Hammad Eman A, Khaled Farah, Shafaamri Majed, Amireh Bara'ah, Arabyat Rasha, Abu-Farha Rana K
Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, Jordan.
Department of Health Economics and Healthcare Administration, Institute of Public Health, University of Jordan, Amman, Jordan.
PLoS One. 2025 Apr 25;20(4):e0320699. doi: 10.1371/journal.pone.0320699. eCollection 2025.
To assess the impacts of pharmacist-led medication reconciliation (MedRec) on medication discrepancies and post-discharge health services utilization in elderly patients in Jordan. And to identify predictors of post discharge outcomes.
Newly admitted patients, aged above 65 years were randomly allocated into either a group receiving pharmacist led MedRec or standard care. Within 24 hours of admission, a clinical pharmacist compiled a list of the Best Possible Medication History (BPMH) using at least two sources of information. The pharmacist compared the BPMHs to the admission charts to identify discrepancies and resolved them accordingly. One month post-discharge, patients were assessed for health services use, namely hospital readmissions, emergency department (ED) visits, and adverse drug events (ADEs). Logistic regressions used to investigate predictors of post discharge outcomes.
A total of 128 patients with 151 medication discrepancies were included: 82 (54.3%) discrepancies in the intervention group, and 69 (45.7%) in the control group. A total of 52 Pharmacist-led interventions were recommended to physicians, of which 49 (94.2%) were accepted/implemented. At discharge, the majority of unintentional discrepancies were successfully resolved (p < 0.001). At 30 days post-discharge, patients who were readmitted to the hospital and visited the ED were significantly from the control group. There was no significant difference with respect to experiencing ADEs among the study groups. Patients who received pharmacist-led MedRec had almost 70% lower likelihood of hospital readmission and ED visits. Discrepancies at discharge was associated with higher odds of hospital readmissions.
Pharmacist-led MedRec services improved continuity of care for elderly patients. Implementing a structured reconciliation process successfully resolved discrepancies and reduced hospital readmissions as well as ED visits at 30-days post-discharge. This outlines potentials for healthcare cost savings. Future studies are recommended to explore long-term benefits, cost-effectiveness, and integrating pharmacist-led MedRec into standard discharge planning.
评估药剂师主导的用药核对（MedRec）对约旦老年患者用药差异及出院后医疗服务利用情况的影响。并确定出院后结局的预测因素。
将65岁以上新入院患者随机分为接受药剂师主导的MedRec组或标准治疗组。入院后24小时内，临床药剂师使用至少两种信息来源编制最佳可能用药史（BPMH）清单。药剂师将BPMH与入院病历进行比较以识别差异并相应解决。出院后1个月，评估患者的医疗服务使用情况，即再次入院、急诊就诊和药物不良事件（ADE）。采用逻辑回归分析来研究出院后结局的预测因素。
共纳入128例存在151处用药差异的患者：干预组82处（54.3%）差异，对照组69处（45.7%）差异。共向医生推荐了52项药剂师主导的干预措施，其中49项（94.2%）被接受/实施。出院时，大多数无意的差异得到成功解决（p＜0.001）。出院后30天，再次入院和急诊就诊的患者主要来自对照组。各研究组在发生ADE方面无显著差异。接受药剂师主导的MedRec的患者再次入院和急诊就诊的可能性降低了近70%。出院时的差异与再次入院的较高几率相关。
药剂师主导的MedRec服务改善了老年患者的护理连续性。实施结构化核对流程成功解决了差异，并减少了出院后30天的再次入院和急诊就诊情况。这凸显了节省医疗成本的潜力。建议未来的研究探索长期效益、成本效益，以及将药剂师主导的MedRec纳入标准出院计划。
