INTRODUCTION

Hospital discharge is a critical step in patient care. A patient experiences a mean of four medication changes and may suffer from adverse drug events during their stay.¹,²,³ The therapy at discharge has to be continued as prescribed by the clinicians until the next consultation with a general practitioner (GP). However studies from Australia and Switzerland show that GP appointments are often delayed.⁴,⁵ In some countries, community pharmacists are therefore the first health care professionals encountered by the recently discharged patient, providing medication supply and pharmaceutical care.²

Insufficient communication between hospitals and community pharmacists was identified as a main barrier to appropriate medication reconciliation.⁶ It can lead to discrepancies between different documentation⁷,⁸, medication supply gaps⁹, and subsequent hospital readmissions.¹⁰ The readmission rate may be reduced by a community pharmacy-based intervention.¹¹ Drug related problems were detected in 25% of hospital discharge prescriptions.¹² In these cases, pharmacies had to handle prescriptions without quantities or with unusual doses. A recent intervention study in a Swiss region, aiming at optimising communication found a reduction of interventions by the community pharmacies after an in-hospital intervention.⁴ But it is unknown if the performed optimisations met the pharmacists’ needs and objectives. To our knowledge, no study so far has compared the currently available information with the desired information in a mixed method study.

The needs and wishes of subsequent health professionals when dealing with discharged patients have been studied for GPs, pointing out the insufficient quality and quantity of information transfer.¹³,¹⁴,¹⁵,¹⁶,¹⁷ One study in GPs compared the available and desired information after discharge and found significant discrepancies.¹⁸ Information about drug discontinuation was available for 14% of GPs, while 89% desired to receive it. The authors also compared information desire between GPs and community pharmacists and found very similar needs. Even though pharmacists are often encountered earlier as many patients visit them before the GP, there are only a few studies focusing on them.¹⁸,¹⁹,²⁰,²¹,²²,²³ These studies assessed the information transfer from hospitals, the community pharmacists’ challenges and needs in France, United Kingdom and Belgium. The survey with Belgian community pharmacists conducted after a prospective study found that they are highly interested in obtaining more information at discharge.¹⁹

In Switzerland, GPs are automatically provided with the discharge summary, but its content depends on the hospital software and the prescriber.¹²,¹⁶ Patients usually receive summaries along with their discharge prescription, but it remains unclear how many of them hand it to their pharmacist. A specialty of the Swiss health care system is, that in some regions prescribed medicines may be dispensed directly by physicians, their medical team or hospitals (so called “self-dispensing”).²⁴ Some hospitals provide bridging supplies to their discharged patients, whilst others have public pharmacies. Therefore, community pharmacies in Switzerland may play different roles depending on regions.

According to the Joint-FIP/WHO Guidelines on Good Pharmacy Practice, pharmacists should fulfil certain roles, such as “provide effective medication therapy management” (Role 2).²⁵ Specifically, Function B (“manage patient medication therapy”) outlines that pharmacists play an essential role in evidence based treatment. They take the responsibility for coordinating the interdisciplinary team’s work, and transfer their knowledge to other health care professionals in order to ensure appropriate medication use. Function C encourages community pharmacists to “monitor patient progress and outcomes”. By assessing, interpreting and documenting clinical data and test results, pharmacists may monitor and influence health outcomes of their patients. But, in order to fulfil these roles, access to therapy-related, health-related and care-related data and collaboration on an organisation-related level are essential. To our knowledge, there is no study evaluating if pharmacists fulfil these roles.

This study aims to a) Identify community pharmacists’ current problems at hospital discharge, their self-defined roles and the fulfilment of internationally defined roles, b) Assess the information needs by evaluating current availability and usefulness of information in community pharmacies, specifically therapy-, health-, care- and organisation-related information, and c) Gain insight into community pharmacists’ objectives and strategies for discharge optimisation.

