A 2016 systematic review and meta-analysis evaluated pharmacist-led medication reconciliation at hospital transitions, including 17 studies involving 21,342 adults. Interventions commonly included obtaining or confirming an accurate medication history, reconciling medications at discharge, providing discharge counseling or documentation, and conducting postdischarge telephone calls or home visits. Most included studies featured multiple transitions. Compared with usual care, these programs reduced all-cause readmissions by 19% (relative risk [RR], 0.81; 95% confidence interval [CI], 0.70-0.95) and medication-related adverse drug event hospital revisits by 67% (RR, 0.33; 95% CI, 0.20-0.53). The reduction in readmissions was significant during earlier follow-up, generally within 30 days (RR, 0.77; 95% CI, 0.60-0.98), but not during longer follow-up (RR, 0.83; 95% CI, 0.68-1.06), suggesting that the benefit may be greatest shortly after discharge. However, substantial heterogeneity, inclusion of lower-quality observational studies, and the use of multifaceted interventions prevented the authors from determining whether discharge medication history and reconciliation alone produced the reduction or which specific component was most effective. Overall, the findings support pharmacist-led discharge medication reconciliation as part of a broader medication-safety transition program to reduce early readmissions, while highlighting the need for larger, high-quality randomized trials. [1]
A 2020 overview assessed five systematic reviews examining the effects of medication reconciliation across care transitions, with particular attention to patient outcomes and healthcare utilization. The interventions were generally pharmacist-led and often combined reconciliation with creation of an accurate postdischarge medication list, patient counseling, postdischarge communication, or medication review. The evidence did not demonstrate a consistent reduction in unplanned readmissions: a meta-analysis of five randomized controlled trials found no significant benefit within 5 to 30 days after discharge (RR, 0.72; 95% CI, 0.44-1.18), while another analysis of seven studies found a pooled RR of 0.91 (95% CI, 0.66-1.25) with substantial heterogeneity. One cohort study reported fewer readmissions at 7 and 14 days, but this benefit was no longer significant at 30 days. Results for composite healthcare utilization, usually readmissions and emergency department visits, were mixed, with one review showing a significant reduction (RR, 0.77; 95% CI, 0.63-0.95) but two others showing no clear benefit. Although pharmacist-obtained medication lists appeared to contain fewer errors, the review found no firm evidence that discharge medication history and reconciliation reduced readmissions because the underlying reviews were low or critically low quality, outcomes were frequently secondary or underpowered, and reconciliation was often bundled with other discharge interventions, preventing assessment of its independent effect. [2]
A 2018 systematic review and meta-analysis of 14 studies also evaluated pharmacist-led medication reconciliation in the community after hospital discharge. The intervention involved comparing the preadmission medication history with the discharge medication list, updating primary care or community pharmacy records, resolving discrepancies, and ensuring that patients or caregivers understood medication changes. Although pharmacists identified and resolved more discrepancies than usual-care processes, the meta-analysis of seven studies involving 2,336 patients found no significant reduction in readmissions (RR, 0.91; 95% CI, 0.66-1.25), with substantial heterogeneity (I²=71%). Three individual studies reported significantly fewer readmissions, one reported increased readmissions, and the remaining studies found no significant effect. The authors noted that inaccurate discharge medication documentation may limit the effectiveness of postdischarge reconciliation because correcting community records using an erroneous discharge list may perpetuate unintended medications. Overall, discharge medication history and reconciliation improved discrepancy identification and resolution but did not consistently reduce readmissions; interpretation was limited by variation in study designs, interventions, follow-up periods, and outcome definitions, as well as moderate or high risk of bias in 12 of the 14 studies. [3]