Clinical Pharmacist Intervention and Risk of Readmission

Study Questions:

Can in-hospital readmission rates be reduced by a multipart pharmacist intervention involving medication review, motivational interview, and follow-up contact with patient and primary care physician?


This was a randomized, multi-center trial in Denmark. Included patients (n = 1,467) were 18 years or older, had polypharmacy (≥5 prescribed daily medications), spoke Danish, and were new acute admissions. Patients were randomized (1:1:1) to usual care (n = 498), basic intervention (n = 493), or extended intervention (n = 476). Basic intervention included a medication review by a clinical pharmacist soon after admission. This included review of indications, drug dose, renal function, adverse drug reactions, interactions, and duplications. Recommendations were placed in the electronic medical record and, if possible, discussed directly with the physician. The extended intervention by the clinical pharmacist included the medication review and a discharge medication reconciliation, a 30-minute motivational interview with the patient to review new medications, changes, side effects, adherence, and discontinuations. A summary letter was then sent to the primary care provider. The primary care provider, caregiver, and primary pharmacy were contacted by telephone 3 days post-discharge. Clinical pharmacists also provided 2 follow-up phone calls to the patient at 1 week and 6 months post-discharge.


Primary outcomes included readmission within 30 days and 180 days after inclusion and composite endpoint of readmissions and emergency department visits within 180 days. Drug-related readmissions within 30 and 180 days after inclusion and all-cause and drug-related mortality were secondary outcomes. Median age of patients was 72 years, with 679 (46.3%) male and 788 (53.7%) female. With the extended intervention group versus usual care, a significant difference was found in 68 patients (14.3%) versus 111 patients (22.3%) with readmission within 30 days (hazard ratio [HR] 0.62; 95% confidence interval [CI], 0.46-0.84), or 189 patients (39.7%) versus 243 patients (48.8%) within 180 days (HR 0.75; 95% CI, 0.62-0.90). A difference was also found in 193 patients (40.5%) versus 243 patients (48.8%) with composite of readmissions or emergency department visits within 180 days (HR 0.77; 95% CI, 0.64-0.93). Subgroup analysis found significant difference for men (HR 0.64; 95% CI, 0.48-0.84), age ≥65 (HR 0.80; 95% CI, 0.64-0.99), >8 drugs at admission (HR 0.73; 95% CI, 0.59-0.90), and Charlson comorbidity score 0-2 (HR 0.69; 95% CI, 0.52-0.91). Drug-related readmissions or drug-related deaths were not significantly different. Pharmacists recommended 946 interventions to hospital physicians, of which 449 (47.5%) concerned risk of drug-related readmission. To primary care, 75/183 (41%) were concerning this risk. Rate of recommendations implemented were 61% in the hospital setting and 66% in primary care. Mean time spent on extended intervention was 51.8 minutes versus 14.7 minutes for basic interventions.


Clinical pharmacists in the hospital setting providing the comprehensive approach of medication review, discharge medication reconciliation, motivational interviews with the patient, and follow-up phone calls to primary care physicians may play a significant part in preventing hospital readmissions in patients discharged on multiple medications.


Future studies may help to identify patients at highest risk of drug-related problems to better tailor the extended interventions. Because extensive interventions were performed by clinical pharmacists and were found to be more time intensive than basic interventions, they may require more pharmacist resources to perform. Therefore, focusing on high-risk patients who will derive benefit such as those in the subgroup analysis where benefit was found (patients age ≥65 or taking >8 medications at admission) will assist in targeting patients in need of clinical pharmacist extended intervention.

Keywords: Pharmacists, Patient Readmission, Physicians, Primary Care, Caregivers, Pharmaceutical Services, Patient Discharge, Drug-Related Side Effects and Adverse Reactions, Medication Reconciliation

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