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eISSN: 2379-6367

Pharmacy & Pharmacology International Journal

Mini Review Volume 12 Issue 3

Medication reconciliation in in-patients with chronic pathologies: a narrative review

Elena María Vega, Macarena Mora-Villaseñor, Pía Córdova-Mariángel, Pola Fernández-Rocca, Tamara Sandoval-Quijada

Universidad de Concepción, Facultad de Farmacia, Departamento de Farmacia, Concepción, Chile

Correspondence: Elena María Vega, Departamento de Farmacia, Facultad de Farmacia, Universidad de Concepción, Barrio Universitario S/N, Concepción, Chile, Tel +56-41-2204208

Received: April 20, 2024 | Published: May 10, 2024

Citation: Vega EM, Mora-Villaseñor M, Córdova-Mariángel P, et al. Medication reconciliation in in-patients with chronic pathologies: a narrative review. Pharm Pharmacol Int J. 2024;12(3):80-87. DOI: 10.15406/ppij.2024.12.00438

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Abstract

Objective: To analyze the effectiveness of the medication reconciliation process by pharmacists at the hospital level in patients with chronic non-communicable diseases, evidenced through the analysis of readmissions and the acceptance of pharmaceutical interventions.

Method: A narrative bibliographic review was conducted in databases of the University of Concepción between 2011 and 2021. Keywords used in the search included medication reconciliation, hospital readmission, clinical pharmacy, discrepancy, among others. The search was conducted in both English and Spanish. Clinical studies, trials, descriptive observational studies, and analytical observational studies (case and control reports) were included, involving a population over 18 years old with chronic or non-communicable diseases and reconciliation at admission, during the stay, and at hospital discharge.

Results: A total of 36 articles were reviewed, of which only 23 compared the impact on unplanned readmissions within 30 days of hospital discharge, and 4 mentioned visits to the emergency department during the same period. Only 15 articles presented physician acceptance of interventions carried out by pharmacists during the medication reconciliation process, with an acceptance rate of at least 60%.

Conclusions: Based on this bibliographic review, it can be concluded that medication reconciliation has an impact on the quality of care. This is reflected in a reduction in both the number of visits to the emergency department and hospital readmissions during the 30 days following discharge.

Keywords: medication reconciliation, patient readmission, pharmacists, pharmaceutical interventions, discrepancies

Introduction

In Chile, the Ministry of Health recognizes pharmaceutical services as activities carried out in both ambulatory and hospital care settings. These services are related to pharmaceutical care and pharmacovigilance, including medication reconciliation.1

Transitional care ensures continuity of care as patients move between different stages and settings of healthcare. Unintended medication discrepancies arising at care transitions have been reported as prevalent and are linked with adverse drug events (e.g. rehospitalisation).2

Medication reconciliation is defined as the formal process that involves obtaining a patient’s comprehensive current medication list and comparing it to any medication they request or are being given at any healthcare stage, in order to identify and resolve any discrepancies according to the standards of medication frequency, route, dose, combination and therapeutic purpose.3

These discrepancies are consulted with the prescriber to assess their justification and correct them if necessary, and are subsequently documented for the patient and their healthcare provider. Reconciliation is a process that requires the participation of all professionals responsible for the patient, including nurses, physicians, pharmacists, as well as the patient and their caregivers.4

Medication reconciliation programs have proven to be a useful strategy in reducing medication errors related to healthcare transitions by 42-90% and reducing adverse events resulting from these errors by 15-18%.3,5

Unintentional discrepancies occur in approximately half of hospitalized patients upon hospital admission and persist to a similar extent at hospital discharge. Most importantly, medication errors at transitions of care can lead to patient harm.6

Medication reconciliation is crucial, especially at hospital discharge, as it ensures that the patient is well-informed about their new and existing medications. This information includes how and when takes the medications, which side effects require urgent medical attention, and highlights any new medications, discontinuations, and changes in dosage or formulation compared to the pre-admission medication.7

