Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis

Abstract

Background

Readmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community.

Objective

To assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions.

Methods

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect.

Results

In total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR = 0.87, CI:0.79–0.97, p = 0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR = 0.78, CI:0.67–0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR = 0.92, CI:0.80–1.06; low certainty of evidence).

Conclusions

The totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.

Introduction

Patients with chronic conditions are often confronted with complex care plans and significant changes to their medication regimen prior to discharge from hospital.¹ For many patients, discontinued medications are unintentionally continued, newly prescribed medications are omitted, and dose changes are not implemented.² Readmissions to hospital due to medication-related problems are common and may be preventable.³ A systematic review found rates of medication-related readmissions varied between 3 and 64% across nine included studies, with a median rate of 21%.³ On average, 69% of these readmissions were considered preventable.³ Patients who have a medication discrepancy (a difference between prescribed medication and medication actually taken) following hospital discharge are twice as likely to be readmitted to hospital within 30 days.⁴

Pharmacists play a key role during care transitions from hospital to community through optimising medicine use and reducing medication discrepancies,^5,6 identifying and rectifying medication errors such as incorrect medication or dosing schedule,7, 8, 9 and improving medication adherence.⁷ A commonly performed pharmacist-led intervention is medication reconciliation (matching prescribed medicine with actual medicine use), with a meta-analysis by Mekonnen and colleagues showing that hospital-based pharmacists performing medication reconciliation at admission and/or discharge reduced all-cause readmissions by 19% compared to usual care.⁶ In contrast, a review of studies of pharmacist-led medication reconciliation in the community setting shortly after hospital discharge did not demonstrate significant reductions in hospital readmissions.⁸ This difference may be explained by the inclusion in the former review of studies that used other components (e.g. medication review, patient follow-up by the pharmacist, or communication with primary care providers) which may have contributed to improved patient outcomes.⁶

A pharmacist-led intervention which involves liaising with the patient, hospital and primary care team after discharge provides an opportunity to improve communication and care during a time that is often associated with medication misadventure and readmission to hospital.^10,11 Indeed, several studies have described pharmacist-led interventions which involve communication with the primary care provider (physician or nurse practitioner) (PCP) during the transition back into the community after hospitalisation with the aim of reducing readmissions.12, 13, 14, 15, 16, 17 However, between-study differences in interventions and level of PCP involvement do not allow identification of the most effective components. A further constraint are analyses which use different follow-up time-points. While unplanned readmissions at 30 days is commonly reported as a measure of quality of hospital care transitions, exploring outcomes at later time-points allows better assessment of the duration of intervention effects.

In 2012, Guerts and colleagues undertook a systematic review of interventions of pharmacist and physician collaboration aimed at improving patient outcomes.⁷ Only three studies reported readmissions as an outcome and findings were mixed. Since then, pharmacist and GP collaboration in the post-discharge period have increased worldwide, and more studies have likely been published.^12,17 We undertook a focused systematic review and meta-analysis of the literature relating to any pharmacist-led interventions involving communication with a PCP, with the aim of assessing the impact of these interventions on reducing readmissions to hospital.

Specific objectives were to:

• Investigate whether pharmacist-led interventions which include PCP communication reduce readmission to hospital.

• Identify and describe the characteristics of included interventions.

• Explore differences in effectiveness of interventions at different follow-up time-points and between different patient groups.