US Pharm. 2019;44(6):HS-2-HS-8.

ABSTRACT: Medication adherence is known to be closely associated with patient outcomes, including morbidity, mortality, and healthcare expenditure. Although community pharmacists have long shown potential in improving adherence and associated outcomes, the hospital setting may also offer pharmacists the opportunity to impact adherence. Various pharmacist-provided in-hospital services and interventions have been found to have varying degrees of benefit, including discharge counseling, medication reconciliation, telephone follow-up services, and bedside medication delivery. Prioritizing formulary planning and communicating costs to the patient may also help decrease the potential for medication nonadherence. 

 It should come as no surprise that adherence to medication regimens has been found to be an important factor in effective medical treatment, with significant benefit linked with many clinical outcomes. Defined by the World Health Organization as “the degree to which use of medication by the patient corresponds with the prescribed regimen,” medication adherence is vital to healthcare.1 It is associated with significant decreases in morbidity, mortality, and hospitalizations.2,3 Additionally, nonadherence is also a significant financial burden, with deficits in medication adherence being associated with direct healthcare costs of approximately $100 billion to $300 billion annually.4

Despite the clear benefits of adherence, patients often struggle with taking their medications as prescribed. In fact, of the 3.8 billion prescriptions written in the United States annually, it is estimated that a staggering one in five are never filled.4 Further complicating this deficit, it is estimated that 50% of the prescriptions that are filled are not taken as intended.4 This can include incorrect dosage, timing, frequency, and duration. These numbers are eye-opening and illustrate the magnitude of the challenge faced by both the patient and the healthcare team.

Efforts to improve medication adherence have come from many different disciplines, but few are in a better position to intervene than the members of the pharmacy community.5 In the community setting, pharmacists regularly provide patient counseling on the importance of adherence, as well as proactively identifying additional reasons for nonadherence, such as medication side effects and cost barriers. The benefits of such interventions are well-established, with data supporting community pharmacists’ contribution to improving adherence and overall disease control.6,7

Given this clear value offered by community pharmacists, it is fair to wonder what opportunity exists for pharmacists in other settings. Pharmacists working in the institutional environment are quietly becoming more involved in confronting these medication-adherence challenges. These efforts have come in the form of pharmacist-led services and interventions. This article reviews some of the programs and services that have been implemented and evaluated. These services, while sometimes used at differing points of hospitalization, often focus largely on the process of patient discharge.

Hospital Discharge and Medication Adherence

It is known that hospital-associated transitions of care, particularly hospital discharge, leave patients in a vulnerable position for medication-related errors and associated issues.8,9 During this transition period, patients may be overwhelmed with changes in medication therapy and new information, leaving them at high risk for poor adherence after discharge. Patients may also face challenges to adherence that are unexpected, such as cost barriers, impairments, and other personal limitations. These limitations are not only on the part of the patient—there is also increased risk of errors by prescribers, including medication omissions, unnecessary polypharmacy, and inadequate education.10

The changes in medication regimens in patients being discharged from the hospital can be considerable. An observational cohort study published in 2013 examined elderly patients at hospital discharge and found that, on average, elderly patients have two new medications prescribed, 0.8 medications discontinued, and 0.7 changes in medication frequency at discharge.11 Given these dramatic changes, medication errors and miscommunications are practically inevitable. To combat this deficiency it is necessary to explore opportunities for everyone on the healthcare team to intervene to help improve medication adherence and overall patient outcomes. This, of course, can include hospital pharmacists.

Discharge Counseling and Medication Reconciliation

One well-researched method to help decrease negative outcomes associated with hospital discharge is pharmacist-led discharge counseling and medication-reconciliation services.12 While individual services can vary from program to program, the core idea for intervention is using a hospital pharmacist to provide strategic patient counseling, with a focus on the necessity of medication adherence, as well as other information that may help the patient properly adhere to their prescribed medication regimen. Many institutional programs include pharmacist-led medication reconciliation intended to provide a clinical assessment of the patient’s medication list, identify drug-related problems, and resolve any issues prior to discharge.

