Original research
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
For numbered affiliations see
end of article.
Correspondence to
Dr Lauren Lapointe-Shaw,
Medicine, University Health
Network, Toronto, ON M5G
2C4, Canada;
​lauren.​lapointe.​shaw@​mail.​
utoronto.​ca
Received 11 March 2019
Revised 12 July 2019
Accepted 19 July 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published by
BMJ.
To cite: Lapointe-Shaw L,
Bell CM, Austin PC, et al.
BMJ Qual Saf Epub ahead of
print: [please include Day
Month Year]. doi:10.1136/
bmjqs-2019-009545
Community pharmacy medication
review, death and re-admission after
hospital discharge: a propensity
score-matched cohort study
Lauren Lapointe-Shaw,‍ ‍ 1,2,3,4 Chaim M Bell,2,3,4,5 Peter C Austin,3,4
Lusine Abrahamyan,3,6 Noah M Ivers,3,7,8 Ping Li,4
Petros Pechlivanoglou,3,9 Donald A Redelmeier,2,3,4,10 Lisa Dolovich11
ABSTRACT
Background  In-hospital medication review has been
linked to improved outcomes after discharge, yet there
is little evidence to support the use of community
pharmacy-based interventions as part of transitional
care.
Objective  To determine whether receipt of a
postdischarge community pharmacy-based medication
reconciliation and adherence review is associated with a
reduced risk of death or re-admission.
Design  Propensity score-matched cohort study.
Setting  Ontario, Canada
Participants  Patients over age 66 years discharged
home from an acute care hospital from 1 April 2007 to
16 September 2016.
Exposure  MedsCheck, a publicly funded medication
reconciliation and adherence review provided by
community pharmacists.
Main outcome  The primary outcome was time to death
or re-admission (defined as an emergency department
visit or urgent rehospitalisation) up to 30 days. Secondary
outcomes were the 30-day count of outpatient physician
visits and time to adverse drug event.
Results  MedsCheck recipients had a lower risk of 30-
day death or re-admission (23.4% vs 23.9%, HR 0.97,
95% CI 0.95 to 1.00, p=0.02), driven by a decreased
risk of death (1.7% vs 2.1%, HR 0.79, 95% CI 0.73 to
0.86) and rehospitalisation (11.0% vs 11.4%, HR 0.96,
95% 0.93–0.99). In a post hoc sensitivity analysis with
pharmacy random effects added to the propensity score
model, these results were substantially attenuated.
There was no significant difference in 30-day return to
the emergency department (22.5% vs 22.8%, HR 0.99,
95% CI 0.96 to 1.01) or adverse drug events (1.5%
vs 1.5%, HR 1.03, 95% CI 0.94 to 1.12). MedsCheck
recipients had more outpatient visits (mean 2.11 vs 2.09,
RR 1.01, 95% CI 1.00 to 1.02, p=0.02).
Conclusions and relevance  Among older adults,
receipt of a community pharmacy-based medication
reconciliation and adherence review was associated
with a small reduced risk of short-term death or
re-admission. Due to the possibility of unmeasured
confounding, experimental studies are needed to clarify
the relationship between postdischarge community
pharmacy-based medication review and patient
outcomes.
Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
Introduction
The period of transition home after
hospitalisation presents numerous risks
to patients. In addition to reduced func-
tioning, patients may experience a clin-
ical deterioration or complications from
treatment. Medications are the most
frequent cause of postdischarge adverse
events, with medication-related events
occurring after 13%–16% of hospital
Protected by copyright.
admissions.1–3 This rate reflects errors in
discharge medication lists, inappropriate
prescribing, inadequate understanding
of medication changes and insufficient
monitoring.3–5 In some cases, medica-
tion-related adverse events lead to costly
hospital re-admissions.6
Medication safety is a pillar of optimal
discharge practices, and appears in
multiple checklists.7–9 Medication-related
interventions are frequently included in
multicomponent transitional care inter-
ventions, many of which have reduced
all-cause hospital re-admissions.10 In
Canada, medication review at discharge
is a hospital accreditation standard.11 Yet,
studies investigating the effect of medi-
cation reconciliation alone have yielded
inconsistent results.12 Medication recon-
ciliation by in-hospital pharmacists has
been found to reduce potential medica-
tion errors and drug-related re-admis-
sions, but not all-cause re-admissions.13 14
In a recent systematic review, medication
reconciliation delivered on the phone or
in a clinic setting by community-based
pharmacists did not reduce the subse-
quent rate of re-admission.15 Other
systematic reviews examining medication
review by pharmacists in any community
setting (ie, primary care, in the home
   1
Original research
or in pharmacy) found mixed effects on medication
adherence, clinical symptom improvement and health-
care resource utilisation, highlighting the challenge in
understanding the effectiveness of a general medica-
tion review conducted in a community setting.16–18
In 2007, the Ontario Ministry of Health and Long-
Term Care introduced MedsCheck, a programme
of medication reconciliation and adherence review
by community pharmacists.19 Patients presenting
to pharmacy were eligible for a MedsCheck if they
were receiving at least three chronic medications.20
The effect of MedsCheck on outcomes after hospital
discharge has not been studied. Our objective was
to determine if patients receiving MedsCheck after
hospital discharge have lower rates of subsequent death
or re-admission than eligible patients not receiving a
MedsCheck assessment.
Methods
Setting, design and data sources
We conducted a retrospective propensity score-
matched cohort study of patients discharged home
from an Ontario hospital between 1 April 2007 and
16 September 2016. ICES houses de-identified linked
health administrative data for all Ontario residents
who have a valid provincial health insurance card. This
includes information on demographics,21 hospitali-
sations,22 emergency department visits,23 outpatient
visits,24 home care and time of death.25 The Ontario
Drug Benefit database includes information on medi-
cations and professional pharmacy services (including
MedsCheck) provided to low-income patients and
those over age 65 years.26 As provincial health insur-
ance is granted universally to all citizens and perma-
nent residents, this study is population-based.
Study population
We included patients who were ≥66 years of age at
discharge, were eligible for MedsCheck and filled a
prescription at a community pharmacy within 7 days
of discharge. Eligibility was defined, consistent with
criteria for MedsCheck reimbursement, as taking
three or more chronic medications over the previous
6-month period.27 MedsCheck programme documen-
tation did not define ‘chronic medications’, however
we adopted a previously used definition (online
supplementary eTable 1).19 28 The 7-day window for
the prescription fill was selected to capture medication
changes resulting from hospitalisation.29
We restricted the analysis to patients who were
discharged to the community, excluding discharges
or transfers to nursing homes, rehabilitation or other
healthcare institutions. We also excluded three groups
likely to have markedly different re-admission risk:
newborns, patients admitted for an obstetrical delivery
or those receiving palliative care (online supplemen-
tary eFigure 1).
2 Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
The MedsCheck eligibility date was the earliest
date at which an eligible patient filled a prescription
in a community pharmacy. To ensure comparability
of groups, we excluded patients who experienced an
outcome or MedsCheck prior to their MedsCheck
eligibility date. We also excluded patients with a
missing age, sex, invalid home location or invalid death
date. We selected each patient’s first hospital discharge
during the study period, and excluded all others.
Exposure
The MedsCheck service was offered by a community
pharmacist in a pharmacy or home setting. Programme
guidelines for MedsCheck during the time of our study
described it as a ‘one-on-one interview between the
pharmacist and the patient to review the patient’s
prescription and non-prescription medications’ and
that it is expected to last approximately 20–30 min.27
In addition to taking at least three chronic medica-
tions, requirements for the service include: (1) Agree-
ment by the patient. (2) One-on-one interview in an
acoustically private area. (3) Provision to the patient
of a complete list of prescription and non-prescription
medications.27 Pharmacists may or may not have access
to the hospital discharge medication list as this is typi-
cally provided in paper form by the patient. Follow-up
Protected by copyright.
on medication discrepancies or any other drug therapy
problem is at the discretion of the pharmacist.
There are several MedsCheck billing codes, each
corresponding to a specific patient population (online
supplementary eTable 2). As an example, MedsCheck
Annual can be done once yearly ($60), and MedsCheck
follow-up ($25) can be provided at any time for any
of the following indications: (1) Hospital discharge in
the previous 2 weeks. (2) Before a planned hospital
admission. (3) Physician referral. (4) Pharmacist deci-
sion based on previous non-adherence, medication
changes or a change of pharmacy (online supplemen-
tary eTable 2).30 Pharmacists are not compelled to
provide the service to all qualified patients, but can
offer the service to eligible patients at their discretion.
The exposure in our study was receipt of any
MedsCheck service. We allowed for MedsCheck to
occur up to 14 days following hospital discharge.30
Other variables
We included patient, hospital and pharmacy-level vari-
ables which were likely to be associated with receipt of
MedsCheck or an outcome.28 These included patient
demographics, comorbidities, measures of previous
healthcare usage (including receipt of MedsCheck in
the previous year), hospital and hospitalisation char-
acteristics (including year of discharge). Medication
usage variables included the total number of medi-
cations and history of potentially inappropriate or
high-risk medications in the previous year. Potentially
inappropriate medications were as identified in the
2012 and 2015 Beer’s lists.31 32 High-risk medications

