Pharmacist-led discharge interventions have a limited impact on reducing overall post-discharge healthcare use for older patients with polypharmacy, but may significantly benefit certain high-risk patient groups such as those with low literacy, according to a recent study.
Conducted across two urban academic medical centres in the US and published in the journal JAMA Network Open, the pragmatic randomised clinical trial evaluated whether pharmacist-led transitions-of-care interventions could reduce healthcare utilisation among older adults with complex medication regimens.
The trial involved 6,478 hospitalisations among adults aged 55 years or older. Polypharmacy was defined as taking 10 or more long-term medicines or using three or more high-risk drugs, such as anticoagulants or insulin. The average age of participants was 75.5 years, with patients taking a median of 16 medications.
Patients were randomised to either usual care (n=3,215), comprising medication history and admission reconciliation, or to a pharmacist-led intervention (n=3,213), which included medication review, discharge reconciliation, patient education and post-discharge follow-up, alongside optional adherence and safety support.
The primary outcome was unplanned all-hospital utilisation, defined as hospital or emergency department (ED) visits within 30 days of discharge. Secondary outcomes included same-hospital utilisation, individual utilisation components and mortality.
Pharmacist-led discharge and subgroup benefits
In the per-protocol population with Medicare data (n=4,472), unplanned all-hospital utilisation occurred in 26.4% of usual care patients compared with 25.6% in the intervention group (absolute difference 0.9 percentage points; 95% CI −1.7 to 3.5; risk ratio 0.97).
Similarly, no significant differences were observed secondary outcomes including same-hospital unplanned utilisation (19.5% vs 18.5%; difference 1.0 percentage point; 95% CI −1.0 to 3.0), or mortality.
However, among 589 patients with low medication adherence and literacy, the pharmacist-led discharge intervention significantly reduced same-hospital unplanned utilisation by 10.4 percentage points (28.8% vs 18.3%; P=0.003; odds ratio 0.56, 95% CI 0.38–0.82).
This effect remained robust after adjustment and multiple imputation (OR 0.61; 95% CI 0.42–0.90).
Implications for post-discharge care
Several factors may explain the neutral primary outcome. The trial was underpowered due to early termination (6,478 vs the planned 9,776 enrolments), and only around 72% of patients had Medicare data available for the primary endpoint.
In addition, both groups received robust baseline medication reconciliation, potentially limiting incremental benefit of pharmacist-led discharge, while healthcare utilisation may be an imperfect proxy for care quality, the authors said.
Further limitations included reliance on ED visits to classify unplanned admissions outside study hospitals, evolving eligibility criteria and missing or inconsistent medication and literacy data. The authors added that generalisability may also be restricted to well-resourced centres with established pharmacy services.
Nevertheless, a strength of this study was its pragmatic design, meaning its estimates of benefit are likely applicable to routine clinical settings. The findings also highlighted a clinically relevant signal: patients with low medication adherence and literacy appear to benefit most from pharmacist-led discharge care.
Notably, this subgroup represented fewer than 10% of the enrolled participants across the two study centres, suggesting that targeting such patients may improve feasibility and help reduce implementation costs for similar organisations.
The authors concluded that future research should refine the identification of high-risk subgroups, improve the assessment of health literacy at admission, and suggest tailoring pharmacist-led discharge interventions to patients with cognitive impairment or involving carers more explicitly.
Reference
Pevnick JM et al. Pharmacist-led discharge care to reduce postdischarge health care utilisation: a randomised clinical trial. JAMA Netw Open 2026;9(3):e260719.
