Schnipper Jeffrey L, Kirwin Jennifer L, Cotugno Michael C, Wahlstrom Stephanie A, Brown Brandon A, Tarvin Emily, Kachalia Allen, Horng Mark, Roy Christopher L, McKean Sylvia C, Bates David W
Brigham and Women's/Faulkner Hospitalist Program, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02120-1613, USA.
Arch Intern Med. 2006 Mar 13;166(5):565-71. doi: 10.1001/archinte.166.5.565.
Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs.
We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs.
Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization.
Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.
住院及随后出院回家常常涉及护理的间断、药物治疗方案的多次变更以及患者教育不足，这些可能导致药物不良事件（ADEs）及可避免的医疗保健利用。我们的目标是识别住院期间及出院后的药物相关问题，并确定药师进行患者咨询及随访对可预防的ADEs的影响。
我们在一家大型教学医院对178名从普通内科出院回家的患者进行了一项随机试验。干预组患者在出院时接受药师咨询，并在3至5天后接受随访电话。干预重点在于明确药物治疗方案；复查药物的适应证、用法及潜在副作用；筛查依从性障碍和早期副作用；并在适当的时候提供患者咨询和/或医生反馈。主要结局是可预防的ADEs发生率。
药师在干预组中观察到以下药物相关问题：49%的患者入院前药物治疗方案与出院用药医嘱之间存在无法解释的差异，29%的患者出院用药清单与出院后治疗方案之间存在无法解释的差异，23%的患者存在用药不依从。比较出院30天后的试验结果，对照组11%的患者和干预组1%的患者检测到可预防的ADEs（P = 0.01）。两组在总ADEs或总医疗保健利用方面未发现差异。
药师进行药物审查、患者咨询及电话随访与出院30天后可预防的ADEs发生率较低相关。出院前后的用药差异是常见的干预目标。
