title: Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
abstract: BACKGROUND
  Medication discrepancies are common at hospital discharge and can result in adverse events, hospital readmissions, and emergency department visits. Our objectives were to characterize medication discrepancies at hospital discharge and test the effects of a pharmacist intervention on health care utilization following discharge.
  
  
  METHODS
  We used a prospective, alternating month quasi-experimental design to compare outcomes of patients receiving the intervention (n = 358) with controls (n = 366). All patients were discharged to home and were at high risk for medication-related problems following discharge because of the number or types of medications they were prescribed, multiple medication changes during hospitalization, or problems managing medications. The intervention consisted of medication therapy assessment, medication reconciliation, screening for adherence concerns, patient counseling and education, and postdischarge telephone follow-up. The primary outcomes were 14-day and 30-day readmission rates and emergency department visits within 72 hours of discharge. Medication discrepancies occurring at discharge were also characterized.
  
  
  RESULTS
  Medication discrepancies at discharge were identified in 33.5% of intervention patients and 59.6% of control patients (P < .001). Although all discrepancies were resolved in the intervention group prior to discharge, readmission rates did not differ significantly between groups at 14 days (12.6% vs 11.5%; P = .65) and 30 days (22.1% vs 18%; P = .17), nor did emergency department visits (2.8% vs 2.2%, respectively; P = .60).
  
  
  CONCLUSIONS
  While our intervention improved the quality of patient discharge by identifying and reconciling medication discrepancies at discharge, there was no effect on postdischarge health care resource utilization.
authors.affiliation: College of Pharmacy, The University of Michigan Health System, 1500 E Medical Center Dr, UH B2D301, Ann Arbor, MI 48109-5008, USA. pcwalker@umich.edu
authors.forename: Paul C
authors.initials: PC
authors.lastname: Walker
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Bernstein
authors.forename: Jasmine N Tucker
authors.initials: JN
authors.lastname: Jones
authors.forename: John
authors.initials: J
authors.lastname: Piersma
authors.forename: Hae-Won
authors.initials: HW
authors.lastname: Kim
authors.forename: Randolph E
authors.initials: RE
authors.lastname: Regal
authors.forename: Latoya
authors.initials: L
authors.lastname: Kuhn
authors.forename: Scott A
authors.initials: SA
authors.lastname: Flanders
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000592:standards; D003266:Continuity of Patient Care; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008499:Medical Records; D006278:Medicare; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010348:Patient Care Team; D010351:Patient Discharge / Q000592:standards*; D010359:Patient Readmission / Q000706:statistics & numerical data; D017060:Patient Satisfaction; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D024382:Professional Role; D011446:Prospective Studies; D014481:United States