The process reduces the likelihood of patient hospital readmissions for the same reason as the initial admission. In the United States, many patients return to the emergency room due to medication-related problems, experiencing adverse effects associated with it, affecting 11 to 17% of patients between 4 and 6 weeks after hospital discharge.8 Hospital readmissions are becoming frequent, increasing healthcare costs. Factors attributed to this situation include comorbidities, polypharmacy, and length of hospital stay.9

Despite medicine reconciliation being recognized as a key aspect of patient safety, there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption.2

A proper medication reconciliation for patients with chronic non-communicable diseases during their hospital stay and transitional care, to reduce medication errors, increase life expectancy and quality of life, and minimize healthcare costs and associated harms, is mandatory.

Pharmacists are the professionals best prepared to perform reconciliation due to their extensive knowledge of medications and their use in various diseases, enabling them to identify medication-related problems and selecting appropriate therapeutic alternatives for specific patients.

Therefore, the purpose of this work is to present a literature review that determines the pharmacist's involvement, through the analysis of readmissions and acceptance of pharmacist interventions based on the number of reported discrepancies, in the medication reconciliation process at the hospital level in patients with chronic non-communicable diseases.

Objective: To analyze the effectiveness of implementing a medication reconciliation process by pharmacists at the hospital level in patients with chronic non-communicable diseases.

Material and methods

A narrative literature review was conducted. To identify potentially relevant documents, the following bibliographic databases were searched from 2010 to 2021: Medline, Scielo, Google Scholar, Scopus, and Web of Science, provided by the University of Concepción. The keywords used in the search included: pharmaceutical reconciliation, Hospital readmission, clinical pharmacy service, discrepancy, internal medicine, medication reconciliation, adult, chronic disease, Pharmacy, medication error, hospital admitting, and 30 days. These keywords were used both in English and Spanish.

The selection criteria for the studies were as follows:

  • Studies and clinical trials, descriptive and analytical observational studies.
  • Patients over 18 years old with chronic pathologies or non-communicable diseases.
  • Internal medicine, emergency, cardiology, respiratory, and endocrinology departments.
  • Health centers of second and third level where the reconciliation process is carried out by a pharmacist or pharmacy students trained and supervised by a pharmacist.
  • Papers in English and Spanish.
  • Years 2010-2021.

Exclusion criteria involved studies with oncologic, HIV, and surgical patients, patients with mental disorders; reconciliation process conducted in outpatient pharmacies or inpatients discharged to nursing homes.

The analysis covered the reconciliation process performed by the pharmacist at different stages of care transition, including admission, hospital stay or inpatients transfers, and discharge, either collectively or separately. The main inpatients diseases, readmissions at 30 days, discrepancies found, and evaluation of pharmacist interventions were reported.

Regarding hospital readmission, it was considered if it was related to the same health problem as the admission. Also the pharmacist's influence on the process was evaluated by comparing the number of hospital readmissions between the control group (without pharmacist intervention) and the intervention group (with pharmacist intervention).

Finally, the consideration of pharmacist interventions by healthcare professionals (mainly prescribing physicians) was reported through the percentage of acceptance of these interventions at the time of medication reconciliation. This information was extracted from the selected documents when available.

All information obtained from the different articles was organized into tables to facilitate comparison. The statistical significance used was that provided by the original studies.

Results

Among the five search engines, 8741 potential documents were found. After applying the inclusion and exclusion criteria, 8593 articles were eliminated. Among these, 112 were repeated among the five databases, resulting in the review of 36 articles (Figure 1).

Figure 1 Diagram showing the selection of eligible studies for including in the review.

Regarding the types of studies, the most frequent were observational, including both prospective and retrospective analytical studies, conducted in medium to high-complexity tertiary hospitals. The studies focused primarily on internal medicine and cardiology, with particular emphasis on cardiovascular, respiratory, and endocrine diseases, such as type 2 diabetes mellitus.

The most studied population consisted of individuals over 55 years old, and in 28 studies, medication reconciliation was conducted at hospital discharge (Table 1).

