Impact of pharmacist intervention in patient counseling at point of hospital discharge in a specialized cardiac center in Saudi Arabia

Purpose: To determine the interventions associated with the pharmacist’s patient counseling and review of discharge prescriptions of patients from a specialized cardiac center in Saudi Arabia. Methods: This was a prospective interventional study conducted at Prince Sultan Cardiac Center (PSCC) in Riyadh, Saudi Arabia for a duration of 12 months. The pharmacist responsible for providing patient counseling reviewed the patient records, collected patient demographics and clinical data, as well as medical and medication history, diagnosis and discharge (treatment) plan. Results: The study included 2008 patients who met the inclusion criteria. The counseling pharmacist identified and provided interventions to 358 (18 %) patients for 508 (3.4 %) items. About half of counseling pharmacist interventions concerned involved the addition of a drug to treatment regimen followed by drug discontinuation (28.1 %). The most common reason for adding the drug during patient counseling was the omission of medications (35 %). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs), antidiabetics and antihyperlipidemics were the classes of drugs often associated with counseling pharmacist interventions. The cost-saving interventions identified were 200 (39.4 %). Out of these, drug discontinuation (n = 143) was the most frequent suggestion provided by the intervening pharmacist, followed by a dose reduction resulting in cost savings of 66.5 % (US $ 6,590.10) and 8.9 % (US $ 882.32), respectively. Conclusion: The results indicate that discharge medication discrepancies decrease as a result of pharmacist-facilitated patient counseling at the point of hospital discharge.


INTRODUCTION
Medication discrepancies at the point of hospital discharge are a common occurrence [1][2][3]. A recent study reported that 41.3 % of patients had at least one inadvertent medication discrepancy at hospital discharge, and 55.3 % were at risk for possible unintentional discrepancies [3]. In addition, a randomized controlled trial among 851 discharged cardiac patients concluded that half of the patients (50.8 %) experienced clinically important medication errors after hospital discharge and 22.9 % of such errors classified to be serious [4]. Also, a Canadian study reported that nearly 23 % of patients experienced at least one adverse event after hospital discharge and 72 % of which related to medications [5].
Structured patient counseling and medication reconciliation at the time of hospital discharge may help to prevent these discrepancies [3]. Global studies conclude that providing information at the time of hospital discharge to patients and post discharge support decreases the number of readmissions and advance the patient's quality of life [6][7][8]. Also, in a study, Al-Rashed et al. [9] concluded that pre-discharge counseling provided with improved drug information and compliance together with reduced readmissions and unplanned visits to the physician. A study conducted at a teaching hospital among patients being discharged home from the hospital concluded that a reasonably lower rate of preventable adverse drug events occurred after medication review and discharge counseling by pharmacists [10]. Another study in a tertiary hospital in Saudi Arabia concluded that implementation of the patient counseling program to discharge patients reduced adverse drug events from 24 to 2.3 % [11].
The studies related to the impact of pharmacist's interventions in patient counseling prior to hospital discharge in Saudi Arabia are limited. This study aimed to determine the impact of pharmacist's counseling and review of discharge prescriptions for patients discharged from a specialized cardiac center in Saudi Arabia. Also, we examined the potential financial impact that could result from implementation of counseling pharmacist provided intervention at this cardiac center.

METHODS
This was a prospective interventional study conducted at Prince Sultan Cardiac Center (PSCC) in Riyadh, Saudi Arabia for 12 months duration (January to December 2012). PSCC is a specialized healthcare center provides comprehensive cardiovascular services to all armed forces personnel, their dependents, and other patients referred to the center for further evaluation and specialized treatment and include about 190 beds dedicated to adult and pediatric cardiac patients. The study included all discharged adult cardiac patients of either sex from adult cardiology wards, including Day-Case post catheterization patients and coronary care unit patients. Exclusion criteria were adult cardiac surgery patients, pediatric patients, patient discharged without medication, transferred patients (to another ward or another care facility), patients with cognitive defect, the patient discharged without patient counseling, patient who received patient counseling from staff other than a pharmacist, patient who rejected patient counseling and lastly, patients with incomplete patient demographic/clinical data. This study was carried out in accordance with the Declaration of Helsinki [12], and Good Clinical Practice guideline [13]. The pharmacy administration and research department of the hospital reviewed and approved the study (ref no. R&EC03.1.acv).
After the processing of discharged medications and once the medication was available in the ward, the assigned nurse received and checked the medications before contacting patient counseling pharmacist to provide medication counseling to discharge patients. With each plan of discharge, the pharmacist responsible for providing patient counseling reviewed the patient record, identified patient demographics and clinical data, medical and medication history, diagnosis and discharge (treatment) plan. The pharmacist counseling the patients handled the review of the discharge medication and correction of any discrepancy before starting and during a patient counseling session. After completing the session, the pharmacist documented any discrepancy encountered. The pharmacist also required to resolve these discrepancies by contacting the assigned ward clinical pharmacist or treating physician and document that intervention in the patient's file and patient counseling form. The intervention considered in this study was defined as "any action by a pharmacist that directly resulted in a change in patient management or therapy" [14].

Data analysis
The direct medication cost saving calculated, for interventions that cause discontinuation of medication due to inappropriate use (e.g., duplicate therapy, lack of indication, errors, and drug interactions); medication dose reduction, duration or frequency adjustment; or substitution of less expensive alternative (e.g., oral vs. intravenous route of administrations). With patient discharge medications, the cost savings for the whole prescribed periods (about 3 months) were calculated because the intervention will most probably not to take place until the patient's next visit to a refill or an appointment. Direct medication cost savings calculated by multiplying the medication's average annual unit acquisition price as provided by the supply department -times the number of total daily doses and the number of days reduced. The results expressed in US Dollars (US $). Annual cost savings calculated by extrapolating the net cost savings made during the 3 months to over 1 year.
Statistical Package for the Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA) used for descriptive statistical analysis. The data are summarized using descriptive statistics and categorical variables expressed as frequencies and percentages (%).

