The Effect of a Pharmacist Home Visit on Drug-related Problems Post-discharge.

Inaccuracy of medication histories and lack of knowledge on actual medication use results in confusion about medication regimens and medication mismanagement before- during - and after hospital admission. This phenomenon accounts for many readmissions, longer duration of admission and preventable and serious Adverse Drug Events (ADEs) as a result of Drug Related Problems (DRPs). Several studies show that discharge medication reconciliation (MR) and counseling by a pharmacy employee reduces the amount of discrepancies in the discharge prescription lists. Still, no unequivocal effect of MR on the occurrence of DRPs after discharge has been shown. This is due to a shift in underlying potential harmful discrepancies from mainly patient based (unintended nonadherence) to mainly system based (eg dispensing errors) and might be explained by (1) suboptimal transfer of information (2) an overload of information during a stressful situation and (3) difficulty to implement changes in medication at home. Therefore the reduction of DRPs, improvement of patients' medication knowledge and initial adherence can probably most effectively be addressed in a multifaceted integrated transmural intervention. Repetition of important information is the key to success. Moreover, the first weeks following hospital discharge are most crucial in preventing drug-related problems as patients could slip back in old medication schemes, or new problems may arise, such as emerging ADEs due to medication changes made during hospitalization.

Inclusion criteria

• patient uses more than three prescribed systemic drugs intended for chronic use at admission and discharge
• patient has an expected length of stay of 48 hours or longer

Exclusion criteria

• Patients admitted for scheduled chemotherapy
• Patients admitted for radiation therapy
• Patients admitted for transplantation
• Patients transferred from another hospital
• Patients transferred from another non-eligible ward within the same hospital
• No informed consent signed
• A live expectancy less than 6 months
• Inability to be counselled (e.g. cognitive dysfunction, language constraints who cannot be solved with an interpreter)
• Discharge to a nursing home (presuming dependence on medication administration)
• If patients' community pharmacy is not participating in this study