Facilitating the transfer of care from secondary to primary care: a scoping review to understand the role of pharmacists in general practice

Background Limited published research exists on the role of pharmacists in general practice (primary care pharmacists) in facilitating post-hospital discharge care of patients. Aim To summarise and map the nature and extent of current evidence on the role of primary care pharmacists in facilitating patient discharge from secondary to primary care and to inform future practice and research. Method Six electronic databases were systematically searched from inception to March 2022 for studies published in the English language that described and/or evaluated primary care pharmacist-led interventions for patients following hospital discharge. Grey literature and reference lists of included studies were also searched. Two authors independently screened articles for selection. A structured, pilot-tested form was used for data extraction. Results Twenty articles were included. The majority of studies (n = 17; 85%) were conducted in the USA. The most frequently reported intervention made by primary care pharmacists were medication reviews (n = 18) and medication reconciliation (n = 16). Studies have demonstrated the emerging roles of pharmacists involving collaboration with other healthcare professionals, review of laboratory monitoring, referrals, and follow-up. A wide range of outcomes such as the impact on hospital readmission rates, healthcare utilisation and reduction of potential adverse drug events were reported. Conclusion Pharmacists in general practice can offer a range of interventions in facilitating transfer of care of patients from secondary to primary care with positive patient and healthcare utilisation outcomes. However, more rigorous research evidence is required to establish the effectiveness, generalisability, acceptability, and sustainability of these services. Supplementary Information The online version contains supplementary material available at 10.1007/s11096-023-01547-3.


Introduction
Research suggests that patients will have, on average, 4.4 drug changes upon hospital discharge [1] and 50% of adult patients experience medication errors or unintentional medication discrepancies during this transition [2]. This is a wellknown risk factor for medication-related harm, a significant burden on healthcare systems globally and identified as a national and global priority area for quality improvement [3,4]. It is estimated that 74% of potentially avoidable costs are attributed to medication prescribed at hospital discharge [5,6] and medication being one of the three main causes of potentially preventable 30-day hospital re-admissions [7]. Hospital discharge is often a very disruptive time for patients with many factors contributing to poor understanding and adherence of medications [8,9], increasing the risk to patient safety.
Much consideration in terms of research, policy and practice has been invested to achieve safer transition of care such as implementing digital transfer of information [3,10,11], and recognising the need for timely intervention pathways post-discharge [12]. Nonetheless, medication management during transitions remains a significant problem, especially for the most vulnerable patients [13,14].
Pharmacists in collaboration with patients, other healthcare professionals and/or carers [15], can play an important role to support safe and effective medicines-related continuity of care [15,16]. Many studies have evaluated the impact of pharmacist interventions such as medicines reconciliation [16][17][18], and medication reviews [19], in hospital and community pharmacy settings. Many systematic reviews and meta-analyses to date have reported limitations with poor and inconsistent descriptions of pharmacist interventions in such studies [17][18][19][20][21]. Some systematic reviews on medicines reconciliation in the primary care sector do not differentiate between the role of the primary care pharmacist (PCP) in a general practice setting or in a community pharmacy setting [17]. This nuance of where particular packages of care are delivered and by whom they are delivered are important pieces of contextual information about intervention implementation and delivery and crucial to better understanding of how, and why an intervention works or not [22].
Clinical pharmacy practice is evolving at pace around the world [23,24]. Primary care is experiencing unprecedented pressures in patient health-seeking behaviours but also in managing a backlog following the COVID-19 pandemic [25,26]. There is an accelerated training and mobilisation of pharmacists into general practice to increase capacity in this sector in the UK [27][28][29]. Healthcare systems continue to identify roles and responsibilities for these pharmacists and their involvement in hospital discharge care is highly likely [28,29].
This scoping review sought to explore the role of PCPs in the transfer of care of patients from hospital back home to ensure ongoing policy, practice and research is informed by current evidence. PCPs for the purpose of this review are defined as pharmacists working in a general practice setting, not in community pharmacy or hospital settings.

