Evaluation of two medication safety-related interventions for cardiovascular inpatients in a German teaching hospital: standardized discharge education and simplification of complex therapies

Objectives: Clinical pharmacists are a valuable addition to the clinical team in hospital. However, in order to convince hospital administrations to employ clinical pharmacists, clinical pharmacy services and their benefit need to be defined and investigated in much more detail.

Methods : Two randomized controlled prospective studies were performed by clinical pharmacists in a German university hospital. Details are listed in the following table:

study	patients	intervention	endpoints
study A	200 cardiovascular patients	standardized pharmaceutical discharge education (duration limit 30min)	self-reported adherence (MARS), medication knowledge, patient satisfaction, quality of life (SF-12)
study B	240 patients of the internistic and urologic wards	pharmaceutical counselling of physicians to reduce medication complexity	self-reported adherence (MARS), medication complexity (MRCI), patient satisfaction, quality of life (SF-12)

Results: The studies showed the feasibility of the respective service within the clinical routine, both of the pharmacist and of patient management processes (such as arranging the counselling appointment of pharmacist and patient directly before discharge). Patient satisfaction and medication-related knowledge were significantly improved (study A). The complexity of discharge medications could be reduced by 15% after recommendation of combination or extended release drugs by the pharmacist (study B). Part of this effect, however, was lost in subsequent ambulatory prescriptions, possibly due to financial reasons affecting prescription behaviour of general practitioners. Although adherence was not influenced, patients advised by the pharmacist rated their quality of life as better than control patients who had been advised solely by a physician.

Conclusions: Both clinical pharmacy services are practicable within the structure and organisation of a German teaching hospital. They have good potential to increase the safety of patients in pharmacotherapy across the interface between hospital and ambulatory care by enhancing patient knowledge and by decreasing medication complexity, respectively.