Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission A Randomized Clinical Trial
Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission A Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2017.8274
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发表时间：
2018-03-01
影响因子：
39
通讯作者：
Hallas, Jesper
中科院分区：
文献类型：
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作者：
Ravn-Nielsen, Lene Vestergaard;Duckert, Marie-Louise;Hallas, Jesper
重要性再次住院在接受多种药物治疗的患者中很常见，给患者和社会带来了相当大的成本。目的确定基于药物回顾、患者访谈和随访的多方面药剂师干预是否可以减少再次住院和急诊科(ED)就诊的次数。参与者这项随机临床多中心研究(欧登塞药剂师试验调查部门转移的药物干预[乐观主义])从2013年9月1日至2015年4月23日招募患者，并于2015年10月31日完成6个月的随访。在急性入院病房中连续使用5种或5种以上药物的18岁或以上的内科患者被邀请参加。在被邀请参加的1873名患者中，1499名(80.0%)接受了。用药回顾和患者访谈在医院进行，并与初级保健合作进行随访。根据治疗意向将患者随机分为3组，分别接受常规护理(无干预)、基础干预(用药回顾)和扩展干预(用药回顾、3次激励性访谈以及对初级保健医生、药房和疗养院的随访)。主要结果和衡量标准为30天或180天内再次入院，180天内急诊室就诊。主要的综合终点是180天内再次入院或急诊。结果共有1467名患者(男性679人[46.3%]，女性788人[53.7%]；年龄中位数72岁；四分位数范围63-80岁)进入主要分析，其中498人随机接受常规护理，493人随机接受基础干预，476人随机接受扩展干预。扩展干预对纳入后30天内(风险比0.62；95%CI，0.46-0.84)或180天内(HR，0.75；95%CI，0.62-0.90)内再次入院的患者数量以及经历初级复合终点的患者数量(HR，0.77；95%CI，0.64-0.93)有显著影响。这项研究表明，纳入后30天内(HR，0.65；95%CI，0.39-1.09)和180天内(HR，0.80；95%CI，0.59-1.08)内与药物有关的再次住院人数和死亡率(HR，0.83；95%CI，0.22-3.11)没有显著下降。需要治疗才能达到扩展干预(与常规治疗相比)的主要综合结果的数量为12。结论和相关性多方面的临床药剂师干预可能会减少急诊室就诊和再次住院的数量。
IMPORTANCE Hospital readmissions are common among patients receiving multiple medications, with considerable costs to the patients and society.OBJECTIVE To determine whether a multifaceted pharmacist intervention based on medication review, patient interview, and follow-up can reduce the number of readmissions and emergency department (ED) visits.DESIGN, SETTING. AND PARTICIPANTS This randomized clinical multicenter study (Odense Pharmacist Trial Investigating Medication Interventions at Sector Transfer [OPTIMIST]) enrolled patients from September 1, 2013, through April 23, 2015, with a follow-up of 6 months completed on October 31, 2015. Consecutive medical patients in an acute admission ward who were 18 years or older and who used 5 or more medications were invited to participate. Of 1873 patients invited to participate, 1499 (80.0%) accepted. The medication review and patient interview were conducted in the hospital and followed up in collaboration with primary care. Analysis was based on intention to treat.INTERVENTIONS The patients were randomized into 3 groups receiving usual care (no intervention), a basic intervention (medication review), and an extended intervention (medication review, 3 motivational interviews, and follow-up with the primary care physician, pharmacy, and nursing home).MAIN OUTCOMES AND MEASURES The prespecified primary outcomes were readmission within 30 or 180 days and ED visits within 180 days. The primary composite end point was readmission or an ED visit within 180 days. Secondary outcomes were drug-related readmissions within 30 and 180 days after inclusion, and all-cause mortality and drug-related mortality.RESULTS A total of 1467 patients (679 men [46.3%] and 788 women [53.7%]; median age, 72 years; interquartile range, 63-80 years) were part of the primary analysis, including 498 randomized to usual care, 493 randomized to the basic intervention, and 476 randomized to the extended intervention. The extended intervention had a significant effect on the numbers of patients who were readmitted within 30 days (hazard ratio [HR], 0.62; 95% CI, 0.46-0.84) or within 180 days (HR, 0.75; 95% CI, 0.62-0.90) after inclusion and on the number of patients who experienced the primary composite end point (HR, 0.77; 95% CI, 0.64-0.93). The study showed a nonsignificant reduction in drug-related readmissions within 30 days (HR, 0.65; 95% CI, 0.39-1.09) and within 180 days (HR, 0.80; 95% CI, 0.59-1.08) after inclusion and in deaths (HR, 0.83; 95% CI, 0.22-3.11). The number needed to treat to achieve the primary composite outcome for the extended intervention (vs usual care) was 12.CONCLUSIONS AND RELEVANCE A multifaceted clinical pharmacist intervention may reduce the number of ED visits and hospital readmissions.