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Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of care. Cochrane Database Syst Rev. 2018 Aug 23;8:CD010791. doi: 10.1002/14651858.CD010791.pub2. (Systematic review)
Abstract

BACKGROUND: Transitional care provides for the continuity of care as patients move between different stages and settings of care. Medication discrepancies arising at care transitions have been reported as prevalent and are linked with adverse drug events (ADEs) (e.g. rehospitalisation).Medication reconciliation is a process to prevent medication errors at transitions. Reconciliation involves building a complete list of a person's medications, checking them for accuracy, reconciling and documenting any changes. Despite reconciliation being recognised as a key aspect of patient safety, there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption.

OBJECTIVES: To assess the effect of medication reconciliation on medication discrepancies, patient-related outcomes and healthcare utilisation in people receiving this intervention during care transitions compared to people not receiving medication reconciliation.

SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, seven other databases and two trials registers on 18 January 2018 together with reference checking, citation searching, grey literature searches and contact with study authors to identify additional studies.

SELECTION CRITERIA: We included only randomised trials. Eligible studies described interventions fulfilling the Institute for Healthcare Improvement definition of medication reconciliation aimed at all patients experiencing a transition of care as compared to standard care in that institution. Included studies had to report on medication discrepancies as an outcome.

DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. Study-specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals (CI). We used the GRADE approach to assess the overall certainty of evidence for each pooled outcome.

MAIN RESULTS: We identified 25 randomised trials involving 6995 participants. All studies were conducted in hospital or immediately related settings in eight countries. Twenty-three studies were provider orientated (pharmacist mediated) and two were structural (an electronic reconciliation tool and medical record changes). A pooled result of 20 studies comparing medication reconciliation interventions to standard care of participants with at least one medication discrepancy showed a risk ratio (RR) of 0.53 (95% CI 0.42 to 0.67; 4629 participants). The certainty of the evidence on this outcome was very low and therefore the effect of medication reconciliation to reduce discrepancies was uncertain. Similarly, reconciliation's effect on the number of reported discrepancies per participant was also uncertain (mean difference (MD) -1.18, 95% CI -2.58 to 0.23; 4 studies; 1963 participants), as well as its effect on the number of medication discrepancies per participant medication (RR 0.13, 95% CI 0.01 to 1.29; 2 studies; 3595 participants) as the certainty of the evidence for both outcomes was very low.Reconciliation may also have had little or no effect on preventable adverse drug events (PADEs) due to the very low certainty of the available evidence (RR 0.37. 95% CI 0.09 to 1.57; 3 studies; 1253 participants), with again uncertainty on its effect on ADE (RR 1.09, 95% CI 0.91 to 1.30; 4 studies; 1363 participants; low-certainty evidence). Evidence of the effect of the interventions on healthcare utilisation was conflicting; it probably made little or no difference on unplanned rehospitalisation when reported alone (RR 0.72, 95% CI 0.44 to 1.18; 5 studies; 1206 participants; moderate-certainty evidence), and had an uncertain effect on a composite measure of hospital utilisation (emergency department, rehospitalisation RR 0.78, 95% CI 0.50 to 1.22; 4 studies; 597 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS: The impact of medication reconciliation interventions, in particular pharmacist-mediated interventions, on medication discrepancies is uncertain due to the certainty of the evidence being very low. There was also no certainty of the effect of the interventions on the secondary clinical outcomes of ADEs, PADEs and healthcare utilisation.

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Comments from MORE raters

Physician rater

I am afraid that despite the results of this excellent meta-analysis, our politicians and health officials will maintain medication reconciliation as a viable alternative in terms of economics and health. We must get used to supporting or rejecting interventions based only on good scientific evidence, as is the case.

Physician rater

We started using electronic medical records 2 years ago. Initially we did not know what reconciliation meant and most of in our facility did not do it. This immediately triggered the documentation crew to hound and cite us. We are used to it by now and we do it automatically. I am happy to see a study that evaluated the reconciliation system and I must say I was surprised about the conclusions. I felt that reconciliation was helpful in giving me an idea about the patients' medications. We need more studies to determine its usefulness in order to decide whether to re-conciliate or not.

Physician rater

Medication reconciliation seemingly has to be valuable and reduce adverse outcomes. However, this review shows that evidence does not support that claim. Given the resources allocated to carry out this process, better research to confirm efficacy is warranted.
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