Author, Year, Country

Study design

Length

Clinical areas

Diseases

N° of patients

Average of inpatients age

Transition of care assessed

Hellström et al.,10

Descriptive

10 months

IM

CV, DM, Resp

670

81

Admission

Lancaster et al.,11

Descriptive cross sectional

2 months

IM

CV

52

67

Admission

Mendes et al.,12

RCT

6 months

IM

CV, DM

136

53

Admission

Contreras Rey et al.,13

Observational, descriptive, retrospective study

6 months

IM, Cardiology, Pulmonology

CV, DM, GI, Resp

220

67

Admission

Pevnick et al.,14

RCT

1 month

Emergency

CV, DM, Resp

278

72

Admission

Lee et al.,15

Consecutive-cohort study

12 weeks

Geriatric

CV, Inf, Resp

372

83.2

Admission

Chiarelli et al.,16

Interventional prospective study

12 months

IM, Geriatric

CV, DM

90

82

Admission

Bell et al.,17

RCT

16 months

Cardiology

CV

851

60

Admission / Discharge

Casper et al.,18

Prospective, randomized, controlled study

25 months

Cardiology

CV

40

53

Admission / Discharge

Karapinar-Çarklt et al.,19

Prospective interrupted time-series study

20 months

IM

DM, GI, Inf, Renal

706

65

Admission / Discharge

Daliri et al.,20

Prospective cohort study

7 months

IM

CV, Resp, Neurological

197

73

Admission / Discharge

Wilkinson et al.,21

Prospective, cohort, nonrandomized trial

6 months

IM

CV, DM, Resp

229

57.4

Admission / Inpatient transfers / Discharge

Ravn-Nielsen et al.,22

RCT

25 months

Acute admission ward

DM, GI, Inf, Resp

1.467

72

Admission / Inpatient transfers / Discharge

Kripalani et al.,23

RCT

16 months

---

CV

851

60

Admission / Inpatient transfers / Discharge

Eggink et al.,24

Open randomized intervention study

14 months

Cardiology

CV

85

73

Discharge

Sánchez-Ulayar et al.,25

Experimental, controlled, randomized study

2 months

IM

CV, DM, GI, Resp

100

76

Discharge

Kilcup et al.,26

Ad hoc retrospective comparison

5 months

High risk patients Geriatric

CV, GI, Resp

494

67

Discharge

Luder et al.,27

Prospective, quasi-experimental study.

14 months

IM

CV, Resp

90

66.3

Discharge

Budiman et al.,28

Prospective study

3 months

Cardiology

CV

126

64.7

Discharge

Cavanaugh et al.,29

Retrospective observational study

7 months

IM

CV, DM, Resp

140

57

Discharge

Truong J et al,30

Retrospective, cohort study

16 months

Cardiology

CV

632

74.9

Discharge

Sawyer et al.,31

Prospective cohort study

1 month

Pulmonary unit

CV, GI, Resp, Neurological, Renal

118

63

Discharge

Rose et al.,32

Cluster RCT

36 months

Ambulatory

CV, DM, Resp

129

76.4

Discharge

Phatak et al.,33

Prospective, randomized, longitudinal study

1 year

IM

CV, GI, Inf, Resp

278

55

Discharge

Zemaitis et al.,34

Prospective, historical control study

6 months

IM

CV, DM, Resp

690

61

Discharge

Aniemeke et al.,35

Retrospective chart review

3 months

IM

CV, DM, Inf, Resp, Renal

89

53.1

Discharge

Kovacik et al.,36

Retrospective chart review

9 months

Cardiology, respiratory

CV, Resp

104

70.6

Discharge

Neeman et al.,37

Prospective, interventional, interrupted time series analysis

7 months

IM

CV, DM, Resp

118

76

Discharge

Shanika et al.,38

Non-RCT

5 months

IM

CV, DM, GI, Resp

645

57.6

Discharge

Ip et al.,39

Prospective, non-randomized, quasi-experimental study

2 months

Urgencies

CV

85

81

Discharge

Cooper et al.,40

Retrospective cohort study

3 months

IM

CV, DM, Resp

203

62.1

Discharge

Shaver et al.,41

Retrospective records review

5 months

IM

CV

1219

64.3

Discharge

Oñatibia-Astibia et al.,42

Non-controlled before-and-after study.

