Background: During transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs). Aim: To investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge. Method: In this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital’s community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital’s community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs. Results: Overall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03). Conclusion: Our results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.

The role of pharmacists is changing; in many countries, pharmacists have acquired new competencies. A survey conducted in 2013 mapped the clinical pharmacy services in Swiss hospitals by quantifying full-time equivalents (FTE) and depicting clinical pharmacy activities. The aim of this survey was to update these results and analyze the development in Swiss hospitals. An online questionnaire was sent to chief hospital pharmacists (n = 60). The questionnaire was developed based on the previous survey and on a literature search. The survey took place from June to September 2017. In the survey, 44 hospital pharmacies participated (return rate 73%). They counted 265.8 FTE for pharmacists; 31 offered clinical pharmacy services. Hospitals participating in both surveys (n = 32) showed a significant increase in FTE for hospital (+24.5%) and clinical (+62.7%) pharmacists. The number of training positions available for the certificate of proficiency in “clinical pharmacy” has increased by 5.5. Patient-related services are less commonly implemented in comparison to treatment and process-related services. In conclusion, the increase in FTE of clinical pharmacists was more pronounced than of hospital pharmacists in general. For further development and broader implementation of clinical pharmacy services, however, hospital pharmacies should increase the number of training positions and should direct more activities towards patient-related services.

Readmissions to the hospital are frequent after hospital discharge. Pharmacist-led interventions have been shown to reduce readmissions. The objective of this study was to describe pharmacist-led interventions to support patients’ medication management at hospital discharge in Switzerland and to compare them to international guidelines. We conducted a national online survey among chief hospital pharmacists focusing on medication management at hospital discharge. To put our findings in perspective, Cochrane reviews and guidelines were searched for summarised evidence and recommendations on interventions. Based on answers in the survey, hospitals with implemented models to support patients at discharge were selected for in-depth interviews. In semi-structured interviews, they were asked to describe pharmacists’ involvement in the patients’ pathway throughout the hospital stay. In Swiss hospitals (n = 44 survey participants), interventions to support patients at discharge were frequently implemented, mostly “patient education” (n = 40) and “communication to primary care provider” (n = 34). These interventions were commonly recommended in guidelines. Overall, pharmacists were rarely involved in the interventions on a regular basis. When pharmacists were involved, the services were provided by hospital pharmacies or collaborating community pharmacies. In conclusion, interventions recommended in guidelines were frequently implemented in Swiss hospitals, however pharmacists were rarely involved.