These programs are supported by considerable literature demonstrating that discharge counseling and medication reconciliation can have a significant impact on outcomes, particularly when conducted by pharmacists or pharmacy students.12-15 Although published evaluations of such services can vary in method and scope, many identify improvements in several outcomes, including hospital readmissions, emergency-department visits, and pharmacist interventions.12-15

One such study by Tran and colleagues published in 2017 evaluated a full-time equivalent pharmacist-managed program to provide discharge counseling to patients presenting with factors that put them at a high risk for readmission.14 The pharmacist would conduct counseling sessions and perform medication reconciliation at discharge with the intention of providing disease-state–specific education and optimizing medication therapy. The researchers identified a significant difference in hospital readmissions and emergency-department visits. Of the 889 discharged patients evaluated, 488 (55%) were counseled by a pharmacist at discharge, with this group showing a hospital readmission rate of 11.3%, lower than the uncounseled group rate of 15.0%.14 From an outcomes perspective, these data support the efficacy of pharmacist-led patient education at discharge.

A 2016 meta-analysis by Mekonnen and colleagues offers an interesting appraisal of pharmacist-led medication reconciliation, on a large scale, through different individual services.15 Nineteen studies including 15,525 patients were evaluated and assessed on the outcome of medication discrepancies. Their results indicated that pharmacist-led medication-reconciliation programs had a role in decreased medication discrepancies, leading to potential benefits in adherence and other outcomes. Interestingly, programs that focused on a single transition, such as at admission or discharge, were found to show a 66% reduction in patients with medication discrepancies. This benefit was not seen in programs targeting multiple transitions.15 The compiled data indicate overall benefit in the initiation of pharmacist-led medication-reconciliation programs.

Telephone Follow-Up Sessions

Many community pharmacies use systematic patient follow-up calls to encourage adherence to medications.16,17 With evidence supporting the positive effects of such services on adherence and outcomes, some hospitals have employed similar methods by translating this process into a hospital-pharmacist role. Evaluations of this process have presented promising results.

A recent study by Odeh and colleagues published in 2019 assessed the impact of pharmacist-led telephone follow-up calls on 30-day and 90-day readmission rates in patients at high risk for readmission.18 Using a pragmatic, prospective, quasi-experimental format, the researchers evaluated outcome differences between an interventional group and a control group consisting of adult patients receiving at least ten prescribed medications for chronic diseases. The service scheduled three telephone follow-up calls at 10 days post discharge, 1 month post discharge, and the start of the third month post discharge. These clinical-pharmacist–led discussions would assess noted issues in treatment or illness, as well as encourage adherence to medications. Patients who received all three follow-up calls were found to have a significant, 10% reduction in 30-day readmissions (P <.001) and a 15.2% reduction in 90-day readmissions (P = .021). Other improvements were also identified, including overall time to readmission (70.9 vs. 60.1 days [95% CI, 55.4-64.7]) and length of hospital stay on first readmission (7.8 vs. 5.3 days; P <.001).18 This is encouraging evidence that hospital-pharmacist intervention may have a large impact on adherence and associated outcomes well after discharge.

A similar study by Spiegel and colleagues published in 2018 evaluated pharmacist-led telephone follow-up from a cost-effectiveness perspective.19 A program consisted of residency-trained pharmacists providing post-discharge phone-call sessions for patients identified as high risk for readmission. Pharmacists conducted the phone calls within 72 hours of discharge and used a standardized process to assess the patient and provide education on managing adherence barriers and other important drug-related problems. This intervention group was compared with a control group that did not undergo pharmacist follow-up. The patients in the intervention group were found to have a 30-day readmission rate of 16.2% compared with the control group’s rate of 21.6%. Although this was found to be statistically insignificant, the authors suspect this was due to the small size of the group that did not receive follow-up. Numerically, however, the data suggest value in the program. The average overall cost per patient was found to be $3,433 and $4,015 for the intervention and control groups, respectively, a difference of $582 (Monte Carlo 95% CI, $528-$635). This program demonstrated cost savings and added value in providing this service. Furthermore, it was noted that the program would pay for itself provided each pharmacist contacted at least 34 patients each month with at least 21% of these patients speaking with the pharmacist and completing the session. Any additional intervention would offer further cost savings.19

