Date of Award

Summer 2017

Document type

Thesis

Degree Name

PhD (Doctor of Philosophy)

First Supervisor

Professor Tom Fahey

Second Supervisor

Dr Tamasine Grimes

Third Supervisor

Dr Ronan McDonnell

Funder/Sponsor

Thank you to the Health Research Board of Ireland (HRB) who funded my systematic review through a Cochrane Research Training Fellowship (CTF/2012/7), as well as the HRB Centre for Primary Care Research who supported me in undertaking this PhD and the academic and administrative team of the HRB PhD Scholar’s programme in Health Services Research for their support, and for providing a structured environment for this research.

Keywords

Medication Reconciliation

Abstract

Background

The aim of this thesis was to examine medication reconciliation at the primary secondary care interface and to identify the impact of hospitalisation on the continuity of medication post discharge as well methods to both implement and improve reconciliation.

Methods

A mixed methods research approach was used. A questionnaire was used to gather the opinion of primary care based healthcare professionals (HCPs) on the perceived quality of medication reconciliation both within and between primary and secondary care. A retrospective cohort of general practice patients was recruited to assess the impact of hospitalisation on the continuity of chronic medications post hospitalisation. A systematic review of the literature was performed to report the most effective method of reconciliation (e.g. HCP mediated, Information Communication Technology (ICT), multifaceted). Qualitative techniques were used to gather the opinions of secondary and primary care based HCPs on the barriers and facilitators to implementing effective reconciliation. The findings from all studies were triangulated to provide recommendations on methods to improve medication safety at this transition point.

Results

A total of 897 general practitioners (GPs) and community pharmacists (CPs) responded to the questionnaire – reporting satisfaction with GP/CP communication, mixed quality of communication with secondary care and an extremely common experience of prescribing errors following transitions of care (>80%). Analysis of a cohort of patients (n=19,777) from 44 practices, prescribed chronic medications long-term, reported a proportion of medication discontinuity ranging from 6-12% in the six months post-hospitalisation. There was reduced odds of discontinuity of respiratory inhalers (adjusted odds ratio AOR 0.53 95%CI [0.39, 0.71]) and thyroid medications (AOR 0.54 95%CI [0.33, 0.89]) in those hospitalised versus those not hospitalised, with no impact of hospitalisation on the continuity of antithrombotics and lipid lowering medication. A systematic review and meta-analysis of reconciliation interventions showed a positive impact on medication discrepancies with a reduction in the relative risk (RR 0.58, 95%CI [0.46 to 0.73], 18 studies) by interventions that were primarily delivered by pharmacists. There is no certainty of this effect due to the low quality of included studies. Thematic analysis, of interviews with thirty-five HCPs, revealed that existing organisational practices, infrastructural deficits and the opinion of HCPs were the main barriers to effective reconciliation with improved communication, multidisciplinary teams and use of information technology listed as facilitators.

Conclusions

There is a frustration with the current standard of medication reconciliation between primary and secondary care with the experience of errors following transitions being commonly reported. This thesis provides evidence on the impact of transitions post hospital discharge on medication continuity, reviews successful reconciliation interventions, and examines the key suggestions of stakeholders in implementing reconciliation.

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File Size

8.14 MB

Comments

A thesis submitted for the degree of Doctor of Philosophy from the Royal College of Surgeons in Ireland in 2017.

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