METHODS

The mixed method approach comprised both qualitative and quantitative measures. The qualitative focus group discussion helped to gain a deeper insight in the subject in order to design the subsequent quantitative questionnaire.²⁶

This study did not involve health related patient information, nor health or illnesses were studied. Therefore, according to Swiss law on human research, no ethical approval was needed.²⁷

RESULTS

Thematically similar results from the focus group discussion and the questionnaire are presented, related to each other, in the results’ subsections. Subsections refer to the three aims. Pharmacists contributing to the focus group are named „participants”, while pharmacists answering the questionnaire are called „respondents”. Characteristics of participants and respondents are shown in Table 1 and Table 2. Of 1348 questionnaires sent out, 194 (14.4%) were completed and returned.

DISCUSSION

This is the first published study evaluating current practices of information transfer between hospitals and community pharmacies in Switzerland, in direct comparison with the needs and objectives expressed by community pharmacists. To summarise, community pharmacists stated to have limited access to essential information, and they called for further therapy-related, health-related, care-related, and organisation-related information. A need for discharge optimisation and organisational collaboration was claimed by both the participants in focus group discussion and the community pharmacists responding to the questionnaire. Better counselling, treatment continuity for patients, and reduced workload for pharmacists were identified as major objectives.

In particular, this study revealed that community pharmacists see the hospital discharge as an important step in care transition. Participants and respondents complained about a lack of information, which impairs patient care in daily practice. These challenges are as well described in the literature.²⁰,³⁶ Both groups reported treatment gaps to be a frequent consequence. To compensate, community pharmacists invest a lot of time and effort in avoiding therapy gaps and in fulfiling their role as therapy managers. However, questionnaire respondents who were confronted with the Joint-FIP/WHO Guideline on Good Pharmacy Practice stated that they do fulfil their role (rather) badly. Focus group participants felt capable of doing more than just dispensing medicine, and they wished to apply their expertise more often. A comparison of the provision of pharmaceutical care by community pharmacists across Europe revealed over-average scores for Switzerland e.g. in direct patient care activities and in patient monitoring.³¹ These conflicting findings may be due to methodology that limits the value of self-reported behaviour. It would be of interest to study how other European pharmacists judge their role fulfilment if confronted with the Joint-FIP/WHO Guideline. Nevertheless, our study indicates a high need for better exchange of information at discharge, and revealed the potential of community pharmacists to improve treatment continuity.

Regarding content of the information, four categories (A-D) evolved from the focus group discussion (Table 4). The availability of the different items varied significantly, and it differed also among pharmacies. This is possibly due to special settings which combine a GP practice and a pharmacy; a new development in Switzerland. Outstanding examples of pharmacies with extended collaboration were also described before²², but it is unknown if specialised pharmacies with a GP practice in the community pharmacy responded to the questionnaire. It needs to be taken into account that respondents may have answered for general availability of information, and not always specifically for recently discharged patients. However, all respondents deplored insufficient quantity and quality of information, as well as delayed information transfer.

Looking at the categories (A-D) in detail reveals a mixed pattern. Therapy-related items (A) like patient identification, therapy duration or up-to-date medication lists were rated with the highest availability. In accordance with that, they are also valued the most essential by the respondents. During a hospital stay, therapy changes such as new or altered treatments are common.¹ However, our results show that they are usually not communicated, which makes medication reconciliation labour-intensive. Therefore, detailed information on changes was strongly desired, as well as a complete list containing all medicines a patient should use. Other studies had similar findings, where pharmacists and GPs also stated a need for more information about medication changes.⁶,¹⁶ Surprisingly, information about reasons for changes was not as desired as the information that there was a change. This is congruent with a Belgian study.¹⁹ Pharmacists seem not to reevaluate clinical decisions, which may be due to a lack of time or limited clinical expertise. Regarding stop orders, focus group participants repeatedly stated that insufficient transfer of such information may put patients at risk. The explicit need for this information was supported by literature, where 76% of interviewed American pharmacists saw a need for this information.¹⁸ Likewise, this was put on a “wish list” by Kennelty et al.⁶ A second therapy-related focus was “off-label” use. It usually remains hidden because diagnoses are rarely accessible for community pharmacists. In this situation the indication would be essential in order to check the appropriateness of the prescription.