were the drugs most frequently implicated in adverse
drug events (online supplementary eTable 3).33–35 We
also included the number of new medications filled
postdischarge, as well as a whether a new high-risk
medication or potentially inappropriate medication
was dispensed. We categorised into quartiles each
pharmacy’s ratio of annual MedsCheck volume to
total volume, to account for differences in MedsCheck
delivery patterns between pharmacies. Observations
with missing information for categorical variables
were included in the analysis by creating an additional
variable level to explicitly denote missingness.
Main outcome measures
The primary outcome was time to death or re-admis-
sion. We defined re-admission as inclusive of both
unscheduled emergency department visits and urgent
rehospitalisations. The date of death was obtained
from the Registered Persons Database, which captures
over 98% of Ontario deaths.25 The date of re-admis-
sion was obtained from the Discharge Abstract Data-
base (DAD), and has been found to be 99.9% accurate
when compared with chart abstraction.22 The date of
emergency department visit was obtained from the
National Ambulatory Care Reporting System. This
field is 100% complete and has not been previously
validated. It can be expected to have similar accuracy
to the date of admission in the DAD, since both are
entered by the same trained hospital coders.
Secondary outcomes were time to adverse drug event
requiring emergency department visit or hospitalisa-
tion (based on International Statistical Classification
of Diseases and Related Health Problems, 10th Revi-
sion, Canada (ICD-10-CA) codes, online supplemen-
tary eTables 4 and 5)34 36 37 and the count of outpatient
physician visits. All outcomes were measured to 30
days after MedsCheck receipt.
Subgroups
We prespecified three subgroups at potentially higher
risk for re-admission,38 and for whom a MedsCheck
might be beneficial due to a higher risk of adverse
drug events:34 36 37 (1) Patients with an admitting diag-
nosis of heart failure, (2) Patients with an admitting
diagnosis of chronic obstructive pulmonary disease
(COPD), (3) Patients filling a prescription for a new
high-risk medication (online supplementary eTable
3). An additional subgroup analysis was undertaken
in response to reviewer comments: we compared the
outcomes of early MedsCheck recipients and controls
(time from discharge ≤2 days) to the outcomes of late
recipients and controls (>2 days).
Analysis
Patient, hospital and pharmacy characteristics of
those receiving and not receiving a MedsCheck
were compared using descriptive statistics. Compari-
sons were made using standardised differences, with
Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
Original research
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
differences of 10% or greater considered to be mean-
ingful.39 40 MedsCheck recipients were matched 1:1
to eligible controls based on the logit of the propen-
sity score and hard matching on subgroup variables.
Further details are available in the appendix (online
supplementary eFigure 2).
We estimated Kaplan-Meier survival curves for the
primary composite outcome and death. We plotted
cumulative incidence function curves for return to the
emergency department and for urgent rehospitalisa-
tion, to account for the competing risk of death. We
reported HRs (with 95% CIs) for all time-to-event
outcomes, obtained from a Cox proportional hazards
model estimated in the matched sample. The hazard of
the outcome was regressed on a single variable (expo-
sure to MedsCheck). A robust variance estimator was
used to account for the paired nature of the data.41
Due to the competing risk of death, we reported
cause-specific HRs for the outcomes of return to the
emergency department, urgent rehospitalisation and
adverse drug events.42
Comparison of the 30-day count of outpatient
visits was made using a negative binomial model with
generalised estimating equations to account for clus-
tering of data within matched pairs. We reported the
risk ratio and 95% CIs. We used a standard Z-test for
Protected by copyright.
the equality of the MedsCheck programme between
those filling a new high-risk medication and those not
filling a new high-risk medication. We similarly tested
the equality of the effect of late receipt of MedsCheck
(vs no MedsCheck) and the effect of early receipt of
MedsCheck (vs no MedsCheck).
Significance was defined as p<0.05 and all hypoth-
esis testing was two-tailed. All analyses were performed
in SAS software, V.9.4 (SAS Institute, Cary, North
Carolina, USA).
Sensitivity analysis
In response to editor feedback, we re-analysed all
outcomes using a modified strategy. We incorporated
pharmacy-specific random effects into the propensity
score model, which effectively brought the propen-
sity scores of patients presenting to the same phar-
macy closer together. We then matched MedsCheck
recipients and controls using the same approach as in
our main analysis. Due to residual imbalance between
matched groups on the proportion of patients filling
their prescription at a high MedsCheck volume phar-
macy, this variable was added as an additional hard-
matching criterion.
Results
We identified 1840  288 discharges eligible for
MedsCheck. Among these, 29  763 (1.6%) were
excluded due to a prior outcome, and 2748 (0.1%)
were excluded because of MedsCheck receipt after
discharge but prior to their eligibility date (online
supplementary eFigure 1). Patients excluded in each
3
Original research
step were compared with the remaining patients
in eTables 6 and 7. From the remaining 1807 777
hospital discharges, we selected the first discharge per
patient, resulting in a sample of 879 497 patients. Of
these, 77 459 (8.8%) received a MedsCheck within
14 days of hospital discharge. Before propensity score
matching, patients receiving a MedsCheck differed
from those not receiving a MedsCheck (online
supplementary eTable 8). The greatest differences
were in the median year of discharge (MedsCheck
2013 vs 2011, Std Diff 66%), the proportion with a
Charlson Score of 0 (MedsCheck 27.8% vs 38.3%,
Std Diff 22%), the proportion admitted electively
(MedsCheck 15.9% vs 30.1%, Std Diff 34%), and
the median length of hospital stay (MedsCheck 5
days vs 4 days, Std Diff 28%).
Characteristics of propensity score-matched cohort
Of patients receiving MedsCheck, 87% (n=67 163)
were successfully matched to a control subject.
Unmatched MedsCheck recipients are compared with
matched MedsCheck recipients in online supplemen-
tary eTable 9. Matched MedsCheck recipients were
similar in terms of all covariates to matched controls,
with no standardised difference exceeding 10%
(table 1). The greatest difference was in the proportion
of patients filling their prescription at a pharmacy in
the highest MedsCheck quartile (MedsCheck 42.6%
vs 39.1%, Std Diff 7%).
Outcomes
Those who received a MedsCheck after hospital
discharge were less likely to experience death or re-ad-
mission within 30 days (23.4% vs 23.9%, HR 0.97,
95% CI 0.95 to 1.00, p=0.02, table 2 and figure 1).
This was explained by a decreased risk of death (1.7%
vs 2.1%, HR 0.79, 95% CI 0.73 to 0.86, figure 2)
and rehospitalisation (11.0% vs 11.4%, HR 0.96,
95% CI 0.93 to 0.99, figure 3). We found no statisti-
cally significant difference in return to the emergency
department (22.5% vs 22.8%, HR 0.99, 95% CI 0.96
to 1.01, online supplementary eFigure 3).
There was no difference in adverse drug events
associated with MedsCheck status (1.5% vs 1.5%,
HR 1.03, 95% CI 0.94 to 1.12). MedsCheck recip-
ients had more outpatient visits than matched
controls (mean 2.11 vs 2.09, RR 1.01, 95% CI 1.00
to 1.02, p=0.02).
Subgroup analyses
Heart failure
Among the 8420 (6.3%) patients hospitalised for heart
failure, MedsCheck was not associated with any reduc-
tion in the composite outcome (MedsCheck 25.5%
vs 27.2%, HR 0.93, 95% CI 0.85 to 1.01, table 2).
However MedsCheck was associated with a reduced
4 Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
likelihood of death at 30 days (MedsCheck 2.1% vs
3.2%, HR 0.65, 95% CI 0.49 to 0.85). There was no
difference in rehospitalisation (MedsCheck 14.9% vs
15.5%, HR 0.95, 95% CI 0.86 to 1.07) or emergency
department visits (MedsCheck 24.5% vs 25.7%, HR
0.95, 95 % CI 0.87 to 1.03).
Among patients admitted for heart failure, there
was no difference in the risk of adverse drug events
between patients according to MedsCheck status
(MedsCheck 2.1% vs 1.7%, HR 1.24, 95% CI 0.91
to 1.69). MedsCheck recipients had more outpatient
visits than controls (mean MedsCheck 2.27 vs 2.18,
RR 1.04, 95% CI 1.00 to 1.07, p=0.03).
Chronic obstructive pulmonary disease
Among the 6168 (4.6%) patients hospitalised for
COPD, there was no association between receipt of
MedsCheck and the primary outcome of death or
re-admission (MedsCheck 22.3% vs 21.7%, HR 1.03,
95% CI 0.92 to 1.14) or any of the subcomponents
of death (2.0% vs 1.9%, HR 1.05, 95% CI 0.74 to
1.50), rehospitalisation (13.0% vs 12.3%, HR 1.06,
95% CI 0.92 to 1.22) or emergency department visit
(21.9% vs 20.9%, HR 1.05, 95% CI 0.94 to 1.17).
There was no difference in the risk of adverse drug
events between patients who did or did not receive a
Protected by copyright.
MedsCheck (MedsCheck 1.2% vs controls 1.3%, HR
0.88, 95% CI 0.56 to 1.38). MedsCheck recipients had
more outpatient visits than did controls (mean 1.78 vs
1.62, RR 1.10, 95% CI 1.05 to 1.14).
New high-risk medication
A total of 83 584 (62.2%) patients filled a prescription
for a new high-risk medication after discharge. Among
those patients who filled a new high-risk medication,
MedsCheck recipients had a lower rate of death or
re-admission (MedsCheck 24.1% vs 25.2%, HR 0.95,
95% CI 0.92 to 0.97, table 2). This was not the case
for those who did not fill a new high-risk medication
(MedsCheck 22.3% vs 21.7%, HR 1.03, 95% CI 0.99
to 1.07, p for interaction=0.0004, online supple-
mentary eTable 10) . Among those who filled a new
high-risk medication, MedsCheck recipients were at
reduced risk of each of emergency department visit
(MedsCheck 23.2% vs 24.0%, HR 0.96, 95% CI 0.93
to 0.98, p for interaction=0.0006), rehospitalisation
(MedsCheck 11.1% vs 11.9%, HR 0.93, 95%  CI
0.90 to 0.97, p for interaction=0.01) and death
(MedsCheck 1.8% vs 2.3%, HR 0.78, 95% CI 0.71 to
0.86, p for interaction=0.57).
Among patients filling a new prescription for a high-
risk medication, we found no difference in adverse drug
events between patients who did or did not receive a
MedsCheck (1.7% vs controls 1.6%, HR 1.06, 95% CI
0.95 to 1.18, p for interaction=0.34). There was no
difference in the count of outpatient visits between
MedsCheck recipients and controls (median 2.17 vs
 Original research

BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
Table 1  Comparison of characteristics of MedsCheck recipients and matched controls
Characteristic MedsCheck N=67 163 Controls N=67 163 Std. Diff. of means
Year of hospital discharge, median (IQR) 2013 (2011–2015) 2013 (2011–2015) 0.03
Age at hospital discharge, median (IQR) 76 (70–82) 76 (70–83) 0.01
Female sex, n (%) 31 554 (47.0) 31 389 (46.7) 0
Rural residence, n (%) 9455 (14.1) 9672 (14.4) 0.01
Does not speak French or English, n (%) 2688 (4.0) 2515 (3.7) 0.01
Charlson Comorbidity Score, n (%)  
 0 18 379 (27.4) 17 638 (26.3) 0.02
 1 20 460 (30.5) 21 359 (31.8) 0.03
 2 11 942 (17.8) 11 644 (17.3) 0.01
 3 9005 (13.4) 9300 (13.8) 0.01
 4+ 7377 (11.0) 7222 (10.8) 0.01
Nearest census-based neighbourhood income quintile
 Missing 230 (0.3) 230 (0.3) 0
 1 13 244 (19.7) 13 123 (19.5) 0
 2 14 047 (20.9) 14 110 (21.0) 0
 3 13 270 (19.8) 13 297 (19.8) 0
 4 13 665 (20.3) 13 624 (20.3) 0
 5 12 707 (18.9) 12 779 (19.0) 0
Arrival by ambulance, n(%) 26 259 (39.1) 26 638 (39.7) 0.01
Elective admission, n(%) 10 805 (16.1) 10 073 (15.0) 0.03
Length of stay, median (IQR) 5 (3–9) 5 (3–9) 0.05
Most responsible diagnosis, n (%)    