Aim
To map the nature and extent of current evidence on the role of PCPs in facilitating patient discharge from secondary to primary care.

Objectives
• To identify literature that investigates the role of primary care pharmacists in patients' post-hospital discharge care. • To identify what study designs and types of interventions carried out by PCPs and what outcomes have been researched in post-discharge care. • To synthesise research evidence and identify gaps in literature to inform future practice and research.

Method
A scoping review was identified as the most appropriate methodology to map the extent and nature of research undertaken on the role of PCPs post-hospital discharge and identify knowledge gaps to inform future research [30,31]. This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [32] and a pre-defined published protocol [33].

Eligibility criteria
This scoping review aimed to include all published primary studies using both observational (e.g., case control, cohort) and experimental (e.g., randomised controlled clinical trials, quasi-experimental) methodologies. Articles were excluded if they primarily involved interventions for hospital in-patients, outpatient clinics, or home medication reviews. Studies involving paediatric and oncology patients were also excluded. Conference abstracts, protocols and case reports were excluded as these were deemed to provide limited evaluative benefit. The eligibility of studies was guided by the Population, Concept and Context (PCC) mnemonic as recommended by the JBI guidelines for scoping reviews [32].

Participants
Adult patients (aged 18 or above) recently discharged from hospital and had an intervention by a PCP, regardless of the outcome assessed, the profile of patients included or the clinical diagnosis on admission.

Concept
Articles must report interventions led by PCP for patients recently discharged from hospital.

Context
This review aimed to summarise PCP interventions carried out in a primary care/ general practice setting.

Search strategy
A comprehensive literature search was undertaken (Supplementary File 1) with the support of a medical research librarian and followed a three-step search strategy as per JBI guidelines [34]. Firstly, an initial limited search on the topic was undertaken in MEDLINE, Cochrane Library and Cumulated Index to Nursing and Allied Health Literature (CINAHL Plus). The text words contained in the titles and abstracts and index terms of relevant articles were used to develop a full search strategy. Secondly, a full systemised search strategy was conducted using MEDLINE, EMBASE, PubMed, Cochrane central register of controlled trials ( All identified articles were collated into an online research tool (Rayyan) [35] and duplicates were removed. Titles and abstracts were screened for eligibility by two independent reviewers (FY and MAH) before full-text screening was undertaken. Cases of disagreement were resolved via discussion or obtaining the full text. If it was still unclear if eligibility criteria were met, a third independent reviewer (HN) was contacted. For full texts that could not be retrieved, corresponding authors were emailed to request the full text of the article. If after this stage, the full text could not be retrieved then these articles were excluded. This was to ensure that only full papers were included for a comprehensive review. Reference lists of full texts included were then reviewed by one reviewer (FY) for further relevant articles.

Data charting
Data were extracted and charted using standardised forms that were piloted on the initial 16 included articles and reviewed by the research team. The data extracted were mapped to answer the key objectives of this scoping review. During the data charting of relevant studies, an inductive content analysis approach was followed to collate the results [36]. Data extracted included: author, year, country, study design, population, concept, context, aims, methodology, outcomes and key findings, financial impacts reported, errors reported, collaborations reported, barriers/facilitators reported, and research gaps identified.
No quality or risk of bias assessment was performed as scoping reviews traditionally do not seek to assess the quality of evidence unlike systematic reviews but rather map what research has been undertaken [37].

Data synthesis
A descriptive numerical and categorical analysis approach was undertaken to examine the extent, nature and distribution of papers included in the review. Key concepts relating to the review question(s) were collated in tabular format to identify themes and synthesise the findings. To classify and summarise the type of evidence available in this field and identify further research recommendations, the PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework [38] was subsequently followed to enhance consistency and methodological rigour.

Results
As shown in the PRISMA-ScR flow diagram (Fig. 1), the search retrieved 2271 publications. After removing duplicates (n = 915), titles and abstracts of 1764 articles were screened resulting in 42 full text articles being retrieved and reviewed for eligibility against inclusion and exclusion criteria. A grey literature search was undertaken as per the protocol and followed the same principles for screening. This yielded 11 articles for full-text screening and a citation-search of included full texts identified a further 8 studies, of which only 3 articles were suitable for inclusion. A total of 20 articles were subsequently included for the purpose of this review.

