Optimizing the Hospital Discharge Process: Perspectives of the Health Care Team.

Background: Prior research capturing pharmacists' perspectives on the discharge process has shown that their involvement is essential. Given the multidisciplinary nature of the hospital environment, it is important to understand the perspectives of nonpharmacist health care providers. Objectives: To explore the perspectives of nonpharmacist health care providers concerning current discharge practices, components of an effective discharge plan, and perceived barriers to an optimal discharge, and to explore their expectations of pharmacists at discharge. Methods: This qualitative study used key informant interviews of allied health professionals and prescribers at Vancouver General Hospital and North Island Hospital Comox Valley (British Columbia). Participants primarily working on general medicine, family practice, or hospitalist wards were invited to participate. Results: A total of 16 health care providers participated, consisting of 12 allied health professionals and 4 prescribers. Thematic analysis of the interview transcripts revealed 5 themes for each group. The following 3 themes were common to both groups: systems-related barriers to an optimal discharge; patient- and community-related barriers to an optimal discharge; and patient involvement and education. For allied health professionals, themes of prioritization of patients for discharge and direct communication/teamwork were also key for an optimal discharge. Prescriber-specific themes were limitations related to technology infrastructure and inefficiency of existing collaborative processes. Key responsibilities expected of the pharmacist at discharge included preparing the discharge medication reconciliation and prescriptions, addressing medication-related cost concerns, organizing adherence aids/tools, and providing medication counselling. Conclusions: Further studies are warranted to investigate optimization of the discharge process through implementation of standardized discharge protocols and electronic health record-related tools. The primary responsibilities of the pharmacist at discharge, as perceived by study participants, were consistent with previous literature.

Contexte: Des recherches antérieures recueillant le point de vue de pharmaciens sur le processus associé au congé de l'hôpital ont démontré que leur implication est essentielle. Compte tenu de la nature multidisciplinaire du milieu hospitalier, il est important de comprendre les perspectives des prestataires de soins de santé non pharmaciens. Objectifs: Étudier les points de vue des prestataires de soins de santé non pharmaciens au sujet des pratiques actuelles relatives au congé, des éléments d'un plan de congé efficace et des obstacles perçus à un congé optimal, et, enfin, prendre connaissance des attentes des prestataires à l'égard des pharmaciens au moment du congé. Méthodologie: Cette étude qualitative a utilisé des entretiens avec des informateurs clés, des professionnels paramédicaux et des prescripteurs au Vancouver General Hospital et au North Island Hospital Comox Valley (en Colombie-Britannique). Les participants travaillant principalement dans les services de médecine générale, de médecine familiale ou d'hospitalisation ont été invités à participer. Résultats: Au total, 16 prestataires de soins de santé ont participé, 12 professionnels paramédicaux et 4 prescripteurs. L'analyse thématique des transcriptions des entretiens a permis d'identifier 5 thèmes pour chaque groupe. Les 3 thèmes suivants étaient communs aux deux groupes: obstacles au congé optimal liés aux systèmes; obstacles au congé optimal liés aux patients et à la communauté; et participation et sensibilisation des patients. Pour les professionnels paramédicaux, les thèmes de la priorisation des patients pour le congé et de la communication directe/du travail d'équipe étaient essentiels pour un congé optimal. Les thèmes spécifiques aux prescripteurs étaient les limitations liées à l'infrastructure technologique et l'inefficacité des processus de collaboration existants. Les principales responsabilités attendues du pharmacien à la sortie comprenaient la préparation du bilan comparatif des médicaments et des ordonnances au moment du congé, la résolution des problèmes de coûts liés aux médicaments, l'organisation des aides/outils à l'observance et la fourniture de conseils en matière de médication. Conclusions: D'autres études sont nécessaires pour étudier l'optimisation du processus associé au congé grâce à la mise en œuvre de protocoles standardisés et d'outils liés aux dossiers de santé électroniques. Les principales responsabilités du pharmacien au moment du congé, telles que perçues par les participants à l'étude, correspondaient à la littérature antérieure.

What Patients Want: A Qualitative Study of Patients' Perspectives on Optimizing the Hospital Discharge Process.

Background: Poor discharge planning can lead to increases in adverse drug events, hospital readmissions, and costs. Prior research has identified the pharmacist as an integral part of the discharge process. Objectives: To gain patients' perspectives on the discharge process and what they would like pharmacists to do to ensure a successful discharge. Methods: Twenty patients discharged from tertiary care hospitals were interviewed after discharge. A phenomenological approach was used to conduct this qualitative study. Results: Five main themes were identified from the patient interviews: interactions with health care professionals, importance of discharge documentation, importance of seamless care, comprehensive and patient-specific medication counselling, and patients' preference for involvement and communication at all stages of hospital stay. Conclusions: Although participants generally reported positive interactions with health care providers at discharge, several areas for improvement were identified, particularly in terms of communication, discharge documentation, and continuity of care. A list of recommendations aligning with patient preferences is provided for clinicians.