Protected by copyright.
 1-Infectious Diseases 1414 (2.1) 1399 (2.1) 0
 2-Neoplasms 3561 (5.3) 4153 (6.2) 0.04
 3-Diseases of the blood 685 (1.0) 671 (1.0) 0
 4-Endocrine 2120 (3.2) 1542 (2.3) 0.05
 5-Mental and behavioural 1051 (1.6) 812 (1.2) 0.03
 6-Nervous system 1424 (2.1) 962 (1.4) 0.05
 7-Eye 65 (0.1) 66 (0.1) 0
 8-Ear 128 (0.2) 93 (0.1) 0.01
 9-Circulatory 30 223 (45.0) 30 223 (45.0) 0
 10-Respiratory 6452 (9.6) 6490 (9.7) 0
 11-Digestive 4171 (6.2) 4829 (7.2) 0.04
 12-Skin 461 (0.7) 462 (0.7) 0
 13-Musculoskeletal 4264 (6.3) 4514 (6.7) 0.02
 14-Genitourinary 3008 (4.5) 2901 (4.3) 0.01
 17-Congenital 36 (0.1) 15 (0.0) 0.02
 18-Symptoms and findings not otherwise specified 3998 (6.0) 3998 (6.0) 0
 19-Injury/poisoning 2276 (3.4) 2565 (3.8) 0.02
 21-Factors influencing health status 1826 (2.7) 1468 (2.2) 0.03
Discharged on a weekend, n (%) 24 534 (36.5) 23 941 (35.6) 0.02
Discharged against medical advice, n (%) 191 (0.3) 147 (0.2) 0.01
Discharged with home care services, n (%) 20 493 (30.5) 20 143 (30.0) 0.01
Discharging hospital type, n (%)    
 Teaching 18 001 (26.8) 18 466 (27.5) 0.02
 Small community 2530 (3.8) 2593 (3.9) 0
 Medium/large community 44 997 (67.0) 44 252 (65.9) 0.02
 Rural 4186 (6.2) 4310 (6.4) 0.01
Home care support services in previous year, n (%) 4772 (7.1) 4630 (6.9) 0.01
At least one physician home visit in previous year, n (%) 2094 (3.1) 2040 (3.0) 0
Outpatient physician visits in previous year, median (IQR) 10 (5–15) 9 (5–15) 0.02
Dementia diagnosis or medication in previous year, n (%) 3911(5.8) 3814(5.7) 0.01
Continued

Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545 5

 Original research

BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
Table 1 Continued
Characteristic MedsCheck N=67 163 Controls N=67 163 Std. Diff. of means
MedsCheck in previous year, n (%) 26 790 (39.9) 25 327 (37.7) 0.04
Emergency department visits in previous 6 months, median 0 (0–1) 0 (0–1) 0.01
(IQR)
Pharmacies visited in previous year, median (IQR) 1 (1–2) 1 (1–2) 0.01
Outpatient physicians seen in previous year, median (IQR) 4 (3–6) 4 (3–6) 0.03
At least one elective hospitalization in previous year, n(%) 1925 (2.9) 1929 (2.9) 0
At least one urgent hospitalization in previous year, n (%) 5887 (8.8) 5653 (8.4) 0.01
At least one adverse drug reaction in previous year, n (%) 4317 (6.4) 4271 (6.4) 0
Number of medications in previous year, median (IQR) 9 (5–13) 9 (5–12) 0.04
Number of high risk medications in previous year, median 2 (1–4) 2 (1–4) 0.02
(IQR)
Number of potentially inappropriate medications in 0 (0–1) 0 (0–1) 0.01
previous year, median (IQR)
Number of new medications filled after discharge, median 3 (1–4) 3 (1–4) 0.03
(IQR)
At least one new high risk medication filled, n (%) 41 792(62.2) 41 792(62.2) 0
At least one new potentially inappropriate medication 4910 (7.3) 4828 (7.2) 0
filled, n (%)
New pharmacy, n (%) 6627 (9.9) 6995 (10.4) 0.02
Pharmacy MedsCheck volume/ total volume quartile, n (%)
 1 4412(6.6) 4855 (7.2) 0.03
 2 13 808 (20.6) 15 019 (22.4) 0.04
 3 20 358 (30.3) 21 005 (31.3) 0.02

Protected by copyright.
 4 28 585 (42.6) 26 284(391) 0.07
Std Diff, standardised difference of means.

2.15, RR 1.01, 95% CI 1.00 to 1.02, p=0.27, p for 0.99 to 1.01, Late RR 1.03, 95% CI 1.01 to 1.05, p
interaction=0.32). for interaction=0.016).

Early or late receipt of MedsCheck Sensitivity analysis: pharmacy random-effects model

