Pharmacists Making House Calls: DISCUSSION part 2

Not all studies that have evaluated an intervention involv­ing a postdischarge home visit have reported positive results. In Tasmania, patients with a cardiovascular diagnosis who were receiving lipid-lowering drug therapy and who had a home visit from a pharmacist 6 weeks after hospital discharge had significantly improved cholesterol levels at 6-month follow-up; however, the improvement was not significantly different from that of the control group.

Moreover, contrary to the favourable results reported above, the HOMER and HeartMed randomized controlled trials performed in the United Kingdom reported increased utilization of health services resources, such as hospital admissions and home visits by general practitioners, for those who received a home visit from a pharmacist within 2 weeks of hospital discharge. The HOMER study included patients at least 80 years of age who were discharged home on at least 2 medicines. The HeartMed study also included patients taking at least 2 medicines at the time of discharge but targeted those with heart failure.

It is unclear why these studies showed no benefit from the intervention, given previous literature demonstrating positive effects. Perhaps the patient populations differed from those in studies reporting benefit. For example, in the HRPIP and the Medication Management Program, patients had to be taking at least 6 regularly scheduled medicines at the time of discharge, which might indicate a greater need for medication manage­ment. Another difference is the timing of the initial home visit: in the studies that demonstrated a benefit and in the Medication Management Program, the initial visit was targeted to occur within the first week after discharge, whereas in the HOMER and HeartMed studies, the initial visit was targeted to occur within the first 2 weeks after discharge. Although the significance of this difference is unclear, it is known that the period immediately after discharge from hospital can be complicated for elderly patients, and earlier intervention may therefore be more beneficial. Also, the focus of the interventions may have differed. Knowledge about medicines and compliance has not been found to be predictive of hospital admissions. Therefore, home-based interventions directed more toward teaching and ensuring compliance with medications may not reduce the number of hospital admissions. Finally, differences among health care systems may have contributed to differences in results. erectalis 20

One of the limitations of the evaluation reported here was the absence of a control group. In this type of study, a control group could help to determine if changes in resource utilization were attributable to the intervention. Selection bias was another limitation. Clinical judgement was used to determine who might benefit from the intervention; in addition, patients’ and caregivers’ willingness to receive the service might have contributed to bias in creating the cohort. Also, because the Medication Management Program is a clinical program and not purely a study, the study population was probably more heterogeneous. The difference in resource utilization between those admitted to hospital before the intervention and those not recently admitted is indicative of the effect of such hetero­geneity on resource utilization. Data on the type of hospital bed used by those who were admitted to hospital was not available; therefore, the fixed hospital cost of $1000 per day limited our ability to determine the exact impact of the intervention on costs of hospitalization. Another limitation was that adminis­trative data for health service resource utilization outside of the region’s geographic boundaries were not released by the Ministry of Health. This might have resulted in an underesti­mation of total resource utilization in the cohort, both before and after the intervention. Finally, complete information on resource utilization in the emergency department was not available because of the mix of salaried and fee-for-service physicians, so this measure of resource utilization was not included in the study. For future studies, a different data source that includes emergency department utilization will be sought.

As the program continues, mechanisms to reduce selection bias and to establish a comparison group according to selection criteria identical with those used for the intervention group will be sought. Also, data from subsequent years will be evaluated to add further information about the effectiveness of the Medication Management Program. cialis professional

CONCLUSIONS

The results of this study, together with previous scientific evidence indicating a benefit of this type of intervention, suggest that a home visit from a pharmacist reduced the utilization and cost of health services in the period after the intervention.

Category: Main

Tags: home visit, pharmacist, resource utilization

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