Table 1.

Characteristics of included studies

Author, Year	Country, Setting	Study design	Intervention	Comparator	Target of intervention	Inclusion	Exclusion	Components of intervention	Comparator	Follow-up Period	Relevant outcomes	Main results
Anderegg et al 201435	USA, single centre	Before–after	1664	1652	Admission, discharge	Age 18 years or older, discharge from internal medicine, family medicine, cardiology, or orthopaedic surgery medical	Mental illness/alcohol or drug use; discharge to a rehabilitation unit/long-term care facility, readmission for chemotherapy/radiation therapy/rehabilitation therapy	Admission MedRec, Discharge MedRec, patient education, medication calendar	Control group (admission MedRec as needed)	30 days	Readmission, Readmission and/or ED visit	30-day readmission and/or ED visit (general population): NS; 30-day readmission (high-risk): 12.3% (I) vs 17.8% (U), p=0.042
Bolas et al 200450	Ireland, single centre	RCT	81	81	Inpatient stay, discharge, postdischarge	Age 55 years or older, at least 3 regular medications	Transfer to another hospital or nursing home, unable to communicate, mental illness or alcohol-related admission, follow-up was declined	Medication liaison service (comprehensive medication history, discharge letter faxed to GP and community pharmacist, medicines record sheet, discharge counselling, home visit/telephone call)	Standard clinical pharmacy service (not include discharge counselling and liaison service)	3 month	Readmission, hospital stay (following readmission)	Readmission rate: p>0.05; Length of stay: p>0.05
Eisenhower 201436	US, single centre	Before–after	25	60	Discharge	Age 65 years or older, with history of COPD	Left the hospital without medical advice, death within 30 days of discharge	MedRec at discharge, Medication reconciliation form, discharge summary	Usual care (pharmacist was not present during baseline data collection)	30 days	Readmission	Readmission rate: 16% (I) vs 22.2% (U)
Farris et al 2014 37	USA, Single centre	RCT	Minimal=312 Enhanced=311	313	Admission, inpatient stay, discharge	18 years or older, English or Spanish speaker, diagnosis of HPN, hyperlipidaemia, HF, CAD, MI, stroke, TIA, asthma, COPD or receiving oral anticoagulation	Admission to psychiatry, surgery or haematology/oncology service, could not use a telephone, had life expectancy <6 months, had dementia or cognitive impairment	Admission MedRec, patient education during inpatient stay, discharge counselling, discharge medication list, telephone call, care plan faxed to primary care physician/community pharmacist	Usual care (admission MedRec, nurse-led discharge counselling and medication list)	90 days	ADEs, readmission, ED visit, readmission and/or ED visit	16% experienced an AE, Healthcare utilisation at 30 days and 90 days: NS
Gardella et al 201238	US, multicentre	Before–after	1624	7335	Preadmission to post discharge	NA	NA	Preadmission medication list, patient education	Historical control group (preadmission medication list gathered by nurse)	60 days	ADE, ED visits and readmission	30-day readmission: 6% (I) vs 13.1% (U) (OR 2.34, 95% CI 1.87 to 2.94, p<0.001); 60-day readmission: 2.7% (I) vs 7.7% (U) (OR 3.02, 95% CI 2.18 to 4.19, p<0.001)
Gillespie et al 200946	Sweden, single centre	RCT	182	186	Admission, inpatient stay and discharge	Age 80 or older	Previous admission during the study period	Admission MedRec, discharge counselling, medication review, faxing discharge summary to primary care physicians, telephone follow-up at 2 months	Usual care (without pharmacist involvement)	12 month	Readmissions, ED visits, mortality	Readmissions: 58.2% (I) vs 59.1% (U) (OR 0.96, 95% CI 0.64 to 1.4); ED visits per patient: 0.35 (I) vs 0.66 (U) (OR 0.53, 95% CI 0.37 to 0.75)
Hawes et al 201439	US, single centre	RCT	24	37	Discharge and post discharge	High-risk patients ( HF, COPD, hyperglycaemic crisis, stroke ,NSTEM, more than 3 hospitalisations in the past 5 years., 8 or more medications on discharge)	Age <18 years, inability to communicate in English, unable to follow-up (no transportation and no telephone access), transfer to facilities other than primary care, decisional impairment, incarceration	Post discharge medication reconciliation	Usual care (with no pharmacist intervention)	30 days	Readmission, ED visit, readmission and /or ED visit	ED visit: 0 (I) vs 29.7% (U), p=0.004; Readmission: 0 (I) vs 32.4% (U), p=0.002; Composite of hospitalisation or ED visit: 0 (I) vs 40.5% (C), p<0.001
Hellstrom et al 201147	Sweden, single centre	Before–after	109	101	Admission, inpatient stay, discharge	Age 65 years or older, at least one regular medication	Staying during the implementation period	LIMM model, admission and discharge MedRec, medication review and monitoring, quality control of discharge MedRec	Standard care (no formal MedRec by clinical pharmacists)	3 month	Readmission and ED visit,ADE-related hospital visit	ED visit and readmission: 45/108 (I) vs 41/100 (U) Mortality, 3 month: 9/108 (I) vs 9/100 (U) ADE-related revisit: 6/108 (I) vs 12/100 (U)
Hellstrom et al 201248	Sweden, single centre	Before–after	1216	2758	Admission, inpatient stay	High-risk patients (age ≥65 years with any of HF, RF)	NA	Admission MedRec, structured medication reviews, follow-up at least two times a week	Usual care (no clinical pharmacists working in the wards)	6 month	ED visits, hospital admissions and mortality	ED visit: 48.8% (I) vs 51.3% (U) (HR 0.95, 95% CI 0.86 to 1.04); All ED visits, hospitalisation or death: 58.9% (I) vs 61.2% (U) (HR 0.96, 95% CI 0.88 to 1.04) Mortality: 18.2% (I) vs 17.3% (U), p=0.55