Among MedsCheck recipients, 51  575 (76.8%)
received the intervention early, that is within 2 days of
discharge. Compared with later recipients and controls,
early recipients and controls had fewer comorbidities,
longer length of stay, were more likely to be diagnosed
with a circulatory condition or symptoms not other-
wise specified, had fewer previous outpatient physi-
cian visits and medications, but more new medications
and new high-risk medications (online supplementary
eTable 11).
Early MedsCheck recipients were at reduced risk
of death or re-admission (24.5% vs 25.3%, HR 0.96,
95% CI 0.94 to 0.98, online supplementary eTable
12), unlike late recipients (19.9% vs 19.3%, HR 1.04,
95% CI 0.99 to 1.09, online supplementary eTable
13, p for interaction=0.007). Early recipients were at
reduced risk of return to the emergency department
(23.6% vs 24.1%, HR 0.97, 95% CI 0.95 to 0.99),
whereas late recipients were at increased risk of return
to the emergency department (19.1% vs 18.2%, HR
1.05, 95% CI 1.00 to 1.05, p for interaction=0.005).
Late recipients were also more likely than early recip-
ients to have a MedsCheck-associated increase in
outpatient physician visits (Early RR 1.00, 95% CI
Incorporating pharmacy-level random effects into the
propensity score model modified our results in several
ways. We successfully matched 1: 1 63 207 (82%)
MedsCheck recipients to controls. MedsCheck receipt
was no longer associated with a decreased rate of the
composite outcome of death or re-admission (HR 0.99,
95% CI 0.96 to 1.01) or a decrease in rehospitalisation
(HR 0.97, 95% CI 0.94 to 1.01), however, it was still
associated with a decreased rate of death alone (HR
0.82, 95% CI 0.75 to 0.89). There was no change in
the results for adverse drug events or outpatient physi-
cian visits (online supplementary eTable 14).
Discussion
Among eligible older patients filling a prescription after
discharge from hospital, receipt of MedsCheck was
associated with a small decrease in the rate of death or
re-admission over 30 days, driven by decreases in the
rate of death and rehospitalisation. Patients admitted
for heart failure had a decreased rate of death if they
received a MedsCheck, though there was no difference
in re-admission. There was no difference in death or
re-admission for patients with COPD. Patients filling
a prescription for a new high-risk medication had a

6 Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545

 Original research

BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
Table 2  Comparison of outcomes in the matched sample at 30 days, for all patients and subgroups
MedsCheck, Controls,
n (%) n (%) Risk difference,
Total N=67 163 Total N=67 163 % (95% CI) HR (95% CI)
All patients
Death or re-admission 15 723 (23.4) 16 057 (23.9) 0.5 (0.0 to 1.0) 0.97 (0.95 to 1.00) p=0.02
 Death 1126 (1.7) 1421 (2.1) 0.4 (0.3 to 0.6) 0.79 (0.73 to 0.86)
 Rehospitalisation 7387 (11.0) 7642 (11.4) 0.4 (0.0 to 0.7) 0.96 (0.93 to 0.99)
 Return to ED 15 135 (22.5) 15 287 (22.8) 0.2 (−0.2 to 0.7) 0.99 (0.96 to 1.01)
Secondary outcomes        
 Time to adverse drug event 1008 (1.5) 981 (1.5) 0.0 (−0.2 to 0.1) 1.03 (0.94 to 1.12)
 30-day count of outpatient 2 (1–3) 2 (1–3) – Risk ratio
physician visits, median (IQR) 1.01 (1.00 to 1.02) p=0.02
Subgroup: Admission main diagnosis of heart failure
MedsCheck
n (%), Controls
Total n (%), Risk difference, %
  N=4210 Total N=4210 (95% CI) HR (95% CI)
Death or re-admission 1072 (25.5) 1146 (27.2) 1.8 (−0.1 to 3.6) 0.93 (0.85 to 1.01)
 Death 87 (2.1) 134 (3.2) 1.0 (0.4 to 1.8) 0.65 (0.49 to 0.85)
 Rehospitalisation 628 (14.9) 653 (15.5) 0.6 (−0.9 to 2.1) 0.95 (0.86 to 1.07)
 Return to ED 1032 (24.5) 1082 (25.7) 1.2 (−0.7 to 3.0) 0.95 (0.87 to 1.03)
Secondary outcomes        
 Time to adverse drug event 89 (2.1) 72 (1.7) −0.4 (−1.0 to 0.0) 1.24 (0.91 to 1.69)
 30-day count of outpatient 2 (1–3) 2 (1–3) – Risk ratio

Protected by copyright.
physician visits, median (IQR) 1.04 (1.00 to 1.07) p=0.03
Subgroup: Admission main diagnosis of COPD
Controls
MedsCheck n (%), n (%),
Total Total Risk difference, %
  N=3084 N=3084 (95% CI) HR (95% CI)
Death or re-admission 689 (22.3) 670 (21.7) −0.6 (−2.7 to 1.5) 1.03 (0.92 to 1.14)
 Death 62 (2.0) 59 (1.9) −0.1 (−0.8 to 0.6) 1.05 (0.74 to 1.50)
 Rehospitalisation 400 (13.0) 378 (12.3) −0.7 (−2.4 to 0.9) 1.06 (0.92 to 1.22)
 Return to ED 674 (21.9) 644 (20.9) −1.0 (−3.0 to 1.2) 1.05 (0.94 to 1.17)
Secondary outcomes        
 Time to adverse drug event 36 (1.2) 41 (1.3) 0.2 (−0.4 to 0.7) 0.88 (0.56 to 1.38)
 30-day count of outpatient 1 (1–2) 1 (1–2) – Risk ratio
physician visits, median (IQR) 1.10 (1.05 to 1.14)
Subgroup: New high-risk medication filled after discharge
MedsCheck Controls
n (%), n (%),
Total Total Risk difference, %
  N=41 792 N=41 792 (95% CI) HR (95% CI)
Death or re-admission 10 070 (24.1) 10 550 (25.2) 1.2 (0.6 to 1.7) 0.95 (0.92 to 0.97)
 Death 732 (1.8) 939 (2.3) 0.5 (0.3 to 0.7) 0.78 (0.71 to 0.86)
 Rehospitalisation 4656 (11.1) 4960 (11.9) 0.7 (0.3 to 1.2) 0.93 (0.90-.97)
 Return to ED 9691 (23.2) 10 039 (24.0) 0.8 (0.3 to 1.4) 0.96 (0.93 to 0.98)
Secondary outcomes        
 Time to adverse drug event 697 (1.7) 659 (1.6) −0.1 (−0.3 to 0.1) 1.06 (0.95 to 1.18)
 30-day count of outpatient 2 (1–3) 2 (1–3) – 1.01 (1.00 to 1.02) p=0.22
physician visits
COPD, chronic obstructive pulmonary disease; ED, emergency department.

Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545 7

 Original research
Figure 1  Kaplan-Meier curve of time to death or re-admission. Note:
y-axis has been truncated for better visualisation.
decreased rate of death or re-admission if they received
a MedsCheck, driven by an increased rate of all three
subcomponents: emergency department visits, rehos-
pitalisation and death. MedsCheck received within 2
days of discharge was associated with a decrease in the
risk of death or re-admission. Receipt of MedsCheck
was also associated with a small increase in outpatient
physician visits in the whole cohort, as well as for the
heart failure, COPD and late presentation subgroups.
The low rates of MedsCheck (9%) for eligible
patients in our study suggests that there may be chal-
lenges with current programme implementation.43 In
addition, low rates of MedsCheck suggest that recipi-
ents may be highly selected.28 We could not distinguish
which patients declined to receive a MedsCheck and
which were simply not offered the service despite being
eligible. Furthermore, we have no data on how much
the variation in MedsCheck delivery relates to these
factors. Although we accounted for differences in base-
line healthcare usage, MedsCheck recipients might be
more likely to seek care or engage in self-management.
The increased rate of outpatient visits in MedsCheck
recipients is consistent with this explanation. It is also
possible that receipt of MedsCheck triggers outpatient
visits to follow-up on identified medication-related
issues.
We noted that late MedsCheck was associated with
increased physician and emergency department visit
but no reduction in death or re-admission, unlike
early receipt of MedsCheck. It is possible that early
MedsCheck is more effective at preventing adverse
medication events, and that late MedsCheck triggers
Figure 2  Kaplan-Meier curve of time to death. Note: y-axis has been
truncated for better visualisation.
8 Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
Figure 3  Cumulative incidence curve of time to urgent rehospitalisation.
increased visits as adverse events are detected. Alter-
natively, late-presenting patients may be sicker, and
more likely to experience a worse outcome regardless
of MedsCheck receipt.
Postdischarge medication review has been included
as one component of several bundled transitional care
interventions. Such multifaceted interventions have
led to reductions in re-admission rates.9 44 45 However,
a recent systematic review reported that communi-
ty-based medication reconciliation interventions did
not on their own reduce the risk of re-admission after
hospital discharge.15 Included interventions were
mainly delivered by phone or in outpatient clinics.
Protected by copyright.
The only study conducted in a community pharmacy
setting did not report re-admission rates.46 We identi-
fied one additional study conducted in a community
pharmacy that reported a reduction in re-admissions
(adjusted OR 0.07, 95% CI 0.01 to 0.63) for patients
choosing medication review instead of usual care.47
These results were likely affected by immortal time
bias since the outcome was measured from discharge,
not from the time of intervention.
How MedsCheck might reduce the risk of death is
uncertain. We found that patients filling a new high-risk
medication did better if they received a MedsCheck,
despite no corresponding difference in adverse drug
events. One explanation may be that adverse drug
event hospitalisation or emergency department visit
codes are specific yet insensitive for medication-related
complications. Consistent with this, the overall rate
of adverse drug events in our study was considerably
lower than reported in chart review-based studies.1 2 6
When directly measured, others have found that tran-
sitional care interventions can reduce adverse drug
events.48 MedsCheck may also improve adherence,
resulting in increased clinical stability. That a benefit
was observed in the subgroup with heart failure but
not those with COPD could point to differences in
the effect of medications on each condition’s disease
trajectory.
Our study was population-based and benefited from
multiple linked health administrative databases. As
a result, we were able to account for differences in
sociodemographic characteristics, previous healthcare
usage, hospitalisation and pharmacy characteristics,

