Impact of pharmacist-led discharge medication reconciliation at an Academic Medical Center

Prior studies evaluating the impact of pharmacist-led discharge medication reconciliation have demonstrated higher rates of medication discrepancy detection and intervention with variable effects on hospital readmission. The purpose of this study was to evaluate the impact of a newly developed pharmacist-led hospital discharge medication reconciliation process implemented with an interdisciplinary Internal Medicine Service. This was a retrospective, single-center, pre-post observational cohort study. Institutional review board approval was obtained. The primary end point was quantification and categorization of medication discrepancies identified on the hospital discharge medication list. Secondary end points included characterization of interventions made during the discharge medication reconciliation process, and 30-day hospital readmission rates that were adjusted using a multivariable logistic regression model. A total of 144 patients were included in the pharmacist-led discharge medication reconciliation intervention group and 144 patients were included in the historical control. There was a statistically significant four-fold reduction in the number of medication discrepancies identified on discharge medication lists in the intervention group (77 vs. 18 in the historical control vs. intervention groups, respectively; p < 0.0001). When adjusted for length of stay (L), acuity of the admission (A), comorbidity of the patient (C), and emergency department use in the last 6 months (E) (LACE) index and age, the adjusted odds ratio (aOR) for 30-day readmission was 0.51 (95% confidence interval: 0.27-0.95) in the intervention versus the historical control group. Implementation of an interdisciplinary pharmacist-led discharge medication reconciliation program was associated with a significant reduction in medication discrepancies on the discharge medication list, as well as a reduction in the adjusted odds of 30-day hospital readmission.