Information items categorised as health-related (B) are almost never available. Within those items, allergies were accessible to some responding pharmacies. Allergy information was considered essential by most of the respondents, matching results of previous studies.¹⁸,¹⁹ Interestingly, other health-related items like kidney function results were significantly less desired. This may be due to a lack of experience in judging the appropriateness of individual doses. This low interest in clinical details opposes earlier statements, that pharmacists would rather be seen as competent health care professionals. Although, focus group participants called for further education in these topics, for example evaluation of laboratory results and wound care.

Besides dispensing and counselling a patient, pharmacists have a role in coordinating patient care.²⁵ Therefore, care-related information (C) would be helpful but is currently only sometimes available. The knowledge of a patient’s social situation, the needs for support in the management of medicines or the information about the next appointment with the GP would enable community pharmacists to fulfil their role more adequately. Our findings underline similar results from other studies, where the date of the next GP appointment or knowing how the patient manages their medication at home were highly rated.⁶,¹⁹ With this information, coordinating care within the interdisciplinary team would be easier for pharmacists.

In both study parts, different objectives for discharge optimisation evolved. During focus group discussion, there was a desire for reducing the pharmacist’s workload, whilst in the questionnaire, more patient-oriented than pharmacist-oriented objectives were chosen. This discrepancy may be due to methodological reasons (free discussion versus single-choice question). However, objectives expressed by participants and respondents were similar to a Belgian and a Swiss intervention study, where continuity of treatment was targeted.¹⁹,³⁷ To achieve the above mentioned optimisations, different strategies were discussed. Participants and respondents suggested an enhanced information transfer from hospital to community pharmacy. No other substantial concepts were discussed when participants were asked for additional ideas, highlighting this as a priority issue.

Pharmacists in both settings insisted on an early transfer of information. They preferred concise and clearly structured information. A well-designed form would help hospitals to implement such documentation, and pharmacists to read it efficiently. While questionnaire respondents prioritised electronic tools, focus group participants preferred paper-based solutions like handovers, because they were afraid of any implementation delay with a new system. Surprisingly, there was no clear trend of younger pharmacists preferring electronic tools. However, electronic platforms were welcomed for organisation-related information (D). Such organisation-related information was sometimes or seldom accessible, although rated as very helpful. As a general impression from the focus group discussion, pharmacists see their surrounding hospitals as “lucky dips” or “black boxes”, not knowing what happens inside and being surprised by what comes out. Similar opinions have been collected among Swiss GPs.¹³ Personal knowledge of the treating personnel may enhance collaboration.⁶,¹⁹ Through extended collaboration on an organisational level (E), e.g. shared education, this impression of GPs and community pharmacists may be diminished.

Some limitations have to be taken into account. This was a mixed method approach leading to qualitative, and subsequent quantitative results. Country- and population-specific characteristics like self-dispensing may limit applicability to other health care systems. There may be a selection bias for pharmacists, however, age²⁹,³⁸, gender²⁹,³⁰,³⁸ and experience³¹ of respondents, as well as location²⁹,³¹ and size³²,³⁸ of pharmacies, were very similar in both groups compared to other studies. There was no evaluation of different pharmacy settings, which would have been useful to compare. Response to the questionnaire was rather low compared to response rates of 43 - 57.4% in similar settings.²⁹-³¹,³⁸ This may be due to an overload of surveys being sent to this population lately and the fact that the questionnaire was sent to pharmacies and not to personal email accounts. A response bias cannot be excluded. The mixed method approach helped to enrich the knowledge gained from the 194 respondents, enabling a broader insight in the subject. Through focusing on information transfer, other important strategies of discharge optimisation may have gone underreported.

CONCLUSIONS

To conclude, insufficient communication at hospital discharge may cause therapy interruptions and introduce additional workload for community pharmacists. Although the very essential therapy-related information is sometimes available for Swiss community pharmacists, desired health-related and care-related information is mostly inaccessible. Interviewed community pharmacists called for enhanced collaboration to support patient safety, mainly through information transfer. Its layout was hoped to be concise and well-structured to enable quick and easy reading. No clear preference for a transfer method was identified. We recommend that any optimisation of hospital discharge should be adapted to community pharmacists’ competencies and needs. With this, they would possibly be more able to support patients in their therapy to their best.