title: Transition of care: A set of pharmaceutical interventions improves hospital discharge prescriptions from an internal medicine ward.
abstract: BACKGROUND
  Continuity of care between hospitals and community pharmacies needs to be improved to ensure medication safety. This study aimed to evaluate whether a set of pharmaceutical interventions to prepare hospital discharge facilitates the transition of care.
  
  
  METHODS
  This study took place in the internal medicine ward and in surrounding community pharmacies. The intervention group's patients underwent a set of pharmaceutical interventions during their hospital stay: medication reconciliation at admission, medication review, and discharge planning. The two groups were compared with regards to: number of community pharmacist interventions, time spent on discharge prescriptions, and number of treatment changes.
  
  
  RESULTS
  Comparison between the groups showed a much lower (77% lower) number of community pharmacist interventions per discharge prescription in the intervention (n=54 patients) compared to the control group (n=64 patients): 6.9 versus 1.6 interventions, respectively (p<0.0001); less time working on discharge prescriptions; less interventions requiring a telephone call to a hospital physician. The number of medication changes at different steps was also significantly lower in the intervention group: 40% fewer (p<0.0001) changes between hospital admission and discharge, 66% fewer (p<0.0001) between hospital discharge and community pharmacy care, and 25% fewer (p=0.002) between community pharmacy care and care by a general practitioner.
  
  
  CONCLUSIONS
  An intervention group underwent significantly fewer medication changes in subsequent steps in the transition of care after a set of interventions performed during their hospital stay. Community pharmacists had to perform fewer interventions on discharge prescriptions. Altogether, this improves continuity of care.
authors.affiliation: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland.
authors.forename: Marine
authors.initials: M
authors.lastname: Neeman
authors.affiliation: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland.
authors.forename: Maria
authors.initials: M
authors.lastname: Dobrinas
authors.affiliation: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland; Pharmacie du Marché, Vevey, Switzerland.
authors.forename: Sophie
authors.initials: S
authors.lastname: Maurer
authors.affiliation: Hôpital Riviera-Chablais, Vaud-Valais (HRC), Vevey, Switzerland.
authors.forename: Damien
authors.initials: D
authors.lastname: Tagan
authors.affiliation: Hôpital Riviera-Chablais, Vaud-Valais (HRC), Vevey, Switzerland.
authors.forename: Annelore
authors.initials: A
authors.lastname: Sautebin
authors.affiliation: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland. Electronic address: annelaure.blanc@phel.ch.
authors.forename: Anne-Laure
authors.initials: AL
authors.lastname: Blanc
authors.affiliation: Pharmacie des Hôpitaux de l'Est Lémanique (PHEL), Vevey, Switzerland; Division of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Widmer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007388:Internal Medicine; D008297:Male; D059065:Medication Reconciliation; D008875:Middle Aged; D010343:Patient Admission; D010351:Patient Discharge; D010360:Patient Transfer / Q000592:standards*; D010594:Pharmacies / Q000592:standards*; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000592:standards*; D024382:Professional Role; D013557:Switzerland
keywords: Clinical pharmacist; Community pharmacy; Discharge planning; Hospital discharge prescription; Medication reconciliation; Transition of care