17.

Include ward-based pharmacists in the multidisciplinary care of people admitted to hospital with a medical emergency.^a

Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, length of stay in hospital, prescribing errors, missed medications, and medicines reconciliation were considered by the guideline committee to be critical outcomes.

Readmissions, admissions to hospital, discharge from hospital and staff satisfaction were considered by the committee to be important outcomes.

A total of 18 studies (20 papers) were identified that assessed ward based pharmacist support. They were split into three categories:

Regular in-hospital ward based pharmacy support compared to no ward-based pharmacist

Eight randomised controlled trials were identified. The evidence suggested that regular in-hospital pharmacist support may provide benefit for reduced mortality, reduced preventable adverse drug events in hospital and at 90 days, length of stay and increased patient and/or carer satisfaction. However, there was no effect on readmission, adverse drug events at 3 to 6 months post discharge and admission. Evidence for the outcome prescribing errors at discharge suggested no difference between the groups for the outcome of reducing prescribing errors at discharge; however there were increased prescribing errors at 30 days in regular in-hospital pharmacist support group compared to no pharmacist support group. No evidence was found for quality of life, missed medications, medicines reconciliation, admissions to hospital, discharges or staff satisfaction.

Pharmacist at admission compared to no ward-based pharmacist

Six randomised controlled trials were identified. The evidence suggested that pharmacists at admission may provide benefit by reduced medicine errors, total medication errors within 24 hours of admission and physicians agreement. However, there was no difference for quality of life, length of stay, or future hospital admissions and a possible increase in mortality at 3 months. However, the mortality outcome was graded very low quality and the committee interpreted this with caution as it was from 1 small study with low events and wide confidence intervals. No evidence was found for avoidable adverse events, patient and/or carer satisfaction, readmissions, prescribing errors, missed medications or discharges.

Pharmacist at discharge compared to no ward-based pharmacist

Four randomised controlled trials were identified. The evidence suggested that pharmacists at discharge may provide benefit for reduced prescription errors, reduced readmissions up to 22 days post discharge and prescriber errors (drug therapy inconsistencies and omissions) at discharge. The evidence suggested that pharmacists at discharge have no effect on quality of life scales. No evidence was found for mortality, patient or staff satisfaction, length of stay, future hospital admissions, missed medications, avoidable adverse events or discharges.

Summary

Overall the evidence demonstrated some potential benefits for ward-based pharmacists supplementing the prescribing and drug delivery activities provided by physicians and nurses. The mechanism by which pharmacists might improve patient outcomes would most likely be through minimising prescribing errors and drug interactions, by ensuring appropriate prescribing or discontinuation of drugs. Pharmacist education and support is likely to improve patient and/or carer satisfaction.

Evidence was found for these outcomes, though not in all populations and with some inconsistencies. No evidence was found relating to 7 day provision of a ward pharmacist.

The committee decided to make a strong recommendation for ward based pharmacists because there was evidence of benefit in many of the facets of pharmacists’ work even though overall the evidence was relatively weak. The economic evidence was also in favour of the provision of pharmacy support. In addition, the presence of a ward based pharmacist is common practice in the UK and the experience of the committee was positive overall. The committee noted that studies involving the pharmacist at hospital discharge may have reduced the need for junior doctors to explain prescribing regimens, and the need for the patient to visit their general practitioner following discharge for drug review, which may have improved patient and/or carer satisfaction and which would have had a potential cost benefit.

The committee also discussed the added value of having a pharmacist as part of daily MDTs (see Chapter 29 on MDTs). Prescription and administration errors are amongst the most commonly identified adverse events during a patient’s stay in hospital. Pharmacists as part of the MDT can reduce these errors and ensure that the patient gets the correct treatment in a time effective manner, as well as discontinuing drugs which are no longer required. The pharmacist has an important educational role which will be likely to improve patients’ compliance after discharge. These activities allow doctors to prioritise other tasks.

Regular in-hospital pharmacy support compared to no ward-based pharmacist

Five economic evaluations were identified.

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Three economic evaluations reported that the ward-based pharmacist intervention was dominant (more effective and less costly) compared to usual care.

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One UK cost-utility analysis showed that the ward-based pharmacist intervention was cost-effective with an ICER of £632 per QALY gained (as calculated by the NGC).