Identification of studies via databases and registers
Identification of studies via other methods

Included
Reports sought for retrieval Grey lit (n = 11) Articles from citations (n= 9) Reports not retrieved Unable to access full text (n=1) Reports to be included in review: Articles from citations (n=3) Fig. 1 Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) flow diagram to readmission (18 ± 9 days compared with 12 ± 9 days with usual care; P = 0.015) [56]. Several other studies showed a non-statistically significant reduction in re-admission risk [52] or readmission rates post-hospital discharge [40,43,46,48,51,[56][57][58]. Furthermore, there was no statistically significant difference in outcomes when the pharmacist intervention is delivered face-to-face or over the telephone [57].
The key outcomes with statistically significant results [41,43,44,47,48,50,54,[56][57][58], were mapped to the intervention to review whether there was a common theme amongst them (Table 3). Overall, only ten of the 20 studies reported statistical significance in outcomes and all of those included medication review as part of the intervention. The medication review with a pharmacist varied between face-to-face or telephone medication review and all were conducted within 2 weeks of discharge from hospital varying between 2 and 14 days. The main outcomes where the significant impact was seen were categorised as a reduction in healthcare utilisation, reduction in hospital readmission rates, a longer time to readmission, improved clinical outcomes and beneficial economic impacts.

Economic implications
From the 20 studies, eight studies (40%) reported on the financial impact of the intervention [39,43,44,50,51,54,56,57]. However, only four studies (20%) evaluated the actual cost-savings [43,44,54,56]. Evidence showed that there was a significantly lower total cost of care after pharmacist-clinician collaborative visits whilst also improving clinical outcomes [44]. One study showed an estimated incremental net benefit of $5054 per patient and after sensitivity analysis translated a benefit-cost ratio of 28:1 [43]. Kilcup et al. [54] estimated cost savings per 100 patients to be $35,000, equivalent to $1,500,000 in savings annually.

Collaborations with other healthcare professionals
Seventeen studies reported collaborations of primary care pharmacists with other healthcare professionals [39-44, 47-53, 55-58]. Contact was made with the hospital inpatient team or hospital pharmacists if the information was missing or required clarification. Often, where further support or supervision was required or the task was outside the pharmacists' scope of practice, patient's primary care physician was contacted through verbal, written or electronic approaches [42,52,53,55]. In some studies, a physician appointment immediately followed an appointment with the PCP [43,44,48,[51][52][53]. A team approach was often advocated in medicines-management during transitions of care [42,48,50,56,58]. In addition to collaboration between pharmacist and physicians, communication with community-based health coaches [47], care co-ordinators [40,58] and other healthcare providers [39,42,43,51,55,58,59] were also reported (Fig. 2).

Barriers and facilitators to PCP interventions
The main barriers identified in the studies were time demands in an already busy healthcare environment and lack of resources to provide the timely intervention. Most studies reported time to intervention of between three to seven days [39,51,52,54,56]. The time to deliver the intervention (clinic medication review with the pharmacist and documentation) substantially varied between studies and took between 45 and 90 min [39][40][41]55]. Other key barriers reported were: acceptability of the intervention by the patients [49,50,56], healthcare professionals' acceptability of recommendations [50,53] and lack of awareness of the role or benefits of pharmacists [50,53]. The potential financial impact on patients [54,57] and lack of adequate payment mechanisms/incentives within organisations [50,56], were also highlighted as possible barriers to interventions. In addition, systems and organisational barriers were reported which can be confounded by lack of accessibility to multiple electronic systems and accurate medication lists at discharge [40,51].
Facilitators for the intervention were the value that the pharmacist skills and roles can bring and the collaboration with other healthcare professionals [40,41]. This was recognised for complex cases during a multi-disciplinary team meeting and having a shared pharmaceutical care plan [41]. This shared care plan would enable continuity and easier access across sectors in addition to running the clinic from an established multi-disciplinary clinic to align care goals and also reduce costs [56]. One study by Slazak et al. [46] reported that having a registered nurse contact patients and complete the initial medicines reconciliation and then scheduling a follow-up visit with the pharmacist was a facilitator in the process. Furthermore, the flexibility to provide patients with a choice between face-to-face and telephone appointment was seen as a facilitator, although face-to-face visits assisted communications during transitions of care [40].

