Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients

Jordan D. Haag, Amanda Z. Davis, Robert W. Hoel, Jeffrey J. Armon, Laura J. Odell, Ross A. Dierkhising, Paul Y. Takahashi

Research output: Contribution to journalArticlepeer-review

17 Scopus citations


BACKGROUND: The optimization of medication use during care transitions represents an opportunity to improve overall health-related outcomes. The utilization of clinical pharmacists during care transitions has demonstrated benefit, although the optimal method of integration during the care transition process remains unclear. OBJECTIVE: To evaluate the impact of pharmacist-provided telephonic medication therapy management (MTM) on care quality in a care transitions program (CTP) for high-risk older adults. METHODS: This prospective, randomized, controlled study was conducted from December 8, 2011, through October 25, 2012, in a primary care work group at a tertiary care academic medical center in the midwestern United States. High-risk elderly (aged ≥60 years) patients were randomized to a pharmacist-provided MTM program via telephone or to usual care within an existing outpatient CTP. The primary outcome was the quality of medication prescribing and utilization based on the Screening Tool to Alert Doctors to the Right Treatment (START) and the Screening Tool of Older Persons’ Prescriptions (STOPP) scores. The secondary outcomes were medication utilization using a modified version of the Medication Appropriateness Index, hospital resource utilization within 30 days of discharge, and drug therapy problems. RESULTS: Of 222 eligible high-risk patients, 25 were included in the study and were randomized to the pharmacist MTM intervention (N = 13) or to usual care (N = 12). No significant differences were found between the 2 groups in medications meeting the STOPP or START criteria. At 30-day follow-up, no significant differences were found between the 2 cohorts in medication utilization quality indicators or in hospital utilization. At 30-day follow-up, 3 (13.6%) patients had an emergency department visit or a hospital readmission since discharge. In all, 22 patients completed the study. Medication underuse was common, with 20 START criteria absent medications evident for all 25 patients at baseline, representing 15 (60%) patients with ≥1 missing medications. Overall, 55 drug therapy problems were identified at baseline, 24 (43.6%) of which remained unresolved at 30-day follow-up. CONCLUSION: The use of a pharmacist-provided MTM program did not achieve a significant difference compared with usual care in an existing CTP; however, the findings demonstrated frequent utilization of inappropriate medications as well as medication underuse, and many drug therapy problems remained unresolved. The small size of the study may have limited the ability to detect a difference between the intervention and usual care groups.

Original languageEnglish (US)
Pages (from-to)259-267
Number of pages9
JournalAmerican Health and Drug Benefits
Issue number5
StatePublished - Jul 2016


  • Care transition program
  • High-risk elderly patients
  • Medication therapy management
  • Medication utilization
  • Pharmacist-based
  • START criteria
  • STOPP criteria
  • Usual care

ASJC Scopus subject areas

  • Health Policy
  • Strategy and Management


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