Contexte: Une mauvaise planification du congé hospitalier peut entraîner une augmentation des événements indésirables liés aux médicaments, des réadmissions et des coûts. Des recherches antérieures ont reconnu le pharmacien comme faisant partie intégrante du processus associé au congé de l'hôpital. Objectifs: Recueillir le point de vue des patients sur le processus relatif au congé et sur ce qu'ils aimeraient que les pharmaciens fassent pour assurer la réussite de celui-ci. Méthodologie: Vingt patients d'hôpitaux de soins tertiaires ont été interrogés après leur congé. Cette étude qualitative a été menée en adoptant une approche phénoménologique. Résultats: Cinq thèmes principaux ont émergé à partir des entretiens avec les patients: les interactions avec les professionnels de la santé, l'importance de la documentation au moment du congé, l'importance de soins continus, des conseils complets et spécifiques au patient en matière de médication, et la préférence des patients pour l'implication et la communication à toutes les étapes de leur séjour à l'hôpital. Conclusions: Bien que les participants aient généralement signalé des interactions positives avec les prestataires de soins de santé au moment de leur congé, plusieurs domaines d'amélioration ont été dépistés, notamment sur les plans de la communication, de la documentation au moment du congé et de la continuité des soins. Une liste de recommandations alignées sur les préférences des patients est fournie aux cliniciens.

Characterizing Current and Optimal Involvement of Hospital Pharmacists in the Discharge Process: A Survey of Pharmacists in British Columbia.

Background: Transitions of care represent a vulnerable time when patients are at increased risk of medication errors. Medication-related problems constitute one of the main contributors to hospital readmissions. Discharge interventions carried out by pharmacists have been shown to reduce hospital readmissions. Although clinical pharmacists in British Columbia are involved in discharges, their degree of involvement and the interventions they prioritize in practice have not been fully elucidated. Objectives: To characterize the current involvement of BC hospital pharmacists at the time of discharge, to identify which discharge interventions they believe should be prioritized, and who they feel should be responsible for these interventions, as well as to identify strategies to optimize the discharge process. Methods: A survey of BC hospital pharmacists was conducted in January and February 2022. The survey included questions about pharmacists' current involvement at the time of discharge, interventions required for a successful discharge, solutions for optimizing the patient discharge process, and participants' baseline characteristics. Results: The survey response rate was 20% (101/500). Pharmacists reported performing all interventions for less than 60% of their patients. Interventions such as medication reconciliation on discharge, medication education, and ensuring adherence were considered very important for a successful discharge and were considered to be best performed by pharmacists. Solutions for optimizing the discharge process included improved staffing, weekend coverage, timely notification of discharge, and prescribing by pharmacists. Conclusions: Despite the belief that most interventions listed in the survey are necessary for successful discharge, various barriers prevented pharmacists from providing them to all patients. Increased resources and expanded scope of practice for pharmacists could reduce hospital readmissions and enable broader implementation of discharge interventions.

Contexte: Les transitions de soins sont une période vulnérable pendant laquelle les patients courent un risque accru d'erreurs médicamenteuses. Les problèmes liés aux médicaments constituent l'un des principaux contributeurs aux réadmissions à l'hôpital. Il a été démontré que les interventions au moment du congé effectuées par les pharmaciens réduisent les réadmissions à l'hôpital. Même si les pharmaciens cliniciens de la Colombie-Britannique participent aux congés, leur degré de participation et les interventions qu'ils privilégient dans la pratique n'ont pas été entièrement élucidés. Objectifs: Caractériser l'implication actuelle des pharmaciens des hôpitaux de la Colombie-Britannique au moment du congé; recenser les interventions à ce moment qui, selon eux, devraient être prioritaires et quel praticien, selon eux encore, devrait être responsable de ces interventions; enfin, déterminer des stratégies pour optimiser le processus de congé de l'hôpital. Méthodes: Une enquête auprès des pharmaciens hospitaliers de la Colombie-Britannique a été menée en janvier et février 2022. L'enquête comprenait des questions sur l'implication actuelle des pharmaciens au moment du congé du patient, les interventions requises pour sa réussite, les solutions pour optimiser son processus ainsi que les caractéristiques de base des participants. Résultats: Le taux de réponse à l'enquête était de 20 % (101/500). Les pharmaciens ont déclaré avoir effectué toutes les interventions auprès de moins de 60 % de leurs patients. Les interventions telles que le bilan comparatif des médicaments à la sortie, l'éducation sur les médicaments et l'assurance de l'observance étaient considérées comme très importantes pour la réussite du congé et les pharmaciens étaient considérés comme étant les mieux placés pour effectuer ces interventions. Les solutions suggérées pour optimiser le processus comprenaient un meilleur personnel, une couverture le week-end, une notification en temps opportun du congé et des prescriptions par les pharmaciens. Conclusions: Même si l'on croit que la plupart des interventions énumérées dans l'enquête sont nécessaires pour la réussite du congé hospitalier, divers obstacles ont empêché les pharmaciens de les proposer à tous les patients. Des ressources accrues et un champ d'exercice élargi pour les pharmaciens pourraient réduire les réadmissions à l'hôpital et permettre une mise en oeuvre élargie des interventions au moment du congé.