as well as medication usage profiles. We included
several variables to account for factors affecting the
likelihood of receiving a MedsCheck. This included
history of dementia, language ability and markers of
decreased mobility (use of home care and physician
home visits). We also accounted for discharge year
since MedsCheck use has increased over time.19 To
minimise immortal time bias, we carefully aligned
follow-up periods between recipients and controls.
To ensure comparability of patient groups, we limited
our selection criteria to patients over age 66 years who
would be eligible for MedsCheck. The age criterion
was necessary to obtain medication histories for the
year prior to hospital discharge as medication data are
incomplete for other age groups. Our study findings
are thus limited to elders, and MedsCheck may have
different associations in younger patients.
While our propensity score-matched design
accounted for differences in previous healthcare usage,
residual confounding remains possible. In particular,
our findings of a moderate decrease in mortality with
no difference in emergency department visits suggests
that recipients may differ from controls in ways not
measured here. For example, reduced mobility after
discharge may prevent sicker patients from in-person
pharmacy attendance. While a caregiver can receive
medications on a patient’s behalf, MedsCheck can
only be provided to a caregiver with patient consent.
Further, a clinically deteriorating or frail patient may
have a caregiver pick up medications and be unlikely
to present in-person for a MedsCheck. Incorporating
pharmacy-level random effects into the propensity
score led to a dampening of several small associations.
This change could relate to reduced sample size or to
accounting for variation related to neighbourhood
or pharmacy-level practices. Nonetheless, it suggests
uncertainty about the magnitude and significance of
MedsCheck-related benefit. The potentially modest
benefits contrast with the scale and intensity of this
intervention, suggesting a need to modify MedsCheck
to enhance its impact. One possible strategy may be to
focus on high-risk groups, such as those filling a new
high-risk medication after discharge.
We did not include outcomes related to medication
adherence. In Ontario, 90-day medication dispensa-
tion necessitates a longer follow-up period to measure
drug adherence. This is further complicated by medica-
tion discontinuity occurring around the time of hospi-
talisation. As the health administrative databases do
not contain information on in-hospital medications,
we could not detect postdischarge primary non-ad-
herence.29 Comparing long-term adherence to medi-
cations initiated during hospitalisation is an area for
future research. In addition, MedsCheck is provided
throughout Ontario in community pharmacies of all
types. As a result, delivery likely varies across locations
and providers, with local practices contributing to any
potential effect of MedsCheck on recipients. Further,
Lapointe-Shaw L, et al. BMJ Qual Saf 2019;0:1–11. doi:10.1136/bmjqs-2019-009545
Original research
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009545 on 8 August 2019. Downloaded from http://qualitysafety.bmj.com/ on December 6, 2019 at Western Sydney University.
our findings may not be generalisable to other juris-
dictions where pharmacist payment models and prac-
tice organisation differ significantly from the Ontario
context.
In this study of patients filling a prescription after
hospital discharge, receiving a community pharmacy
medication review was associated with a small reduc-
tion in 30-day death or re-admission. Despite this,
patients receiving MedsCheck were no less likely to
return to hospital for an adverse drug event. In the
subgroup of patients filling a prescription for a new
high-risk medication, MedsCheck was associated with
fewer emergency department visits, hospitalisations
and deaths. Since selection for MedsCheck depends
on both pharmacist initiative and patient willing-
ness, our findings remain limited by the possibility of
residual confounding, as evidenced by dampening of
all observed associations in sensitivity analysis. There
is a need for randomised studies to evaluate the benefit
of community pharmacist-delivered medication review
on postdischarge outcomes, including medication
adherence.
Author affiliations
1
Medicine, University Health Network, Toronto, Ontario, Canada
2
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
3
Institute of Health Policy, Management and Evaluation, University of Toronto,
Protected by copyright.
Toronto, Ontario, Canada
4
ICES, Toronto, Ontario, Canada
5
Medicine, Sinai Health System, Toronto, Ontario, Canada
6
Institute of Health Policy, Management and Evaluation and Toronto General
Research Institute, University of Toronto, Toronto, Ontario, Canada
7
Department of Family and Community Medicine, Women’s College Hospital,
Toronto, Ontario, Canada
8
Family and Community Medicine, University of Toronto, Toronto, Ontario,
Canada
9
Peter Gilgan Centre for Research and Learning, Child Health Evaluative
Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
10
Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
11
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario,
Canada
Correction notice  This article has been corrected since it
published Online First.
Twitter  @LapointeShaw
Contributors  Study contributors: All authors had full access to
all of the data (including statistical reports and tables) in the
study and take responsibility for the integrity of the data and
the accuracy of the data analysis. Study guarantor: LL-S. Study
concept and design: all authors. Analysis and interpretation
of data: LL-S, PL. Drafting of the manuscript: LL-S. Critical
revision of the manuscript for important intellectual content:
all authors. Statistical analysis: LL-S, PL. Obtained funding:
CMB, LD. Study supervision: LD.
Funding  This study was funded by Open Pharmacy Evidence
Network, Canadian Patient Safety Institute, Ontario Ministry
of Health and Long-Term Care, Canadian Institutes of Health
Research. This work was also supported by ICES, which is
funded by annual grants from the Ontario Ministry of Health
and Long-Term Care (MOHLTC). The opinions, results and
conclusions reported in this paper are those of the authors and
are independent from the funding sources.
Competing interests  LL-S reports support from a CIHR
Fellowship Award (FRN 146714), and the Philipson Scholar
program at the University of Toronto. PCA is supported
9
 Original research
by a Mid-Career Investigator award from the Heart and
Stroke Foundation. NMI reports support from CIHR and
the Ontario Ministry of Health and Long-Term Care. DAR
reports support from a Canada Research Chair in Medical
Decision Science. CMB reports support from the Department
of Medicine at the University of Toronto and Sinai Health
System. None of these organisations had any involvement in
the design and conduct of the study; collection, management,
analysis and interpretation of the data; preparation, review
or approval of the manuscript; and decision to submit the
manuscript for publication. Parts of this material are based on
data and information compiled and provided by the Canadian
Institute for Health Information (CIHI) and Immigration,
Refugees and Citizenship Canada (IRCC). However, the
analyses, conclusions, opinions and statements expressed
herein are those of the authors, and not necessarily those of
ICES, MOHLTC, CIHI or the IRCC. No endorsement by
ICES, MOHLTC, CIHI or the IRCC is intended or should
be inferred. The named organisations and funding bodies
had no involvement in the design and conduct of the study;
collection, management, analysis and interpretation of the
data; preparation, review or approval of the manuscript; and
decision to submit the manuscript for publication.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally
peer reviewed.
Data availability statement  Data may be obtained from a third
party and are not publicly available.
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