RESUMO
OBJECTIVES: To study the feasibility and effectiveness of a discharge medication therapy management program. DESIGN: Quasi-experimental pre-post study design. SETTING: Thirty-six-bed hospital within an extended care hospital. PARTICIPANTS: All patients admitted to facility from January 2009 to December 2009 (control) and February 2010 to January 2011 (program). INTERVENTION: Pharmacist review of anticipated discharge following 18-20 days of stay, with suggested medication changes communicated to physicians via patient chart. Agreed changes were implemented on the next day. MEASUREMENTS: Patient readmissions within 30, 60, and 90 days into the hospital system. Medication interventions were quantified as to type. RESULTS: During the control period, 432 patients were followed, and during the intervention period, 369 patients were followed, with similar lengths of stay. In the intervention period, 565 medication interventions were attempted on 216 patients, with an 85.3% acceptance rate. The major intervention was discontinuation of medications. Mean maintenance medications per patient decreased from 10.57 to 9.46 in the intervention group, and daily medication doses per patient decreased from 17.95 to 15.73 (P < 0.001). Readmission rates were lower at 30 and 60 days in the intervention group, with a 90-day overall decrease in system readmission rate from 51% to 39% (P < 0.001). CONCLUSION: The discharge medication management program was successful in decreasing both number and type of discharge medications via pharmacist intervention. Overall, patient system readmission rates were also significantly decreased in the intervention period.
