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.