Pharmacist-Led Discharge Care to Reduce Postdischarge Health Care Utilization

Importance Pharmacist-led peridischarge transitions of care (TOC) interventions reduce adverse drug events after hospitalization. However, health care organizations do not usually see a financial incentive to fund these interventions. Objective To test whether pharmacist-led TOC interventions could drive reductions in health care resource utilization after hospital discharge. Design, Setting, and Participants This pragmatic randomized clinical trial was conducted in 2 urban teaching hospitals in the US. Participants were hospitalized adults aged 55 years or older taking 10 or more long-term prescribed medications or 3 or more high-risk medications (defined as anticoagulants, antiplatelet agents, or antihyperglycemics including insulin), enrolled between December 23, 2019, and December 30, 2022. Data were analyzed from January 2023 to June 2025. Intervention Pharmacist-led peridischarge and postdischarge medication management with patients and their care partners, including medication review, discharge medication reconciliation, and addressing medication adherence and safety. Usual care consisted of obtaining a best possible medication history and conducting an admission medication order reconciliation. Main Outcomes and Measures The primary outcome was the proportion of patients with all-hospital unplanned 30-day postdischarge hospital or emergency department (ED) utilization. A sample size of 9776 patients would detect absolute differences of 2.5% from an expected baseline of 27.5%. Secondary end points included same-hospital unplanned utilization and several prespecified subgroup analyses to evaluate effect modification. Results A total of 6478 patient hospitalizations were randomized and 6428 (3215 usual care and 3213 intervention) were analyzed; 3265 (50.8%) were among male patients. Patients had a mean (SD) age of 75.5 (10.2) years and were taking a median of 16 (IQR, 12-22) long-term prescription medications and 2 (IQR, 1-3) high-risk medications. Three-quarters of patients (4824 [75.0%]) were discharged home. The per-protocol analysis included 6238 patient encounters, 4472 (71.7%) of which were among patients using fee-for-service Medicare for whom all-hospital utilization claims were obtainable; in this group, no significant reduction was found in the proportion with unplanned 30-day all-hospital utilization (593 of 2242 usual care [26.4%] vs 570 of 2230 intervention [25.6%]; difference, 0.9 percentage points [pp]; 95% CI, −1.7 to 3.5 pp). Among all patients randomized, there was also no significant reduction in same-hospital unplanned 30-day utilization (606 of 3112 usual care [19.5%] vs 579 of 3126 intervention [18.5%]; difference, 1.0 pp; 95% CI, −1.0 to 3.0 pp). Among the 589 patients with low medication adherence and literacy, there was a 10.4 pp (95% CI, 3.4-17.4 pp) absolute reduction in same-hospital unplanned utilization (69 of 240 usual care [28.8%] vs 64 of 349 intervention [18.3%]; P = .003) ( P = .01 for effect modification). Conclusions and Relevance Among older adults with polypharmacy, no reduction overall in 30-day unplanned hospital and ED utilization from a pharmacist-led TOC intervention was detected, but a reduction was found among patients with low medication adherence and literacy, suggesting benefit for this subgroup. Trial Registration ClinicalTrials.gov Identifier: NCT04071951