PookieMD's Blog: Where Physicians Learn About the Business of Medicine

I am a fanatic about discharges.  Of all the hand offs we do in medicine, this one seems to be the most dangerous, with discharge medications being the road side bomb of hospital medicine.  A recent article in Archives of Internal Medicine examined the effectiveness of a pharmacist performing medication reconciliation, patient counseling and education and then making a follow up call at 72 hours.  The study examined ED visit and readmission rates at 14 and 30 days, and found no difference between intervention and control groups.

Important highlights of the article:

• one fifth of patients were found to have omitted medications.
• a phone call after discharge reduced readmission risk at 14 days, but the benefit of a post discharge call is not well defined–some data has shown a post discharge call leads to higher utilization of health care resources!  (Perhaps these calls identify other issues that require clinical follow up…)
• only 43% of patients were reached with a post discharge call, so the phone call data is limited.
• the article doesn’t mention how many medications were on the medical reconciliation at discharge.
• it took the pharmacist 87.5minutes to perform the reconciliation and “other discharge activities.” There is no way a discharging physician could spend this much time.  The article doesn’t mention what exactly the pharmacist was doing in these 87.5 minutes!

My (unscientific!) take away: patients with long medication list, lots of changes including stopping old medications and starting new ones, are at the most risk of errors and medical mishap.  These patients are probably older, have limited eye sight and hearing, and may not comprehend the changes.  Additionally, they may be on narcotic pain relievers, “sleepers”, and antidepressants, as well as a plethora of beta blockers, anticoagulants and oral hypoglycemics.  I think that this group of patients deserves their medications to be combed through with a fine tooth comb, and reviewed and reconciled with the family, the patient and other caregivers.  AND, for pity’s sake, the primary care doctor has got to be kept in the loop!  I would like to see a study that focuses on the elderly, and those who go home on 5 or more medications, as well as those on coumadin and diabetes agents.  I bet we would see a large improvement if these patients were the ones studied to examine effectiveness of pharmacist medical reconciliation at discharge.

Anyone interested?

 The November 23 issue isn’t on line yet.  Here’s the citation: “Impactof a Pharmacist-Fracilitated Hospital Discharge Program: A Quasi Experimental Study”, P.C. Walker, PharmD, et al, 2003-2010.