Implementation and sustainability of a medication reconciliation toolkit: A mixed methods evaluation.

PURPOSE: MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here we describe hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit. METHODS: We used a mixed methods, quantitative-qualitative study design. We invited site leaders of the 5 hospitals that participated in MARQUIS to complete a Web-based survey and phone interview. The Consolidated Framework for Implementation Research guided question development. We analyzed the collected data using descriptive statistics (for survey responses) and thematic content analysis (for interview results). RESULTS: Site leaders from each MARQUIS hospital participated. They reported that MARQUIS toolkit implementation augmented their hospitals' existing but limited medication reconciliation practices. Survey results indicated executive leadership support for toolkit implementation but limited institutional support for hiring staff (reported by 20% of respondents) and/or budgetary support for implementation (reported by 60% of respondents). Most participating hospitals (80%) shifted staff responsibilities to support medication reconciliation. Interview findings showed that inner setting (ie, organizational setting) and process factors (eg, designation of champions) both inhibited and facilitated implementation. Hospitals adopted a variety of toolkit interventions (eg, discharge medication counseling) using a range of implementation strategies, including development of educational tools and tip sheets for staff members and electronic health record templates. CONCLUSION: Despite limited institutional support, hospitals can successfully implement, spread, and sustain the MARQUIS toolkit by shifting staff responsibilities, adding pharmacy staff, and using a variety of strategies to facilitate implementation. Although leadership support and resources for data collection and dissemination facilitated implementation, limited staff buy-in and competing priorities may hinder implementation.

A systematic overview of systematic reviews evaluating medication adherence interventions.

PURPOSE: To systematically summarize evidence from multiple systematic reviews (SRs) examining interventions addressing medication nonadherence and to discern differences in effectiveness by intervention, patient, and study characteristics. SUMMARY: MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects were searched for papers published from January 2004 to February 2017. English-language SRs examining benefits of medication adherence interventions were eligible. Inclusion was limited to adult patients prescribed medication for 1 of the following disease conditions: diabetes and prediabetes, heart conditions, hypertension and prehypertension, stroke, and cognitive impairment. Non-disease-specific SRs that considered medication adherence interventions for older adults, adults with chronic illness, and adults with known medication adherence problems were also included. Two researchers independently screened titles, abstracts, and full-text articles. They then extracted key variables from eligible SRs, reconciling discrepancies via discussion. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess SRs; those with scores below 8 were excluded. Conclusions regarding intervention effectiveness were extracted. Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was applied to assess evidence quality. RESULTS: Of 390 SRs, 25 met the inclusion criteria and assessed adherence as a primary outcome. Intervention types most consistently found to be effective were dose simplification, patient education, electronic reminders to patients, and reduced patient cost sharing or incentives. Of 50 conclusions drawn by the SRs, the underlying evidence was low or very low quality for 45 SRs. CONCLUSION: Despite an abundance of primary studies and despite only examining high-quality SRs, the vast majority of primary studies supporting SR authors' conclusions were of low or very low quality. Nonetheless, health system leaders seeking to improve medication adherence should prioritize interventions that have been studied and found to be effective at improving patient adherence, including dose simplification, education, reminders, and financial incentives.

Effect of medication reconciliation interventions on outcomes: A systematic overview of systematic reviews.

PURPOSE: To evaluate and summarize published evidence from systematic reviews examining medication reconciliation. METHODS: MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects were searched for English-language systematic reviews published from January 2004 to March 2019. Reviewers independently extracted information and scored review quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. For reviews with AMSTAR scores above 7, Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to assess evidence quality, with evidence summarized and conclusions compared across reviews. RESULTS: Eleven reviews met the inclusion criteria, 5 of which used meta-analytic pooling. Most systematic reviews included primary studies of comprehensive bundled interventions that featured medication reconciliation as a central component. Reviews largely focused on transitions into and out of hospital settings. Five reviews focused exclusively on pharmacist-led interventions. Of the 5 reviews that considered all types of medication discrepancies, 3 reviews found very low-quality evidence that interventions reduced medication discrepancies. Neither of the 2 reviews that examined clinically significant medication discrepancies found any intervention effect. Of the 5 reviews that examined healthcare utilization outcomes, only 1 found any intervention effect, and that finding was based on low- to very low-quality evidence. Four reviews considered clinical outcomes, but none found any intervention effect. CONCLUSION: An overview of systematic reviews of medication reconciliation interventions found 9 high-quality systematic reviews. A minority of those reviews' conclusions were consistent with medication reconciliation alone having a measurable impact, and such conclusions were almost all based on very low-quality evidence.

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

BACKGROUND: High-quality discharge summaries are a key component of a safe transition in care. The purpose of this study was to determine the effects of standardised feedback and a 'discharge time-out' (DTO) on the quality of discharge summaries. METHODS: During 2006-2007, the authors trained hospitalists to provide two interventions at their discretion: (1) feedback on one discharge summary to each intern using a standardised form and (2) a DTO, modelled after the surgical time-out, in which key questions about the patient's hospital course and discharge plan are answered verbally by the intern during rounds on the day of discharge. To evaluate these interventions, trained clinicians, blinded to group assignment, performed an explicit review of two discharge summaries before and after intervention implementation. The authors used a mixed linear model to evaluate relative improvement over time. RESULTS: The authors compared 14 interns who only received a 1-h lecture and a small-group resident-led training session with 13 interns who also received feedback and 12 interns who received feedback and a DTO. Save greater improvement in the documentation of tasks to be completed after discharge (39% vs 8% absolute improvement, p=0.05) by interns receiving an intervention, most domains were unaffected by having received a DTO and/or feedback. CONCLUSION: These results suggest that standardised feedback and a DTO integrated into attending rounds have limited potential to improve discharge summaries as currently designed. This study stresses the need for developing and refining interventions that can improve the narrative flow of discharge summaries.