Discussion
This is the first review, to the authors' knowledge, that maps the extent and nature of the role of PCPs in a general practice setting, specifically post-hospital discharge. The contributions of pharmacists in the transition from secondary to primary care are heterogenous and outcome success rates have been variable. Evidence has shown that both medication review and medication reconciliation feature frequently Reduction of healthcare utilisation Reduction in ED presentation incidence during the 12 months following hospital discharge Freeman et al. [43] Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. (Medication review, medicines reconciliation, collaboration with other clinicians) At 12 months, ED presentation incidence was 54% lower for intervention than control patients and the composite measure of re-admission and ED presentation incidence was 31% lower. ED presentation incidence and combined re-admission and ED presentation incidence were significantly lower for intervention patients Reduction of acute care visits within 30 days All-cause 30-day readmission occurred significantly less often in patients followed by the CP

Reduction of readmission rates
Stranges et al. [56] Primary care based transitional care program (pharmacist phone call 2-4 days after discharge -medication reconciliation, medication review) then seen in clinic within 1-week post-discharge by a social worker and medical provider, team approach) When those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P

< .001)
Time to readmission Time to Readmission Wiegmann et al. [48] Follow-up clinic appointment within 14 days postdischarge (medication review, medication reconciliation and chronic disease management) Of the 100 patients included in the final analysis, time to readmission was longer in the intervention group versus standard of care group (52 vs 17 days, P = .026) Stranges et al. [56] Primary care based transitional care program (pharmacist phone call 2-4 days after discharge -medication reconciliation, medication review) then seen in clinic within 1-week post-discharge by a social worker and medical provider, team approach) Time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015)

Clinical outcomes Reduction in HgbA1c
Wiegmann et al. [48] Follow-up clinic appointment within 14 days postdischarge (medication review, medication reconciliation and chronic disease management) The average reduction in HgbA1c for patients with diabetes from discharge through the end of the 90-day follow-up period was greater in the CP intervention group versus the standard of care group Cost Improvement in total cost of care in medically complex patients Herges et al. [44] Medication Review-PCC (Pharmacist-clinician collaborative-(30-min visit with a pharmacist, followed immediately by a 30-min visit with a primary care clinician) Medically complex patients had a significantly lower total cost of care in approximately half of the adjusted cost quantiles at 30, 60, and 180 days after hospital discharge when they had a Pharmacist/Physician Collaborative (PCC) visit compared to usual care Cost benefit of the intervention Freeman et al. [43] Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. (Medication review, medicines reconciliation, collaboration with other clinicians) Estimates net cost benefit of the intervention was $5072 per patient, with a benefit-cost ratio of 31:1

