• Karin Willoch, Hege Salvesen Blix, Anne Marit Pedersen-Bjergaard, Anne Kathrine Eek, and Aasmund Reikvam.
• Lovisenberg Diakonale Hospital Pharmacy, Lovisenberggate 17, 0440, Oslo, Norway. karin.willoch@apotek.no
• Int J Clin Pharm. 2012 Apr 1;34(2):382-8.

BackgroundDrug-related problems (DRPs) have been found to be associated with increased morbidity, mortality, and health costs.ObjectiveTo investigate whether the inclusion of pharmacists in a rehabilitation team influences the handling of DRPs in the ward and whether an intervention in hospital affects drug use after discharge.SettingThe rehabilitation ward of a general hospital in Oslo, Norway.MethodsPatients were randomized into an intervention group (IG) or a usual care group (CG). The IG patients were followed prospectively by a pharmacist, who reviewed the patients' drug therapies using information from their medical records and patient interviews. The pharmacist identified DRPs and suggested solutions during multidisciplinary team meetings. The IG patients received targeted drug counselling from the pharmacist before discharge. The drug therapy in the CG, for the period from study randomization to discharge, was assessed retrospectively by the pharmacist, who identified DRPs and recorded how they were acted upon. Three months after discharge, pharmacists who were blinded to the patient randomization, visited the patients at home and interviewed them about their medication.Main Outcome MeasuresTypes and frequencies of DRPs in the IG and CG were compared at hospital admission, at discharge, and 3 months after discharge.ResultsOf the 77 patients included, 40 belonged to the IG and 37 to the CG. Patient characteristics (IG vs CG) were as follows: age 73.5 versus 76.8 years; female 58 versus 68%; mean number of drugs at admission 8.3 versus 7.8; and mean number of drugs at discharge 8.5 versus 7.7. At admission, 4.4 DRPs per patient were recorded in the IG and 4.2 in the CG. Significantly more DRPs were acted upon and resolved in the IG; at discharge, the IG had 1.2 DRPs per patient and the CG had 4.0 (P < 0.01). At the home visit, a significant difference between the groups was found: 1.63 versus 2.62 DRPs (P = 0.02) for the IG and the CG, respectively.ConclusionInvolvement of a pharmacist in drug-therapy management, including participation in multidisciplinary team discussions, markedly improved the identification and resolution of DRPs during a hospital stay. The benefit persisted after discharge.

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