.5) | 6.4 (3.4) | -a | 8.5 (4.1) | 10.8 (4.3) | 7.8 (4.3) |
number discharge medications, mean (SD) | 10.9 (4.8) | 8.2 (4.0) | 11.1 (4.1) | 8.8 (3.6) | 10.4 (4.3) | - |
Number admission/discharge interviewsb | 108/149 | 140/92 | 145/136 | 147/149 | 78/106 | 146/- |
age,mean (SD) | 67.2 (13.3) | 62.1 (16.5) | 61.2 (12.9) | 69.3 (12.4) | 66.1 (14.6) | 69.1 (13.0) |
female, n (%) | 44 (41) | 80 (57) | 97 (67) | 84 (57) | 46 (59) | 79 (54) |
low social class, n (%) | 81 (75) | 83 (59) | 46 (32) | 57 (39) | 13 (17) | 85 (58) |
deprived area, n (%) | 48 (44) | 0 | 2 (1) | 10 (7) | 4 (5) | 4 (3) |
Study population
Medication reconciliation
Quantitative outcomes
Number and type of interventions per patient in the verification - and clarification step of MedRec, i.e. resolving unintentional medication discrepancies and optimizations of pharmacotherapy upon admission and discharge.
Data collection
Analysis
Qualitative part
Design
Participants
Data collection
WHO | A | B | C | D | E | F |
Patient selection: | Non | Non | Non | Non | High risk patientsa | Exclusion UDSb |
Type of pharmacy team members involved: | Pharmaceutical consultant | Pharmacy technician + pharmacist check | Pharmacy technician + pharmacist check | Pharmacy technician + specialized pharmacy technician + pharmaceutical consultant | Specialized pharmacy technician + pharmaceutical consultant + pharmacist | Pharmacy technician |
Nurse | Nurse | |||||
WHERE (location interview) | A | B | C | D | E | F |
Admission | ||||||
On the ward | Outpatient clinic (elective) | @ home (mail/phone) | Elective patients: @ home (mail/phone) | @ home (mail/phone) | Outpatient clinic (elective) | |
On the ward | On the ward | On the ward | On the ward | On the ward | ||
Discharge | ||||||
On the ward | Outpatient pharmacyd | On the ward | Outpatient pharmacy | On the ward | Outpatient pharmacy | |
Outpatient pharmacy | Outpatient pharmacy + @home by phone | |||||
HOW (process) | A | B | C | D | E | F |
Admission | ||||||
Verification: Information collection | digital or paper-based pharmacy dispensing information and GP | Digital pharmacy dispensing information | Patient list, extra check high risk patientsc, lab results | Digital pharmacy dispensing information | digital or paper-based pharmacy dispensing information and GP | digital or paper-based pharmacy dispensing information |
Clarification: Optimisation medication | 8 focuspoints, generally discussed @ discharge | Thrombo-profylaxis, oral antidiabetics | see above: focus on renal function, pain meds | No extra checks | see discharge | no extra checks |
Substitution | No substitution | Substitution | ||||
Suggested medication changes | implementation of medication changes after check with physician | implementation of medication changes by pharmacy without physician check | implementation of medication changes after check with physician | Only acutely based on prescriptions | discussion with doctor after medication review | Only acutely based on prescriptions |
Documentation | On electronic dispensing information from pharmacy and checklist (not visible for other healthcare professionals) | On checklist (not visible for other healthcare professionals) | On Checklist (not visible for other healthcare professionals) | ? not visible for other healthcare professionals | In EPD and on electronic dispensing information from pharmacy (partly available for other healthcare professionals) | Electronic pre-registration (elective patients) available for other healthcare professionals |
Discharge | ||||||
Optimisation (number of focuspoints) | 8 | 2 | 2 | 0 | 6e | 3 (surgical ward only) |
WHEN (timing activity) | A | B | C | D | E | F |
Admission | ||||||
Interview elective patients (moment) Discharge | Day admission | Day admission | Weeks before procedure by mail | Weeks before procedure | Weeks before procedure by phone | Weeks before procedure |
Interview will be performed | If discharge announced 24 h beforehand | Only if patient passes by outpatient pharmacy | Always | Only if patient passes by outpatient pharmacy | If discharge announced 24 h beforehand | Only if patient passes by outpatient pharmacy |
Qualitative Outcome
Analysis
Results
Quantitive part
Number and types of interventions
Unintended discrepancies (verification)
Optimizations of medication
Qualitative part
MedRec differences between hospitals
interviewer: highly trained MedRec interviewers resulted in high numbers of pharmacy interventions (see hospital A: having the highest numbers of interventions, and both higher educated and highly trained interviewers). All participants judged therapeutic knowledge of medicines as an important factor to apply optimization interventions (see below) in order to remove inappropriate and unnecessary medications from a patient’s medication list.patient-mix/physician type: participants agreed that surgical patients generally have less discrepancies versus general wards as they use less medication. Also, participants reflected that a high socioeconomic status would result in less discrepancies due to the higher education level. This could explain the high number of interventions in hospital A with 75% of patients having a low socioeconomic status. Furthermore, all these patients were admitted at the pulmonary ward. In contrast: hospital B, C and D included a substantial percentage of surgical patients with the lowest number of interventions upon discharge (table 1, figures 1,2). According to participating pharmacists, surgeons generally will not act upon optimization interventions.Hospital A and E had very comparable workflows but had different numbers of interventions on discrepancies: 3.0 versus 1.1 on admission (figure 1). Included patients differed highly: lung diseases only (hospital A), as compared to 70% internal medicine patients (hospital E, table 1). In participants‘ opinion, internal medicine doctors pay more attention to medication, probably resulting in a lower number of discrepancies (less found by the pharmacy team), even though high numbers of medication were used.
Pre-admission preparation at home: a form filled out by the patient himself (instead of using the CP medication history to perform MedRec) several weeks before elective admission, resulted in a shift of intervention type from start to dosage (figure 1, hospital C and D). Patients appeared to recall which medicines were used, but failed to note or remember dose and/or strength of a medication. This resulted in a high number of dosage interventions in hospital C and D, as compared to omissions in all other hospitals.Location of the interviews (ward versus outpatient pharmacy): two hospitals, B and D, discussed discharge medication and counselled patients in the outpatient pharmacy only, instead of ward-based counselling. Those hospitals had at least 50% less interventions on discrepancies as compared to hospitals with ward-based MedRec and/or telephone interviews. This might have been the result of a less intense connection with in-hospital activities, according to participants.
Optimizations: hospitals differed in numbers and types of medication optimizations based on whether they embedded the optimization step or not. Hospitals that implemented optimization structurally included up to 8 focus-points on a checklist. The extensiveness of the checklist resulted in large differences in numbers of optimization interventions (figure 2). Furthermore, in hospital E, two pharmacists performed a medication review for selected patients (elderly, more medications) which potentially contributed to the higher number of optimization interventions, specifically upon discharge. This higher yield upon hospital discharge was explained by acceptance of certain clinical situations (in the context of medication use) while being admitted (e.g. accepting potassium suppletion in combination with potassium sparing medications while being admitted, but not upon hospital discharge without frequent laboratory control).