Medication management throughout hospitalization with a focus on discharge – the pharmacist’s contribution

Transitions of care occur when patients are transferred between different settings. Patient hospitalizations are accompanied by several transitions of care, potentially leading to a variety of problems, one type of which are drug-related problems (DRPs). DRPs are issues involving medication therapies that can result in undesired health outcomes. As DRPs can lead to patient harm, they need to be addressed before they reach the patient. Pharmacists have been shown to identify and resolve DRPs by themselves or in collaboration with physicians or patients. Healthcare professionals should strive to prevent these problems from occurring in the first place. Different pharmacist-led services, such as medication reconciliation or medication reviews, have been shown to improve patient safety. Despite the known benefits of pharmacist-led services at transitions of care in other countries, little is known about the hospital discharge management in Switzerland and what the role of pharmacists is. Additionally, Switzerland lacks guidelines at a national level that could direct hospitals in the implementation of such services.
The goal of this thesis was to provide the basis for designing an improved process in supporting patients in their medication management at hospital discharge. We aimed to achieve this goal through the description of the current discharge management with a focus on the role of pharmacists (Part A) and the impact of pharmacist-led services on DRPs at hospital discharge (Part B).
Clinical pharmacy services are constantly evolving; in Switzerland, the status was first described in a national survey conducted in 2013. Since these services continued to develop in the following years, the objective of the first project was to give an overview of the current implementation status of clinical pharmacy in Switzerland and its development in recent years (Project A1). In 2017, we sent an online questionnaire to all chief hospital pharmacists registered at the Swiss Association of Public Health Administration and Hospital Pharmacists (n=60). In total, 44 hospital pharmacies participated (return rate 73.3%) and among the participants all five university hospitals were represented. The participating hospital pharmacies employed a total of 265.8 full-time equivalents of hospital pharmacists, of which 20.4 % were allocated to clinical pharmacy. In the 31 hospital pharmacies that indicated to offer clinical pharmacy services, process-related and treatment-related services were offered more frequently than patient-related services. Activities related to the European Association of Hospital Pharmacists statements on clinical pharmacy were implemented with varying frequency. A direct comparison with the results of the survey in 2013, showed an increase in both hospital (+24.5%) and clinical (+62.7%) pharmacists full-time equivalents.
The objective of the second project was to describe the involvement of pharmacists in medication management at hospital discharge in Switzerland and to compare it to international guidelines (Project A2). We developed an online questionnaire on medication management at discharge that was sent together with the one described in Project A1. Moreover, to gain further insight into the role of the pharmacist, semi-structured face-to-face interviews were conducted with selected hospital pharmacies and where appropriate, the collaborating community pharmacy. During this project, as there are no Swiss guidelines regarding medication management at hospital discharge, we compared our results to international guidelines. We discovered that in Swiss hospitals healthcare professionals frequently conducted interventions recommended by guidelines, such as patient education or communication to primary care providers. Overall, pharmacists were rarely involved at hospital discharge. Seventeen of the 44 (38.6%) hospitals were in close collaboration with a community pharmacy (owned or not owned by the hospital) or had a hospital pharmacy with a counter open to discharged patients. These collaborating pharmacies mainly aimed at assuring initial medication supply.
The first two projects addressed several aspects of discharge processes in regard to medication management. The objective of the third project was to provide an overview of guidelines for medication review in the hospital setting (Project A3). We first conducted a grey literature search with the following inclusion criteria: to contain recommendations on medication reviews in the hospital setting, to be accessible in full text and to be written in English or German. For the development of the categories in the overview, we used an iterative process to identify elements recommended in the guidelines. Our search yielded three international and nine national guidelines. Some guidelines described different types of medication reviews, for instance the Pharmaceutical Care Network Europe differentiated between simple, intermediate, and advanced medication reviews depending on the sources of information available. While all guidelines addressed patient safety and nearly all medication appropriateness, conducting medication reconciliation or obtaining a best possible medication history was recommended in less than half.
As already mentioned, DRPs frequently occur at transitions of care, such as hospital discharge. With Part B we aimed to obtain an impression of frequent DRPs in Swiss hospitals at discharge and the impact of pharmacist-led services on these DRPs.
First, to describe the pattern of DRPs at hospital discharge, we retrospectively analyzed DRPs discovered on discharge prescriptions with a focus on drug-drug interactions in two Swiss hospitals: a regional hospital and a cantonal hospital (Project B1). Pharmacists documented 2539 DRPs at the regional hospital 2754 DRPs at the cantonal hospital. Recommendations following the discovered DRPs were frequently accepted in both hospitals, many resulted in a change of the discharge prescription (regional hospital 70.2% of DRPs, cantonal hospital 69.5%). In both hospitals DRPs were frequently related to dosage problems (regional hospital 53.2%, cantonal hospital 48.1%). When focusing on DRPs due to drug-drug interactions, we found that the most frequent drug combinations could often be grouped into two interaction types: problem of complexation and problem of QT interval prolongation.
The objective of the last project was to assess the effect that two pharmacist-led services (medication reconciliation at admission and interprofessional ward rounds including a pharmacist during the stay) had on DRPs at hospital discharge (Project B2). We conducted a retrospective data analysis of DRPs identified on discharge prescriptions at the cantonal hospital of Zug. We included all patients discharged from the internal medicine ward that filled their discharge prescription in the in-hospital community pharmacy and that were >18 years old. The combination of the two pharmacist-led services was associated with a reduction of DRPs at hospital discharge. Patients receiving a pharmacist-led medication reconciliation at hospital admission had fewer DRPs related to medication reconciliation problems at hospital discharge.
In conclusion, this thesis described the current discharge management in Switzerland and pharmacists’ role in it. It also evaluated the impact of pharmacist-led services on DRPs at hospital discharge. The findings revealed that while clinical pharmacy services have increased, pharmacists are still rarely involved in medication management at hospital discharge. It also shows that when pharmacists have access to clinical data, they can identify and resolve a variety of DRPs. Our results confirmed an association between a comprehensive involvement of pharmacists throughout the hospital stay and a reduction in DRPs at hospital discharge. Based on these findings, hospitals should be encouraged to strengthen the role of pharmacists at transitions of care.