RESULTS
This study included 2008 patients who met the inclusion criteria. The characteristics of these patients are presented in Table 1.

Diagnosis and risk factors
Acute coronary syndrome (ACS) was the most frequent type of diagnoses, occurring in 46 % of the cases, followed by coronary artery diseases (21 %) and heart failure (12 %). Over 60 % of patients had a history of hypertension, 56 % with diabetes mellitus, 44 % with both and 36 % were hyperlipidemic.

Pharmacist interventions
During

Types of interventions provided during patient counseling
The most often provided pharmacist intervention was the addition of drug (48 %, n = 244) followed by discontinuation of the drug (28 %, n = 143) upon the ward clinical pharmacist or treating physician approval (Table 3).

Figure 1: Explanation of interventions during patient counseling
The most common reason for adding the drug during patient counseling was due to omissions of medications (35 %). Prescribing unneeded medications (14 %) was the common reason associated with drug discontinuation Figure 1.

DISCUSSION
The present study is one of the few studies that examine pharmacist-provided patient counseling among adult cardiac patients discharged from a tertiary care hospital and to the best of our knowledge, it is the first of such studies conducted in a specialized cardiac center in Saudi Arabia. In this study, counseling pharmacist identified and provided interventions to 358 (18 %) patients that had medication discrepancy in the time of hospital discharge. This percentage is lower than that (33.5 %) reported by Walker et al in their study [8]. Several other studies have reported incidences of medication discrepancies in 14.1-59.6 % of patients at discharge [3,4,15,16].
A variety of factors contributes to the occurrence of medication discrepancies. Also, prescribers may fail to routinely compare a patient's inpatient medication list to their pre-admission list at the time of prescribing and may not communicate medication information effectively at the time of discharge. Moreover, this study also reported that half of counseling pharmacist interventions concerned with adding a drug to the treatment regimens followed by drug discontinuation (28.1 %), changing the dose or dose schedule of drug and frequency. Furthermore, in an overseas study conducted in Iran, adding a drug to the treatment regimen (20.9 %) and drug discontinuation (19.6 %) were the most frequent clinical pharmacist interventions [17].
In another recently conducted studies in Beirut, it has been illustrated that addition of drugs (31 %) was one of the common interventions recommended by pharmacist [18]. In addition, another study suggested that drugs cessation was the most recurrent (31.9 %) suggestion offered by the intervening pharmacist followed by changes in the frequency of administration (21.3 %) and changes in the drug dose (19.1 %) [19].
Besides, in this study, omissions of medications (35 %) were the most common reason for the addition of the drug during patient counseling. This may happen because of hospital physicians forgetting to prescribe drugs used by patients or inappropriate medication history review on admission and during the hospital stay, which often carries over to discharge. Previous studies have also shown that omission is the most common type of medication discrepancy, with up to 61 % of hospitalized patients having at least one drug omitted from their regimen [16,20,21]. In addition, un-needed medication (14 %) was the foremost reason associated with drug discontinuation.
Un-needed medications include medications prescribed without clear indications or temporary indications and not required to be continued with discharge medication. Also, a study in a large university hospital showed discontinuation of unnecessary drugs (22.7 %) as the most common interventions suggested by intervening pharmacist [22].
Furthermore, in this study ACEI/ARBS, antidiabetic, antihyperlipidemic and antiplatelet were the class of drug often associated with counseling pharmacist interventions. This finding is consistent with the study by Coleman et al. who found that angiotensin-converting ezyme inhibitors (10 %) and lipid-lowering agents (10 %) were among the most common medication classes accounted for identified medication discrepancies [23].
The potential financial impact that could result from implementation of counseling pharmacistprovided intervention in this cardiac center was also determined. The net cost saving was about US $ 9,901.6 per 3 months. If this cost saving extrapolates to the whole year, this would be equivalent to approximately US $ 39,606.6 per year and US $ 198.1 per intervention per year. We couldn't compare these results with similar studies because of limited studies published in this area. However, despite different conceptualization, definitions, and methods some studies have reported financial impact of pharmacist interventions on the cost of drug therapy. A study from Thailand reported that interventions made by pharmacist resulted in the direct cost saving of 1,971.43 US $ over 5 week study period [24]. Another study concludes that clinical pharmacist had a significant impact on the cost of drug therapy as the total net cost savings made over a 7 month study period were US $ 1796.7 [19]. We encourage further research to validate our findings.
The results from this study have important inferences for those health care organizations that are lacking pharmacist involvement in patient counseling at the time of hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Also, this study identifies a few medications discrepancies and highlights some economic consideration.

Limitations of the study
The study has limitations in some aspects. Medication discrepancies occur at the time of admission were not included in the study. Also, the interventions carried out by a single pharmacist in one hospital and hence the findings of this study cannot be generalized to other healthcare facilities in Saudi Arabia.

CONCLUSION
Discharge medication discrepancies are common in cardiac discharge patients. Pharmacistfacilitated patient counseling at the point of hospital discharge is associated with a considerable decrease in the total number of discharge medication discrepancies. The most common type of intervention identified in this study was addition of a drug to the treatment regimen due to medication omissions, followed by drug discontinuation and change in drug dose. This study concludes that pharmacist interventions in patient counseling provide a substantial cost saving for the specialized cardiac center of Saudi Arabia. Additional studies are needed to further illustrate the most efficient ways to implement discharge counseling and establish which elements of the discharge process are best targeted to improve clinical outcomes and reduce resource utilization. We recommend applying such program to all discharged patients, especially in a high risk population.