Discussion
fracture, fractures, osteoporosis
SECONDARY, OSTEOPOROSIS
The Patient Pathway Pharmacist intervention group showed superior medication management and pharmacotherapy, compared to the control group, through higher quality of medication information in discharge summaries, a lower number of PIMs and more anti-osteoporosis treatment and laxatives. The intervention had, however, no impact on readmission rate or mortality. The intervention was successfully implemented for nearly all included hip fracture patients in both primary and secondary care settings. We interpret the findings to be in favour of hip fracture patients’ safety.A higher quality of discharge summaries, as seen for the intervention patients, is important to avoid disrupted transfer of medication information and the consequential medication errors. Previous studies have shown that low quality or missing discharge summaries were associated with rehospitalisation [Intervention patients’ pharmacotherapy improved through medication reviews, by a lower number of PIMs and higher proportion of patients receiving osteoporosis pharmacotherapy at hospital discharge. Reducing the number of PIMs is beneficial to patients as PIMs are associated with new falls and fractures [To the best of our knowledge, we are the first to describe a successful implementation of a clinical pharmacist service designed to follow hip fracture patients throughout the patient pathway, to ensure seamless transfer. This was a key difference from prior clinical pharmacy studies which have focused on a single context, such as ward specific inpatients [The number of PIMs could be reduced through medication reviews at two intervention points; in-hospital and in the patients’ home after discharge. The implementation evaluation showed PIMs to be reduced by 50% through the hospital medication review, but only by 17% in the home setting. We hypothesise that this result has two explanations. First, the PIMs at hospital were the most grave and obvious to discontinue. Thus, in home setting, the PIMs available to discontinue may have been the PIMs that were difficult to stop without an alternative pharmacotherapy or elaborate follow-up from a healthcare professional. Second, the communication between pharmacist and primary care doctor might have been less successful over the telephone (e.g. understanding the pharmacist role or knowledge, or time shortage). Although barriers for de-prescribing is complex and multifactorial [A strength of our study was the contribution towards bridging the gap of silo-organised healthcare systems, which often act as communication barriers between different care settings, thus mediating seamless care transition and continuity. Furthermore, the discharge summary score contained the most clinically relevant criteria for safe medication management in the next care setting, as it was in accordance with international guidelines [We chose not to conduct the study as a randomised controlled trial (RCT) due to the high risk of contamination bias as the study hospital has one orthopaedic ward only, and most often the same doctor is responsible for the ward round in all hip fracture patients [By showing implementation of the interventions steps and improvement in discharge summary score, we claim the Patient Pathway Pharmacist intervention is feasible to be delivered in a clinical setting, and contributed to safe transfer of medication information and appropriate pharmacotherapy in all care settings, thus supporting patient safety [