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One economic evaluation showed that pharmacist support was less effective and less costly, with no clear conclusion regarding cost effectiveness given the absence of a cost-effectiveness threshold for the reported outcomes.

One UK comparative cost analysis, which showed that the ward-based pharmacist intervention was cost saving compared to usual care.

Pharmacist at discharge compared to no ward-based pharmacist

One cost-utility analysis showed that the ward-based pharmacist intervention was not cost effective, with an ICER of £327,378 per adjusted QALY gained. There was a suggestion that the lack of seniority of the pharmacists and lack of integration in the ward team reduced the effectiveness in that study.

The committee noted that clinical pharmacists in the UK studies were generally experienced (band 7/8) and have specialist knowledge in the medications they managed. This may not be the same profile in all the other non-UK studies. Additionally, standard care/control arm in the included studies was not always clearly defined and was variable in terms of clinical pharmacist input. Some studies included a specified level of clinical pharmacist input in the control group which was enhanced in the intervention group (for example, by attendance at ward rounds) while others described the introduction of a de-novo service.

With the exception of the UK modelling study (Karnon 2008²⁹); all studies had a follow-up of 12 months or less and hence would not have assessed the long term impact of the ward based pharmacist intervention. Additionally, the majority of the studies assessed a limited number of cost categories; focusing on medication costs, pharmacist time and less on other staff time and patient-related downstream costs.

The committee felt there was evidence that pharmacist support throughout the stay would achieve saving in terms of medications costs, which was the most frequently assessed cost category in the included studies. One study found the pharmacist cost was completely offset by medication cost savings. The evidence was less clear in terms of impact on other staff time as well as the impact on long-term patient outcomes, which were not always assessed in the included studies. However, in those studies that assessed impact on other staff time and long-term outcomes, the results showed potential for cost saving that could be extrapolated to the other studies. Avoiding medication errors and litigation costs was raised by the committee as another potential positive outcome. Overall, the committee felt that this could be a cost saving intervention.

Overall, the committee concluded that the use of ward-based pharmacists throughout the hospital stay is cost-effective. Pharmacist support only at discharge was shown to be not cost effective but the evidence was limited.

The evidence reviewed for in-hospital pharmacist support was of very low to moderate quality due to risk of bias, imprecision and inconsistency.

The evidence reviewed for pharmacist at admission was of very low to moderate quality due to risk of bias, imprecision and outcome indirectness. The outcome ‘agreement with prescriber’ which was used as a surrogate outcome for staff satisfaction was considered an indirect outcome.

The evidence for pharmacist at discharge was of very low to moderate quality due to risk of bias and imprecision.

The committee noted the improved benefits shown in the UK studies compared to other countries and felt this was due to the fact that ward-based pharmacists are already well embedded in UK practice. However, the committee did note that these studies did not report the level of pharmacist experience and this may limit the interpretation of benefit.

The health economic evidence was assessed to be partially applicable (with only 1 study from the UK and only 1 reporting QALYs). The evidence was also considered to have potentially serious limitations with none of the studies being based on a review of the evidence base and the cost components included being variable.

There was no evidence specifically to support 7 day provision of ward based pharmacists. The committee therefore chose a general recommendation, recognising that pharmacy services would need to be scaled up in parallel with other services in the transition to a 7 day service.

Currently medical wards in the UK do have access to a pharmacist. However, the pharmacist may be responsible for covering several areas concurrently; limiting the level of detail they can bring to medicines reconciliation and patient and staff communication. This is particularly important for an ageing population with multiple co-morbidities for whom polypharmacy adds complexity and may indeed be the cause of the acute admission. In this situation the pharmacist plays a vital role advising the medical team regarding the interactions of drugs and how to prescribe treatment optimally.

Pharmacists are gradually acquiring independent prescribing rights. This allows them (following consultation with the prescribing doctor) to correct prescribing errors or make changes to better agents, relieving doctors of this task. Prescribing drugs to take home at the end of a person’s hospital stay could also facilitate earlier discharge from hospital and allow junior doctors to focus on other tasks such as the ward rounds. Assessment of the cost-effectiveness of prescribing pharmacists in hospital should include these considerations.