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Optimising Medicine Reconciliation at the Healthcare Interface Final Version Optimising Medicine Reconciliation at the Healthcare Interface Eman A. Hammad Submitted for the degree of Doctor of Philosophy University of East Anglia School of Pharmacy Submitted in June 2013 This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that use of any information derived there from must be in accordance with current UK Copyright Law. In addition, any quotation or extract must include full attribution. © 2013 Abstract Optimising medicine reconciliation at the healthcare interface By Eman A. Hammad BSc MSc Keywords: Medicine/ medication reconciliation, care transition, pharmacist service, discharge communication, medication discrepancies, health interface Background: Medicine reconciliation (MR) is the process of obtaining and maintaining an accurate, detailed list of all medicines taken by a patient and using this list anywhere within the health care system to ensure that the patient receives the correct medicines. This thesis aimed to design an MR intervention and develop a strategy for its evaluation. Methods: A health Trust-wide evaluation of the quality of discharge information relative to national guidance for the minimum dataset of information transfer was undertaken to identify the areas of sub-optimal practice. A systematic review informed the content and design of a pharmacy led medicines reconciliation service. A pilot randomised controlled trial was conducted to provide an early indication of the intervention’s costs and effects and to inform the design of a definitive trial. Results: A review of 3,444 discharge summaries in one primary care trust found that 80% had at least one medication discrepancy. On average these were considered to cause moderate patient harm and to take 15 minutes to address. No studies were found to comprehensively assess the cost-effectiveness of pharmacy led medicines reconciliation. Interim analysis of a pilot 24 hour MR service showed that only 20% of errors upon admission were intercepted before discharge in the control group, compared to 98.6% within the intervention arm. The MR service was estimated to contribute to cost savings of almost £3,000 per patient. Conclusions: The existing process to transfer and process information at the healthcare interface is not optimum. Evidence to demonstrate the cost-effectiveness of pharmacy led MR services is not currently available. Interim analysis of a pharmacy led 24 hour MR service suggests that the service may enhance accuracy and transfer of information and reduce overall health resource utilisation. The pilot MR service will inform the feasibility of large scale evaluation for the cost-effectiveness. i Table of contents Abstract ········································································································· i Table of contents ····························································································· ii List of Tables ································································································· x List of Figures ······························································································ xiv List of Commentary Boxes ·············································································· xvi List of Appendices ························································································ xviii List of Abbreviations ······················································································· xx University of East Anglia, Norwich, UK ······························································ xxiii University of Jordan, Jordan ··········································································· xxiv Acknowledgements ·······················································································xxv Dedication ·································································································· xxvi Chapter 1 Introduction ··················································································· 1 1.1 Background ·························································································· 2 1.2 Healthcare transition in the UK ·································································· 3 1.2.1 Primary care to secondary care transition ·············································· 3 1.2.1.1 Planned admissions ··············································································· 3 1.2.1.2 Unplanned admissions ··································································· 4 1.2.2 Secondary care to primary care transition ·············································· 4 1.3 Communication deficits at the health interface: hospital admission and discharge · 5 1.4 Deficits in information transferred to primary care ·········································· 6 1.5 Implications of communication deficits at the health interface ··························· 8 1.6 Contributing factors to the quality of information transfer at health interfaces········ 9 1.6.1 Patient related factors ············································································· 9 1.6.2 Process related factors ····································································· 11 1.6.2.1 Type of discharge summary ···························································· 11 1.6.2.2 Type of admission ········································································ 11 1.6.3 Individual related factors ··································································· 12 1.6.3.1 Training of healthcare professional ··················································· 12 1.6.4 System related factors ······································································ 13 1.6.4.1 Ward speciality ············································································ 13 1.6.4.2 Variation between hospitals ···························································· 13 1.6.4.3 Time and day of admission ····························································· 13 1.7 Medicine reconciliation (MR) ···································································· 14 1.7.1 Definition ······················································································· 14 1.7.2 Terminology ··················································································· 15 1.8 Initiative for MR implementation ································································ 16 1.8.1 MR initiatives in the UK ····································································· 16 ii 1.8.2 Worldwide MR initiatives ··································································· 19 1.9 Interventions to improve information transfer at the health interface ·················· 21 1.9.1 Pharmacy led MR ············································································ 21 1.9.2 Multidisciplinary package to implement MR ··········································· 24 1.9.3 IT based information transfer initiatives ················································ 25 1.9.4 The use of a standardised reconciliation document ································· 26 1.9.5 Discharge planning and post discharge follow up ···································· 27 1.9.6 Education and training health care staff involved with care transition ··········· 27 1.10 Barriers for implementation of medicines reconciliation ·································· 28 1.11 A place for evidence ·············································································· 29 1.12 Thesis purpose ····················································································· 31 1.12.1 Conducting a Trust-wide evaluation of information received in primary care ·· 31 1.12.2 Developing and evaluating an innovative pharmacy led MR intervention ······ 34 1.12.2.1 Identifying the evidence base for pharmacy led MR studies···················· 37 1.12.2.2 Development and evaluation of a novel pharmacy MR intervention ·········· 38 1.13 Cost-effectiveness ················································································· 39 1.13.1 Costs ···························································································· 41 1.13.2 Effectiveness ·················································································· 42 1.13.3 Perspective ···················································································· 44 1.13.4 Making decision using economic evaluation ·········································· 44 Chapter 2 Methods ······················································································· 47 2.1 Quality of discharge information upon hospital discharge: an audit at primary care ··· 49 2.1.1 Audit site ······················································································· 51 2.1.2 Audit tool ······················································································· 52 2.1.3 Data collection ················································································ 53 2.1.4 Pilot······························································································ 53 2.1.5 Inclusion and exclusion criteria ··························································· 54 2.1.6 Audit communication ········································································ 54 2.1.7 Audit distribution and recall ································································ 54 2.1.8 Confidentiality ·················································································
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