1 year

A regional hospital and three primary care units

CV, DM, GI, Inf, Resp

143

72

Discharge

Boockvar et al.,43

Cluster-randomized trial

21 months

Geriatric

CV, DM, Inf, Resp

311

60

Inpatient transfers

Hohl et al.,44

Pragmatic prospective controlled quality improvement evaluation study

17 months

Emergency

Patients in risk of drug related problems

10807

70

Inpatient transfers / Discharge

Odeh et al.,45

RCT

12 months

Cardiology, Pulmonary unit

CV, Resp

62

67.4

Inpatient transfers / Discharge

Table 1 Characterization of included studies in hospitalized patients with chronic non-communicable diseases, ordered by the transition of care assessed
CV: cardiovascular disease; DM: diabetes mellitus; GI: gastrointestinal disease; IM: internal medicine; Inf: Infectious diseases; RCT: randomized clinical trial; Resp: respiratory diseases; USA: United States of America.

Out of the 36 selected documents, only 23 compared the effect on unplanned readmissions within 30 days post- discharge. Four papers compared emergency department visits within 30 days post-discharge when medication reconciliation was performed by pharmacists or not, and only two articles reported on the cause of hospital readmission. Details are presented in Table 2.

Author   Nº of participants

Diseases or patients included

Readmission (number or percentage according to authors

pa

 
   

3 days:

Control: 6.7%

Intervention:4.6%

1

 

Aniemeke et al.,35

89

Cardiovascular, Diabetes Mellitus, Infectious, Renal, Respiratory

 

30 days:

Control: 26.7%

Intervention:18.2%,

0.45

 

Bell et al.,17

851

Cardiovascular

Decrease only in patients with low health literacy

0.94

 

Budiman et al.28

126

Cardiovascular

Control 13%

Intervention 5%

0.18

 

Cavanaugh et al.29

140

Cardiovascular, Diabetes, Respiratory

Control 34.3%

Intervention 14.3%

0.01

 

Hohl et al.44

10807

Patients with high risk of having a drug related problem.

Visits to Emergency

Control: 310

Intervention: 414

0.88

 

Readmissions:

Control: 154

Intervention: 206

0.9

 

Ip et al.,39

85

Cardiovascular

Visit to Emergency (all causes:

Control:47.6%

Intervention: 25.6%

0.035

 

Readmisiones a los 30 días:

Intervención: 25.6%

Control: 47.6%

0.48

 

Karapinar-Çarklt et al.,19

706

Diabetes, Gastrointestinal, Infectious, Renal

Control: 27.3%

Intervention 33.2%

0.2

 

Kilcup et al.,26

494

Cardiovascular, Gastrointestinal, Respiratory

7 days: intervention 2

       control 11

0.01

 

14 days: intervention 11

       control 22

0.04

 

30 days: intervention 28

       control 34

0.29

 

Kovacik et al.,36

104

Cardiovascular, Respiratory

Control: 16.7%

Intervention: 28.6%

0.23

 

Lee et al.,15

372

Cardiovascular, Infectious, Respiratory

Control: 28.8%

Intervention 21.2 %

0.17

 

Luder et al.,27

90

Cardiovascular, Respiratory

Control: 32%

Intervention: 7%

0.017

 

Neeman et al.,37

118

Cardiovascular, Diabetes, Respiratory

Control: 32%

Intervention: 24%

No data

 

Odeh et al.,45

62

Cardiovascular, Respiratory

7 days:

Control: 6,5%

Intervención:0%

0.49

 

14 days:

Control: 12.9%

Intervención:0%

0.45

 

Oñatibia-Astibia et al.,42

143

Cardiovascular, Diabetes, Gastrointestinal, Infectious, Respiratory,

Visits to Emergency:

Before: 77

After: 65

0.405

 

Readmission:

Before: 41

After: 20

0.007

 

