An observational study to identify factors associated with readmission and to evaluate the impact of pharmacist validation of discharge prescriptions on readmission rate

To identify demographic and pharmaceutical factors associated
with readmission and to determine whether pharmacist
validation of discharge prescriptions impacted on readmission
rate in a district general hospital.
• The average number of items prescribed at discharge and the
average age were found to be significantly higher in patients
who were readmitted than those who were not, and mandating
pharmacist validation of discharge prescriptions was
associated with a reduction of around one-fifth in the readmission
rate.
• The study provides evidence of the patient groups it may be
most appropriate for pharmacists to focus on in order to
reduce readmissions.
Introduction
Readmission is a growing problem for the National Health
Service. In England the rate has increased by almost one-third
over ten years, reaching 11.5% in 2011/12.1 In 2009 the Care
Quality Commission reported that 81% of General Practitioners
recorded discrepancies in discharge medication information
“all” or “most of the time.”2 Whilst pharmacist validation
of discharge prescriptions (TTOs) is routine in Calderdale and
Huddersfield NHS Foundation Trust, it was previously
prompted by the need for supply, and due to the successful
implementation of one-stop dispensing theTTOvalidation rate
was surprisingly low. The study aimed to identify factors associated
with readmission, to quantify the effect of enforcing
pharmacist validation of TTOs and to determine whether this
impacted on the readmission rate.
Methods
Retrospective analysis of data from all adults discharged from
Calderdale Royal Hospital’s Short Stay Unit between 30th September
2013 and 19th January 2014 (pharmacist validation of
TTOs became mandatory during normal working hours from
the mid-point). Data collected from TTOs included admission
and discharge dates, demographics and pharmaceutical details
(e.g. number of items prescribed, number of prescription
changes, validation status). The primary outcome measure was
30-day readmission status; readmission interval was the secondary
outcome measure. Ethical approval was not required.
Results
Two hundred eighty-three TTOs were completed during the
baseline evaluation: 101 (35.7%) were validated by a pharmacist
and 42 (14.8%) resulted in readmission. Two hundred
ninety-six TTOs were completed during the intervention
evaluation: 223 (75.3%) were validated by a pharmacist and 36
(12.2%) resulted in readmission. The average age of those
readmitted (73.2) was seven and a half years older than those
not readmitted (65.7) (p < 0.01, 95% CI for the difference
3.20–11.8); patients aged 65 or older were significantly more
likely to be readmitted (17.6%, 63/357) than younger patients
(6.8%, 15/222) (p < 0.01). The number of prescription changes
on the TTO was not found to differ significantly between those
who were readmitted and those who were not; however, those
readmitted were prescribed an average of two more items at
discharge (10.8) than those who were not (8.4) (p < 0.01, 95%
CI for the difference 0.989–3.90). The readmission behaviour
of patients prescribed seven or less items at discharge (n = 221)was found to differ significantly (p < 0.01) from patients prescribed
eight or more (n = 264).
Discussion
The results indicate where pharmacists may have the most
impact on reducing readmissions; specifically patients over 65
years of age and those taking eight or more medicines. Further
work is needed to determine whether readmission can be
reduced in these groups by application of pharmaceutical interventions
and to establish the long term benefits of focusing
limited resources. Mandating pharmacist validation ofTTOs in
working hours was associated with a substantial increase in
proportion validated and a notable reduction in readmission
rate. It is acknowledged that the activity of the Trust’s Virtual
Ward varied during the study, however there was not a pharmacist
on the team at that time; further work will be carried out to
determine the influence of this on the results observed.