Pharmacists Making House Calls: DISCUSSION

The results of this study suggest that this group of 836 patients served by the Medication Management Program used fewer health service resources in the year after a home visit from a pharmacist following discharge from hospital. The majority of this decrease appeared to result from a reduction in the number of hospital admissions. The median net reduction in resource utilization for the Medication Management Program, $3047.43 per patient, was higher than the average net saving of $680 per patient reported from the HRPIP. Our evaluation of the Medication Management Program was not a controlled trial, so we cannot conclude that the reduction was due solely to receipt of a postdischarge home visit from a pharmacist. Other factors that might explain the difference between the 2 studies are the period of analysis (costs for the HRPIP were for 1999/2000) and the personnel involved (the HRPIP involved a nurse, but the Medication Management Program did not). Also, one-time costs for setting up the program and training staff were not included in the current analysis, which would have made the savings appear greater. However, subtracting the median cost of the index hospital admission reduced the difference in overall resource utilization by $7000, which might have removed some of the bias in the calculation.

In contrast to the reduction in resource utilization subse­quent to a postdischarge home visit from a Medication Management Program pharmacist, those for whom the inter­vention did not result from a hospital stay had an increase in utilization of health service resources after the intervention. Several hypotheses may explain these results. A recent hospital stay may be indicative of a higher-risk group for whom the ben­efit of an intervention is readily evident. In addition, those who have not been using health care resources, such as hospitaliza- tion, may have conditions that are not being treated, but once they are identified as needing treatment, their health care needs may increase, along with resource utilization. eriacta

Analyzing the patients with extremes of resource utilization pointed to some heterogeneity within the cohort. Overall, Medical Services Plan costs were lower after the intervention; however, Medical Services Plan costs increased among those with low resource utilization. Removing from the analysis patients with care episodes costing $50 000 or more resulted in a lower median difference, which might mean that including them in the main analysis inflated the benefit of the program.

The Medication Management Program was based on evidence from the HRPIP, which demonstrated a benefit in terms of reduced hospital admissions and reduced length of stay among those who received a home visit from a pharmacist and nurse after their index admission. Although both of these effects were documented in British Columbia, Canada, there were several differences between the 2 programs that might have altered the effect of the intervention. First, the Medication Management Program does not involve nurses, because there is an established Home Health program within the Fraser Health Authority, with nurses to whom patients can be referred if they have nursing issues. Another difference was the nonrandomized selection of patients; instead, participation was based on the willingness of patients and caregivers to have a visit from a pharmacist and on pharmacists’ workload.
Other randomized controlled trials of programs similar to the Medication Management Program have reported benefit from a home visit by a pharmacist after discharge from acute care services in Australia and Tasmania. Stewart and others reported a significant reduction in unplanned readmissions to hospital, number of days in hospital, out-of- hospital deaths, and emergency room visits for the intervention group, who received discharge counselling before leaving hospital, followed by a home visit from a pharmacist and a nurse within a week after discharge. This outcome was also significant for the subgroup of patients with a diagnosis of congestive heart failure. Naunton and Peterson reported that at 90 days after hospital discharge, elderly patients who had received a home visit from a pharmacist within 5 days of discharge had significantly fewer drug-related problems and fewer unplanned readmissions, although the reduced readmis- sion rate was only borderline significant (p = 0.05). Finally, Jackson and others described an intervention in which patients received a home visit from a pharmacist and point-of- care testing of international normalized ratio (INR) on alternate days after discharge. At 8 days after discharge, significantly more patients in the intervention group had a therapeutic INR (67% versus 42%;p < 0.002). Three months after discharge, 15% of patients in the intervention group and 36% of those in the control group had experienced a bleeding event (p < 0.01). viagra plus

MacAulay and others9 reported that patients and members of the health care team were highly satisfied with a service providing home visits to patients recently discharged from hospital in New Brunswick, Canada. Those authors reported 74% acceptance of recommendations to physicians about drug therapy, similar to the acceptance rate in this study (74.6%).


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