Hospital-initiated community pharmacist medication review post-discharge

Drug related problems (DRPs) are commonly encountered by elderly patients on discharge from hospital. Further research is needed into interventions for risk reduction.

To investigate DRPs post-discharge and assess the Australian hospital-initiated community pharmacist medication review (HIMR) service for benefit.

Retrospective analysis of the Ballina Hospital HIMR service from 20/02/2023 to 20/02/2024 was completed. Data included patients baseline demographics, discharge medications, time to HIMR, DRPs identified, actions taken, and pharmacists' recommendations for medication changes.

The study cohort (n = 143) had a mean age of 82.2 ± 10.9 years and were prescribed an average of 9.4 ± 4.0 regular medications with 6.0 ± 4.6 medication changes at discharge. The initial HIMR (HIMR1) was completed 7.6 ± 6.1 days (median: 6.0) post-discharge, identifying non-adherence in 43% and possible adverse drug reactions in 22% of patients. Eleven patients (7.7%) received pharmacist interventions of moderate/high significance. Eighty-three follow-up visits (HIMR2) were attended. The HIMR2 reports showed 18.8% of medication change recommendations suggested by the pharmacist at HIMR1 were implemented.

Significant interventions at HIMR1 were more likely to be experienced by patients ≥ 80 years, when comorbidity increased and when patients were reviewed sooner. Although multiple DRPs were identified, medication change suggestions made at HIMR1 were infrequently actioned in primary care.

DRPs and non-adherence were common in the population reviewed. HIMR was valuable for resolving immediate DRPs and assisting medication management, especially when performed nearest discharge. Further optimisation of this service to strengthen engagement with primary care practitioners is recommended.