Hospital Pharmacy of Funen, Clinical Pharmacy Department, Odense University Hospital, Odense, Denmark.
Hospital Pharmacy of Funen, Clinical Pharmacy Department, Svendborg Hospital, Svendborg, Denmark.
JAMA Intern Med. 2018 Mar 1;178(3):375-382. doi: 10.1001/jamainternmed.2017.8274.
Hospital readmissions are common among patients receiving multiple medications, with considerable costs to the patients and society.
To determine whether a multifaceted pharmacist intervention based on medication review, patient interview, and follow-up can reduce the number of readmissions and emergency department (ED) visits.
DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical multicenter study (Odense Pharmacist Trial Investigating Medication Interventions at Sector Transfer [OPTIMIST]) enrolled patients from September 1, 2013, through April 23, 2015, with a follow-up of 6 months completed on October 31, 2015. Consecutive medical patients in an acute admission ward who were 18 years or older and who used 5 or more medications were invited to participate. Of 1873 patients invited to participate, 1499 (80.0%) accepted. The medication review and patient interview were conducted in the hospital and followed up in collaboration with primary care. Analysis was based on intention to treat.
The patients were randomized into 3 groups receiving usual care (no intervention), a basic intervention (medication review), and an extended intervention (medication review, 3 motivational interviews, and follow-up with the primary care physician, pharmacy, and nursing home).
The prespecified primary outcomes were readmission within 30 or 180 days and ED visits within 180 days. The primary composite end point was readmission or an ED visit within 180 days. Secondary outcomes were drug-related readmissions within 30 and 180 days after inclusion, and all-cause mortality and drug-related mortality.
A total of 1467 patients (679 men [46.3%] and 788 women [53.7%]; median age, 72 years; interquartile range, 63-80 years) were part of the primary analysis, including 498 randomized to usual care, 493 randomized to the basic intervention, and 476 randomized to the extended intervention. The extended intervention had a significant effect on the numbers of patients who were readmitted within 30 days (hazard ratio [HR], 0.62; 95% CI, 0.46-0.84) or within 180 days (HR, 0.75; 95% CI, 0.62-0.90) after inclusion and on the number of patients who experienced the primary composite end point (HR, 0.77; 95% CI, 0.64-0.93). The study showed a nonsignificant reduction in drug-related readmissions within 30 days (HR, 0.65; 95% CI, 0.39-1.09) and within 180 days (HR, 0.80; 95% CI, 0.59-1.08) after inclusion and in deaths (HR, 0.83; 95% CI, 0.22-3.11). The number needed to treat to achieve the primary composite outcome for the extended intervention (vs usual care) was 12.
A multifaceted clinical pharmacist intervention may reduce the number of ED visits and hospital readmissions.
clinicaltrials.gov Identifier: NCT03079375.
重要性：接受多种药物治疗的患者经常会出现医院再入院的情况，这给患者和社会带来了巨大的成本。
目的：确定基于药物评估、患者访谈和随访的多方面药剂师干预是否可以减少再入院和急诊就诊的次数。
设计、地点和参与者：这项随机临床多中心研究（奥登塞药剂师调查药物干预在部门转移中的应用[OPTIMIST]）于 2013 年 9 月 1 日至 2015 年 4 月 23 日期间招募患者，随访于 2015 年 10 月 31 日完成。邀请在急性住院病房使用 5 种或更多药物的 18 岁及以上的连续医疗患者参加。1873 名受邀参加的患者中，有 1499 名（80.0%）接受了邀请。在医院进行药物评估和患者访谈，并与初级保健合作进行随访。分析基于意向治疗。
干预措施：患者被随机分为 3 组，分别接受常规护理（无干预）、基本干预（药物评估）和扩展干预（药物评估、3 次动机访谈和与初级保健医生、药房和疗养院的随访）。
主要结果和措施：预先规定的主要结局是 30 天或 180 天内的再入院和 180 天内的急诊就诊。主要复合终点是 180 天内的再入院或急诊就诊。次要结局是纳入后 30 天和 180 天内与药物相关的再入院和所有原因死亡率和药物相关死亡率。
结果：共有 1467 名患者（679 名男性[46.3%]和 788 名女性[53.7%]；中位年龄 72 岁；四分位距 63-80 岁）参与了主要分析，包括 498 名随机分配到常规护理、493 名随机分配到基本干预、476 名随机分配到扩展干预。扩展干预对纳入后 30 天内再入院（风险比[HR]，0.62；95%置信区间，0.46-0.84）或 180 天内再入院（HR，0.75；95%置信区间，0.62-0.90）以及经历主要复合终点（HR，0.77；95%置信区间，0.64-0.93）的患者数量有显著影响。研究显示，纳入后 30 天（HR，0.65；95%置信区间，0.39-1.09）和 180 天（HR，0.80；95%置信区间，0.59-1.08）与药物相关的再入院和死亡（HR，0.83；95%置信区间，0.22-3.11）的发生率均无显著降低。为了达到扩展干预（与常规护理相比）的主要复合结局，需要治疗的人数为 12。
结论和相关性：多方面的临床药剂师干预可能会减少急诊就诊和医院再入院的次数。
试验注册：clinicaltrials.gov 标识符：NCT03079375。