Financial savings
Kilcup et al. [54] Telephone medication review 3-7 days post discharge Financial savings for Group Health per 100 patients who received medication reconciliation was an estimated $35,000, translating to more than $1,500,000 in savings annually Cost avoidance when intervention was completed Stranges et al. [56] Primary care based transitional care program (pharmacist phone call 2-4 days after discharge -medication reconciliation, medication review) then seen in clinic within 1-week post-discharge by a social worker and medical provider, team approach) Potential cost avoidance was observed only when the intervention was completed. Based on results of the as-treated analysis, Hospitalisation cost avoidance was estimated to be $737,673 among the 345 completed interventions, or $2138 per intervention as part of the PCP intervention which corresponds with evidence about pharmacists' roles more widely [16-18, 24, 63]. The PCP role is evolving to include other interventions such as: monitoring of laboratory results; management of longterm conditions and generating referrals to other health care professionals. There is growing evidence about the value of multi-disciplinary team approaches and collaborations with other practitioners to enable better patient care [25,27] and the continued need for improved communication between secondary and primary care during transition processes [66]. We have identified the emerging of the role of the PCP to date, however there are many areas that require further research as outlined in our PAGER framework (Table 4).
Whilst it is known generally that pharmacists can have positive impacts on patients' understanding of medications [60,61], patient satisfaction [26] and clinical outcomes [20], few studies have looked at this in relation to PCPs role posthospital discharge [48] and this would complement current research. Furthermore, the role of PCP involvement in motivational interviewing and adherence strategies [50] to reduce medication-related problems post-hospital discharge would be useful, especially in those cohorts who may experience poor health literacy or barriers to medication adherence. Few studies have evaluated economic impacts [43,44,54,56] of PCPs post-hospital discharge, however these have reported beneficial impacts at reducing costs indirectly as some health systems have applied payment penalties for high 30-day readmission rates [50,51,57,62]. These indirect cost implications and benefits of PCP involvement post-hospital discharge and in longer-term management should be further explored relevant to the respective healthcare system or certain cohorts of patients that would benefit (i.e. particular health conditions, high-risk medicines or those with specific needs like compliance aids). The lack of controlled studies and consistency in outcomes researched highlights the need for further high-quality research in this field to develop robust transition of care pathways relevant to local healthcare systems. Additionally, studies on a larger scale in different geographical locations to support wider generalisability and transferability of findings would be valuable. The identified barriers and facilitators are those commonly reported when considering the implementation of clinical services by pharmacists in primary care, including barriers to integration and lack of interoperability of digital systems [63]. Further systematic investigation of factors influencing practice would be helpful, particularly using lenses of behavioural and implementation science. This would enable designing or optimising future models of care or interventions that address the barriers and capitalise on the facilitators.

Limitations
The scoping review intended to map the evidence in this field, therefore does not allow for meta-analysis or critical  There is sparse evidence about the impact of PCP involvement on clinical outcomes post-hospital discharge Hospital readmission rates and healthcare utilization are relatively downstream impacts of a postdischarge intervention and are often challenging to attribute to a singular intervention. Impact on more proximal clinical outcomes would be more helpful to explore causal relationships between an intervention and an outcome More high-quality experimental/ quasi-experimental research to investigate the impact of PCP involvement in transitions of care on clinical outcomes and humanistic outcomes would be a significant contribution to inform policy and practice appraisal of the effectiveness of the interventions studied. During the scoping review, conference abstracts and studies relating to home-visits were excluded as per the protocol which may have limited our findings. As this review was primarily conducted to inform further research relevant to the UK population, a grey literature search of only UK professional organisations and websites was a limitation as we did not search for grey literature in other countries. Furthermore, the grey literature found articles that were not eligible due to the strict nature of the inclusion and exclusion criteria in the protocol relating to publication type and primary studies of an experimental or observational nature. This may have limited any audit, evaluation studies or case reports that have been carried out in clinical practice.

Conclusion
The scoping review allowed valuable mapping of the extent of research carried out on the role of primary care pharmacists during post-hospital discharge. It is apparent that there is an evolving scope of practice which could prove valuable to a primary care based multi-disciplinary team with positive effects on patient and healthcare utilisation outcomes. Our findings highlight the gaps in evidence to date to help inform future priorities and directions of research in this area, identifying that more rigorous research is needed to establish effectiveness and generalisability of primary care pharmacist interventions.

Acknowledgements
The authors would like to thank Birmingham Health Partners, Integrated Clinical Academic Research team who supported the funding of an Internship to do this piece of work. Special thanks to colleagues, peers and management at Our Health Partnership who supported us in carrying out this project.
Funding Open Access funding provided by the Qatar National Library. This work was supported by the award of a West Midlands Higher Education England Funded Writing Grant and the NMAHPs Integrated Clinical Academic Research Unit, Birmingham Health Partners.

Conflicts of interest
The authors have no conflicts of interests to declare.
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