Phatak et al.,33

278

Cardiovascular, Gastrointestinal, Infectious, Respiratory

Visits to Emergency:

Control: 21

Intervention: 6

0.001

 

30 days readmission:

Control: 34

Intervention: 28

0.43

 

Drug related

Control: 13

Intervention: 8

1

 

Ravn-Nielsen et al.,22

1467

Diabetes, Gastrointestinal, Infectious, Respiratory,

Visits to Emergency:

Control (1: 22.3%

Basic intervention (2: 19.9%

Extended intervention (3: 14.3%

0.89 (1 and 2

0.62 (1 and 3

 

Drug related readmission

Control (1: 7.6%

Basic intervention (2: 6.9%

Extended intervention (3: 5.0%

0.9 (1 and 2

0.83 (1 and 3

 

Sánchez Ulayar et al.,25

100

Cardiovascular, Diabetes, Gastrointestinal, Respiratory

Control: 10

Intervention: 2

0.05

 

Sawyer et al.,31

118

Cardiovascular, Gastrointestinal, Neurological, Renal, Respiratory,

Control: 18%

Intervention: 17%

No data

 

Shanika et al.,38

645

Cardiovascular, Diabetes, Gastrointestinal, Respiratory

Drug related

Control: 29.9%

Intervention: 13.2%

0.001

 

Shaver et al.,41

1219

Cardiovascular

All causes admissions:

Control:16.86%

Intervention: 6.54%

0.0001

 

Disease related admissions

Control: 13.30%

Intervention: 3.59%

0.01

 

Truong J et al.,29

632            

Cardiovascular

Control 23.8%

Intervention: 12.3%

0.005

 

Wilkinson et al.,21

229

Cardiovascular, Diabetes, Respiratory,

Control: 21.6%

Intervention: 15.7%:

0.04

 

Zemaitis et al.,33

690            

Cardiovascular, Diabetes, Respiratory

All causes admissions:

Control: 24.7%

Intervention: 18%

0.009

 

Table 2 Diseases, number of readmissions, and significance of pharmacist intervention in hospital readmissions within 30 days’ post-discharge in selected documents
a.p-values provided by each paper, and significant results were highlighted in bold.

In 15 articles, the acceptance of interventions performed by pharmacists during the reconciliation process was mentioned by physicians, and these interventions were accepted, reaching at least 60% (Table 3).

Author

N° of discrepancies

N° of interventions

Accepted interventions

Transition of care assessed

Chiarelli et al.,16

259

No data

Two-thirds

Admission

Contreras Rey et al.,13

361

312

29.80%

Admission

Hellström et al.,10

1139

813

567 (70%

Admission

Lee et al.,15

6,5 per patient

No data

100%

Admission

Mendes et al.,12

327

327

63.15%

Admission

Pevnick et al.,14

1016

1016

419 (41%

Admission

Casper et al.,15

17

138

96.20%

Admission / Discharge

Daliri et al.,20

916

916

65% admission;

26% discharge

Admission / Discharge

46.7% post discharge

Admission y Discharge

Ravn-Nielsen et al.,22

No data

946

61%

Admission / Inpatient transfers / Discharge

Wilkinson et al.,21

313

No data

Yes (no numbers

Admission / Inpatient transfers / Discharge

Ip et al.,38

23

51

48 (91,70%

Discharge

Luder et al.,26

No data

7 per patient

46%

Discharge

Rose et al.,31

667

667

336 (54,9%

Discharge

Sawyer et al.,30

661 in control group

116

74 (63,7%

Discharge

723 in intervention group

Boockvar et al.,42

475

36

23 (64%

Inpatient transfers

Table 3 Acceptance of pharmacist interventions, according to the reported in each study

Discussion

Based on the obtained results, pharmacist participation influences hospital readmissions, as evidenced by a decrease in both emergency department visits and readmissions within thirty days post-discharge. Statistically significant differences were shown in the studies by Luder et al., 26 Sánchez et al.,24 Shanika et al.,37 Shaver et al.,40 Truong et al.,29 Wilkinson et al.,21 and Zemaitis et al.33 Reducing patient readmissions not only allows for a decrease in emergency department congestion but also in inpatient bed occupancy. It was observed that the more comprehensive the reconciliation process (including higher staff training, more time allocated, more sources of information, and greater patient involvement), the greater the impact on reducing readmissions.

