Walker Paul C, Bernstein Steven J, Jones Jasmine N Tucker, Piersma John, Kim Hae-Won, Regal Randolph E, Kuhn Latoya, Flanders Scott A
College of Pharmacy, The University of Michigan Health System, 1500 E Medical Center Dr, UH B2D301, Ann Arbor, MI 48109-5008, USA.
Arch Intern Med. 2009 Nov 23;169(21):2003-10. doi: 10.1001/archinternmed.2009.398.
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.
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.
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).
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.
出院时用药差异很常见，可能导致不良事件、再次入院和急诊就诊。我们的目标是描述出院时的用药差异，并测试药剂师干预对出院后医疗保健利用情况的影响。
我们采用前瞻性、交替月准实验设计，比较接受干预的患者（n = 358）与对照组（n = 366）的结果。所有患者均出院回家，由于所开药物的数量或类型、住院期间多次用药变更或用药管理问题，出院后存在用药相关问题的高风险。干预措施包括药物治疗评估、用药核对、依从性问题筛查、患者咨询和教育以及出院后电话随访。主要结局是14天和30天再入院率以及出院后72小时内的急诊就诊情况。还对出院时出现的用药差异进行了描述。
干预组33.5%的患者和对照组59.6%的患者在出院时发现用药差异（P < .001）。虽然干预组在出院前解决了所有差异，但两组在14天（12.6%对11.5%；P = .65）和30天（22.1%对18%；P = .17）的再入院率没有显著差异，急诊就诊情况也没有差异（分别为2.8%对2.2%；P = .60）。
虽然我们的干预通过识别和核对出院时的用药差异提高了患者出院质量，但对出院后医疗保健资源利用没有影响。