Koehler et al 200940	US, single centre	RCT	20	21	Admission, discharge and post discharge	Age 70 years or older, ≥5 medications, ≥3 chronic comorbid conditions, assisted living, English language, phone contact	Primarily surgical procedure, life expectancy ≤6 months, residence in long-term care facility, refusal to participate, not enrolled within 72 h.	Targeted care bundle, medication reconciliation and education, follow-up call, enhanced discharge form	Usual care (nurse and care coordination staff providing care)	60 days	Readmission and/or ED visits	30 days readmission/ED visits: 2/20 (I) vs 8/21 (U), p= 0.03; 60days readmission/ED visits: 6/20 (I) vs 9/21 (U), p= 0.52
Pal et al 201341	US, single centre	NRCT	537	192	Discharge	Age 18 years or older, at least 10 regular medications	NA	Patient counselling, pharmacist medication reconciliation, medication calendar	Usual care (without discharge review by pharmacist)	30 days	Readmission	30 days readmission: 16.8% (I) vs 26.0% (U), p=0.006 ADE prevented: 52.8%
Schnipper et al 200642	US, single centre	RCT	92	84	Inpatient stay, discharge, post discharge	Discharge to home, contacted 30 days after discharge, spoke English, cared for primary care physician/internal medicine resident	NA	Discharge medication reconciliation, telephone follow-up, medication review, standard email template, patient counselling	Usual care (medication review by a pharmacist and discharge counselling by a nurse)		ADEs-related hospital visit, readmission and/or ED visit	Preventable ADE: 1% (I) vs 11% (U), p=0.01; ED visit/readmission: 30% (I) vs 30% (U), p>0.99; preventable medication-related healthcare utilisation: 1% (I) vs 8% (U), p= 0.03
Scullin et al 200749	Ireland, multicentre	RCT	371	391	Admission, inpatient stay, discharge	Age 65 years or older, at least 4 regular medications, taking antidepressants, previous admission in the past 6 months, taking intravenous antibiotics	Scheduled admissions and admissions from private nursing homes	Integrated medicines management service admission and discharge MedRec, inpatient medication review and counselling, telephone follow-up	Usual care (did not receive integrated medicines management service)	12 month	Length of hospital stay, readmission	LoS reduced by 2 days for intervention vs usual care, p=0.003 Readmissions per patient: 0.8 (I) vs 1 (U)
Stowasser et al 200251	Australia, multicentre	RCT	113	127	Admission, discharge	Return to the community following discharge	Outpatients, discharge to hostel or nursing home, previous enrolment, unable to provide consent and follow-up	Medication liaison service—medication history confirmation with community healthcare professionals (telephone, faxing), 30 days post follow-up	Usual care (no medication liaison service)	30 days	Mortality, readmission, ED visit	Mortality, 30 days: 2/113 (I) vs 3/127 (U): NS Readmissions: 12/113 (I) vs 17/127 (U) ED visit per patient: 7.54 (I) vs 9.94 (U)
Walker et al 200943	US, single centre	NRCT	138	366	Discharge, post discharge	Age 18 years or older, 5 or more regular medications, receiving 1 or more targeted medications, having 2 or more therapy modification, unable to manage their medication, receiving a medication requiring therapeutic drug monitoring	Non-English speaking, stay of 21 days or longer	Patient interviews, follow-up plan, medication counselling, telephone follow-up	Usual care (nurse-led service)	30 days	Readmission, ED visit, readmission and/or ED visit	Readmission, 14 days: 12.6% (I) vs 11.5% (U), p=0.65; Readmission, 30 days: 22.1% (I) vs 18.0% (U), p=0.17; Readmissions and/or ED visits: 27.4% (I) vs 25.7% (U), p= 0.61
Warden et al 201444	US, single centre	Before–after	35	115	Admission, inpatient stay, discharge	Age 18–85 years, systolic dysfunction (EF ≤40)	Diastolic dysfunction, valve replacement/left ventricular assist device	Medication reconciliation (admission and discharge), discharge instructions, telephone follow-up	Historical control group (physicians—admission MedRec; nurses- discharge counselling)	30 days	Readmission	All cause readmission, 30-day :17% (I) vs 38% (U) (RR 0.45, 95% CI 0.21 to 0.96, p=0.02), 30 days HF-related readmission: 6%(I) vs 18% (U) (RR 0.31, 95% CI 0.08 to 1.27, p=0.11)
Wilkinson et al 201145	US, single centre	NRCT	229	440	Discharge	Age 18 years or older, English speaking, patients with depression, receiving high-risk medications and polypharmacy, poor health literacy, having an absence of social support, prior hospitalisation within the past 6 months	Refusal of pharmacist education, transfer to a skilled nursing facility, or discharge when the pharmacist was not available	Medication history at admission, during hospitalisation and discharge, patient education on discharge	Control group (pharmacists not provide medication counselling at discharge)	30 days	Readmission	Readmission rate: 15.7% (I) vs 21.6% (U) (RR 0.728, 95% CI 0.514 to 1.032, p =0.04)

ADE, adverse drug event; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; D, days; ED, emergency department; EF, ejection fraction; GP, general practitioner; HF, heart failure; HPN, hypertension; I, intervention; IV, intravenous; LIMM, Lund Integrated Medicines Management; LoS, length of stay; MedRec, medication reconciliation; MI, myocardial infarction; NA, not available; NS, non-significant; NSEMI, non-ST segment elevation myocardial infarction; RCT, randomised controlled trials; RF, renal failure; RR, relative risk; TIA, transit ischaemic attack; U, usual care.