Bedside Medication Delivery

Another potential solution to poor medication adherence being evaluated is the use of bedside medication delivery. Some hospitals have associated retail pharmacies that can fill patient prescriptions prior to the patient leaving the hospital. This may offer several advantages. By making the filling of prescriptions as convenient as possible, patients may be more likely to have their prescriptions filled. Additionally, issues with insurance and high-cost products may be resolved before the patient even discharges, minimizing some known barriers to outpatient medication adherence.

There is some evidence to support hospital bedside delivery as a potentially effective service. A retrospective cohort study by Kirkham and colleagues in two acute-care hospitals within the same hospital system in the southeastern U.S. measured the outcomes of a collaborative pharmacist-led hospital-care transition program that included bedside delivery of medications.20 The main goal of the program was to promote medication adherence and reduce unplanned readmissions by focusing on patient-care transitions. The primary outcome of this study was 30-day readmission rate. A total of 19,659 patients were included in this study, and after adjusting for various demographic and clinical characteristics, the patients who did not participate in the pharmacist-led hospital-care transitions program had nearly twice the odds of readmission in 30 days (odds ratio, 1.90; 95% CI, 1.35-2.67), compared with the program participants.20 This suggests that the interventional program had a positive impact on adherence and associated outcomes.

Formulary Planning and Cost Communication

Although not extensively studied in this context, one potential consideration for hospital pharmacists is the prioritization of formulary planning and cost communication and the application to patient discharge. It is known that identifying barriers is imperative when formulating a plan to improve patient medication adherence. Drug costs are one of the most commonly reported barriers. Since pharmacists are uniquely equipped to address financial barriers, special attention to this may eliminate challenges to adherence before the patient is discharged.

Ensuring the use of a well-managed formulary can guide prescribers to use less-expensive options. ASHP Guidelines on Medication Cost Management Strategies for Hospitals and Health Systems state that clinical pharmacy services are a crucial part of a successful formulary-management program focused on reducing drug costs.21 Clinical pharmacy services have long been associated with reduced drug costs in the inpatient setting. These cost savings can often be transferred to the patient through the use of less-expensive formulary medications that are subsequently less expensive in the outpatient setting as well. This could potentially eliminate a cost-prohibitive barrier for the patient. A report outlining a clinical-pharmacist program at the Egleston Cystic Fibrosis Center at Emory University demonstrated that compliance with home regimens was enhanced when clinical pharmacists were involved with drug selection during the patient’s hospitalization in the adolescent and adult cystic fibrosis population.22

When providing discharge medication counseling, pharmacists should discuss medication costs with the patient when appropriate and ask questions specifically designed to identify financial barriers. Pharmacists are uniquely qualified to make recommendations to prescribers for lower-cost therapeutic alternatives. One cross-sectional analysis by Duru and colleagues showed that therapeutic substitutions to lower-cost alternatives resulted in savings of $389 to $452 annually per patient.23 In cases where less-expensive alternatives are unavailable, pharmacists can provide helpful resources to overcome these financial barriers, such as manufacturer coupons and patient-assistance programs.


Although community pharmacists have long been at the front line of medication-adherence challenges, the literature suggests that a deeper evaluation of the pharmacists’ role may lead to innovation and improvement for patient outcomes. More institutions are now recruiting clinical pharmacists in the inpatient setting in efforts to further address adherence barriers. These services are a creative application of resources that demonstrate definite potential to help patients at risk for nonadherence.



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