Prevalence of Acetylsalicylic Acid Use for Primary Prevention of Cardiovascular Disease Amongst Older Adults From 2017-2021: a Retrospective Cross-Sectional Study.

Background: Three landmark trials on the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) were published in 2018. Since then, major clinical practice guidelines have been updated with recommendations against the routine use of ASA for primary CVD prevention, particularly in older adults. However, little is known about the uptake of this evidence into real world practice. The purpose of this study was to assess the change in ASA usage for primary prevention of CVD in older adults between 2017 and 2021. Methods: A retrospective cross-sectional study of ASA use for primary prevention in ambulatory older adults without known CVD in an urban Canadian city was conducted. Results: Seven hundred and fifty-six participants were included. The mean age was 78.9 years (standard deviation 7.9) and 64.8% were female. One hundred and thirty (17.2%) participants used ASA for primary prevention, including 20.3% in 2017, 17.0% in 2018, 21.8% in 2019, 16.3% in 2020, and 11.0% in 2021 (p = .061). Female sex was associated with lower ASA use (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.29-0.68) and hypertension was associated with higher ASA use (OR 2.72, 95% CI 1.73-4.29). Conclusions: Use of ASA for primary CVD prevention in older Canadians decreased between 2017 and 2021, suggesting an uptake of clinical trial data and practice guideline recommendations. Focusing on deprescribing of ASA for primary CVD prevention continues to be warranted, given the risks associated with ASA in this population.

Barriers and enablers to deprescribing of older adults and their caregivers: a systematic review and meta-synthesis.

PURPOSE: The primary objective of this study was to identify the barriers and enablers to deprescribing from the viewpoint of community-dwelling older adults and their caregivers. METHODS: This meta-synthesis included a systematic review of the literature and an inductive thematic synthesis. Medline and EMBASE were searched for studies that qualitatively explored the perspectives of older adults or their caregivers on deprescribing. Studies had to use qualitative methodologies and include community-dwelling adults (or their caregivers) aged 60 years or older who were taking one or more chronic medications. The quality of studies was assessed using the CASP tool. RESULTS: Fourteen studies were included in the meta-synthesis. All studies included older adults, and 3 included caregivers or companions. Four barriers were identified: favorable perceptions of medications, fear of medication discontinuation, the complexity of the healthcare system and discouragement from healthcare professionals; and seven enablers were identified: medication safety concerns, patient autonomy and confidence, education, follow-up, deprescribing strategies, relationships with physicians, and patient-perceived benefits of deprescribing. CONCLUSION: Multiple barriers and enablers to deprescribing exist within the older adult population. Health system complexity and direct discouragement from healthcare providers were barriers uniquely identified in the older adult population. This population would benefit from interventions to increase their medication literacy, confidence, and autonomy in the deprescribing journey.

Retrospective Cross-sectional Analysis of Older Adults Living with Frailty and Anticoagulant Use for Atrial Fibrillation.

Background: Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns. Methods: Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines. Results: Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose. Conclusions: Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection.

Insights into British Columbian Hospital Pharmacists Perspectives on the Discharge Process.

Background: Transitions of care represent a vulnerable time for patients where unintended therapeutic changes are common and inadequate communication of information frequently results in medication errors. Pharmacists have a large impact on the success of patients during these care transitions; however, their role and experiences are largely absent from the literature. Objectives: The purpose of this study was to gain a greater understanding of British Columbian hospital pharmacists' perceptions of the hospital discharge process and their role in it. Methods: A qualitative study utilizing focus groups and key informant interviews of British Columbian hospital pharmacists was conducted from April to May 2021. Questions asked during interviews were developed following a detailed literature search and included questions regarding the use of frequently studied interventions. Interview sessions were transcribed and then thematically analyzed using both NVivo software and manual coding. Results: Three focus groups with a total of 20 participants and one key informant interview were conducted. Six themes were identified through data analysis: (1) overall perspectives; (2) important roles of pharmacists in discharges; (3) patient education; (4) barriers to optimal discharges; (5) solutions to current barriers; and (6) prioritization. Conclusions and Relevance: Pharmacists play a vital role in patient discharges but due to limited resources and inadequate staffing models, they are often unable to be optimally involved. Understanding the thoughts and perceptions of pharmacists on the discharge process can help us better allocate limited resources to ensure patients receive optimal care.