Regarding emergency department visits, differences in the decrease of visits were found in the intervention group compared to the control group in the studies of Hohl et al.,43 Ip et al.,38 Oñatibia-Astibia et al.,41 Ravn-Nielsen et al.,22 and Shaver et al.,40 demonstrating the pharmacist's influence in this stage of medication reconciliation. However, in three documents, this difference was not statistically significant despite a notable reduction in the absolute number of results. Notably, four out of five documents were analytical observational studies, recording and describing obtained data, with only the study by Ravn-Nielsen et al.,22 being experimental.

Concerning to readmissions, patients with cardiovascular pathologies had the highest rates, followed by those with respiratory conditions and type 2 diabetes mellitus, reflecting the focus of the analyzed studies and the established inclusion criteria.

The reviewed studies indicate a numerical decrease in hospital readmissions within thirty days’ post-discharge in thirteen out of the twenty-three analyzed articles. However, this reduction did not reach statistical significance in most cases. This finding suggests the possibility that important factors, such as the underlying cause of readmissions, may not be adequately considered in the analysis.

Only the study by Ravn-Nielsen et al.,22 compared readmissions caused by medications, while the study by Shaver et al.,40 compared whether the cause of readmission was the same as the previous admission. Regarding the former, pharmacist involvement led to a reduction in readmissions caused by medications. Similarly, when evaluating the cause of readmission, a significant decrease in readmissions for the same reason (13% control versus 3% intervention) and for all causes (16% versus 6%, respectively) was reported.

The studies by Lee et al.,15 and Pevnick et al.,14 offer contrasting perspectives on the impact of pharmacist involvement in hospital stay. Lee et al. 15 found a significant decrease in the average hospital stay, from 18.5 days to 9.5 days, demonstrating significant resource savings for patients, hospitals, and the country. In contrast, the study by Pevnick et al.,14 showed an increase in the average stay with pharmacist intervention, with the usual care group (control) having a stay of 5.2 days, the pharmacist-led reconciliation group with 6.5 days, and the pharmacy technician-led reconciliation supervised by a pharmacist group with 6.2 days. Hence, further research is needed to better understand this variability.

About the acceptability of interventions, approximately half of the reviewed documents evaluated this variable, but no clear relationship was found between the acceptance of interventions and the moment they were conducted. Although these interventions were generally accepted, the lack of detailed data on which interventions were accepted or rejected prevents definitive conclusions from being drawn.

Some limitations of this work include the lack of uniformity in the selected studies, including the age of patients (over 55 years), limiting the understanding of experiences of younger patients. Additionally, there was a limited focus on medication reconciliation only at discharge or hospital admission, rather than considering all patient care transitions. Heterogeneity in sample sizes makes effective comparisons difficult, and lack of detailed information on reasons for hospital readmissions confounds analysis.

Furthermore, deficiencies in the studies related to factors that could hinder the medication reconciliation process were identified, such as the availability of pharmacists 24/7. The lack of studies in Latin America was also highlighted, as most of the reviewed articles came from the United States and Europe. Moreover, the review was limited to articles in Spanish and English, which may have excluded relevant research in other languages.

Conclusion

The literature review clearly demonstrates the significant impact of pharmacist-led medication reconciliation on the quality of care. This is evident from the reduction in readmissions and emergency department visits within thirty days post-hospital discharge, thereby alleviating emergency department congestion. Moreover, patients with cardiovascular, respiratory, and endocrine diseases, including type 2 diabetes mellitus (which was specifically studied in this work), benefited the most. The acceptability of pharmacist interventions was generally high, estimated to be over 50%, with particular emphasis at hospital discharge.

Acknowledgments

None.

Conflicts of interest

The authors declare that they have no conflicts of interest.

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