|Medication reconciliation during transitions of care as a patient safety strategy: a systematic review
|Kwan JL, Lo L, Sampson M, Shojania KG
This review concluded that medication reconciliation alone was unlikely to reduce hospital use after discharge, but it might do combined with other interventions to improve care transition; the effects for in-patients were unclear. This conclusion was a cautious interpretation of an appropriate evidence synthesis and is likely to be reliable.
To assess the effect of medication reconciliation, during transition of care, on errors with the potential for harm, and on hospital attendance after discharge.
MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 2012, for studies reported in English. Search strategies were reported. References of identified studies and reviews were checked.
Randomised controlled trials (RCTs), before-and-after studies, and post-intervention studies, of hospital-based interventions for medication reconciliation, were eligible for inclusion. The minimum definition of medication reconciliation was the completion of a best possible medication history, and the correction of unintended discrepancies between the previous regimen and the proposed medication at admission, transfer, or discharge. Studies had to report emergency department visits and hospitalisations, within 30 days of discharge, or the assessment, by one or more independent clinician, of the severity or clinical significance of unintended discrepancies. Unintended discrepancies had to be clearly distinguished from intentional changes after direct communication with the patients' medical teams.
All the included studies took place in the USA or Canada. Seven of them focused on patients deemed to be at high risk on the basis of age, chronic illness or multiple medication use. The transitions targeted were hospital admission, discharge home, in-hospital transfer, or multiple care transitions. Most of the interventions were delivered by pharmacists and about half were paper-based and half were electronic. Some studies included other interventions in addition to medication reconciliation.
Two reviewers independently assessed the studies for inclusion in the review. Disagreements were resolved through discussion, with a third reviewer, where necessary.
Assessment of study quality
The RCTs were assessed using the Cochrane Collaboration's risk of bias tool. Two reviewers independently assessed them and disagreements were resolved through discussion, and with a third reviewer, where necessary.
The authors did not report how the studies with other designs were assessed.
The data were extracted to calculate relative risks, with 95% confidence intervals, for RCTs. Median effects and interquartile ranges were extracted from studies with other designs. A prespecified form was used. Two reviewers independently extracted the data, with disagreements resolved through discussion, and with a third reviewer, where necessary. Study authors were contacted for further details, where necessary.
Methods of synthesis
Where possible, the relative risks from individual RCTs were combined in a meta-analysis to calculate a pooled relative risk, with 95% confidence interval. Both fixed-effect and random-effects analyses were used.
Where this was not possible for RCTs, and for the studies with other designs, a narrative synthesis was presented. This was structured by the outcome reported.
Results of the review
Eighteen studies of 20 interventions were included in the review. Five were RCTs (1,519 patients), with seven interventions. All RCTs had a low risk of bias. One study had a quasi-experimental design, three were before-and-after studies, and nine were post-intervention studies.
Clinically significant unintended medication discrepancies: There was high variability, between the 12 interventions, in the number of discrepancies per patient. The median percentage of discrepancies judged to be significant was 34 (IQR 28 to 49). The median percentage of patients with one or more discrepancy was 45 (IQR 31 to 56). Two interventions targeted high-risk patients and reported very different results.
One of two RCTs found that fewer patients (1%) in the intervention group experienced preventable adverse drug events, than with control (11%; p=0.01), but the total events did not differ between the groups. The other RCT found a statistically significant reduction in potential adverse drug events (clinically significant unintended medication discrepancies; RR 0.72, 95% CI 0.52 to 0.99).
Another large RCT of the impact of different levels of intervention on unintended discrepancies was listed in an online appendix, but it was not clear whether these results were statistically significant.
Emergency department visits and readmission within 30 days: The pooled three RCTs showed a statistically significant benefit with their interventions (random-effects RR 0.77, 95% CI 0.63 to 0.95). This finding was driven by one RCT of an intensive intervention, which had additional components aimed at reducing readmission.
Across the nine interventions, five were targeted at high-risk patients, but this focus did not appear to increase the benefit of the interventions.
Exploration of the key contextual factors, such as patients' ability to provide up-to-date medication histories, availability of medication data, and ability to integrate medication reconciliation into processes, could not be achieved due to a lack of data.
One model-based study, which was not identified by the review process, found that pharmacist-led medication reconciliation had a reasonable probability of cost-effectiveness, at a threshold of £10,000 per quality-adjusted life-year, as of December, 2012. Further information was given in the paper.
Most patients had no unintentional discrepancies, and most discrepancies had no clinical significance, so the effects of reconciliation were unclear. Medication reconciliation alone did not seem to reduce hospital use after discharge, but it might do combined with other interventions to improve care transition.
This review addressed a clear question, supported by specific inclusion criteria. The search was thorough but, as the authors acknowledged, it did not attempt to identify unpublished studies. The authors reported methods designed to reduce reviewer bias and error throughout the review process. Appropriate methods were used to assess the risk of bias in the RCTs; it was not clear if or how the other studies were assessed. Meta-analysis was limited to one outcome, but it was appropriate. No formal assessment of statistical heterogeneity was reported, but the authors described the differences between the studies. The focus on the RCTs was reasonable and appropriate, particularly as they were at a low risk of bias.
The authors' conclusions were a cautious interpretation of their evidence synthesis and appear likely to be reliable.
Implications of the review for practice and research
Practice: The authors stated that bundling medication reconciliation with other interventions to improve care coordination at hospital discharge was a promising method of reducing emergency department visits or readmissions within 30 days.
Research: The authors stated that future research should examine the effect of medication reconciliation on hospital use beyond 30 days after discharge, and it should identify the patient features that consistently increase the risk of clinically significant unintended discrepancies.
Funded by the Agency for Healthcare Research and Quality (AHRQ), USA.
Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 397-403
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Subject indexing assigned by NLM
Emergency Service, Hospital /statistics & Humans; Medical History Taking; Medication Reconciliation /economics; Patient Discharge; Patient Readmission /statistics & Patient Safety /economics /standards; Pharmacists; Professional Role; Risk Assessment; numerical data; numerical data
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.