title: Impact of early in-hospital medication review by clinical pharmacists on health services utilization.
abstract: BACKGROUND
  Adverse drug events are a leading cause of emergency department visits and unplanned admissions, and prolong hospital stays. Medication review interventions aim to identify adverse drug events and optimize medication use. Previous evaluations of in-hospital medication reviews have focused on interventions at discharge, with an unclear effect on health outcomes. We assessed the effect of early in-hospital pharmacist-led medication review on the health outcomes of high-risk patients.
  
  
  METHODS
  We used a quasi-randomized design to evaluate a quality improvement project in three hospitals in British Columbia, Canada. We incorporated a clinical decision rule into emergency department triage pathways, allowing nurses to identify patients at high-risk for adverse drug events. After randomly selecting the first eligible patient for participation, clinical pharmacists systematically allocated subsequent high-risk patients to medication review or usual care. Medication review included obtaining a best possible medication history and reviewing the patient's medications for appropriateness and adverse drug events. The primary outcome was the number of days spent in-hospital over 30 days, and was ascertained using administrative data. We used median and inverse propensity score weighted logistic regression modeling to determine the effect of pharmacist-led medication review on downstream health services use.
  
  
  RESULTS
  Of 10,807 high-risk patients, 6,416 received early pharmacist-led medication review and 4,391 usual care. Their baseline characteristics were balanced. The median number of hospital days was reduced by 0.48 days (95% confidence intervals [CI] = 0.00 to 0.96; p = 0.058) in the medication review group compared to usual care, representing an 8% reduction in the median length of stay. Among patients under 80 years of age, the median number of hospital days was reduced by 0.60 days (95% CI = 0.06 to 1.17; p = 0.03), representing 11% reduction in the median length of stay. There was no significant effect on emergency department revisits, admissions, readmissions, or mortality.
  
  
  CONCLUSIONS
  We were limited by our inability to conduct a randomized controlled trial, but used quasi-random patient allocation methods and propensity score modeling to ensure balance between treatment groups, and administrative data to ensure blinded outcomes ascertainment. We were unable to account for alternate level of care days, and therefore, may have underestimated the treatment effect in frail elderly patients who are likely to remain in hospital while awaiting long-term care.
  
  
  CONCLUSIONS
  Early pharmacist-led medication review was associated with reduced hospital-bed utilization compared to usual care among high-risk patients under 80 years of age, but not among those who were older. The results of our evaluation suggest that medication review by pharmacists in the emergency department may impact the length of hospital stay in select patient populations.
authors.affiliation: Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.|Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.|Emergency Department, Vancouver General Hospital, Vancouver, Canada.
authors.forename: Corinne M
authors.identifier: http://orcid.org/0000-0002-9210-7838
authors.initials: CM
authors.lastname: Hohl
authors.affiliation: Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.|Coordinator, Clinical Pharmacy Services, Vancouver General Hospital, Vancouver, Canada.
authors.forename: Nilu
authors.initials: N
authors.lastname: Partovi
authors.affiliation: Ghement Statistical Consulting Company Ltd, Richmond, Canada.
authors.forename: Isabella
authors.initials: I
authors.lastname: Ghement
authors.affiliation: Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.|Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.
authors.forename: Maeve E
authors.initials: ME
authors.lastname: Wickham
authors.affiliation: School of Population and Public Health, Vancouver, Canada.
authors.forename: Kimberlyn
authors.initials: K
authors.lastname: McGrail
authors.affiliation: Vancouver Coastal Health, Vancouver, Canada.
authors.forename: Lisa N
authors.initials: LN
authors.lastname: Reddekopp
authors.affiliation: Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.|School of Population and Public Health, Vancouver, Canada.
authors.forename: Boris
authors.initials: B
authors.lastname: Sobolev
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001955:British Columbia; D004358:Drug Therapy / Q000706:statistics & numerical data*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000175:diagnosis*; D005260:Female; D006760:Hospitalization; D006761:Hospitals; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010595:Pharmacists; D010607:Pharmacy Service, Hospital / Q000379:methods*; D010865:Pilot Projects; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data; D012307:Risk Factors