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What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study
  1. Jeffrey L Schnipper1,2,3,
  2. Harry Reyes Nieva1,2,
  3. Catherine Yoon1,
  4. Meghan Mallouk4,
  5. Amanda S Mixon5,6,7,
  6. Stephanie Rennke8,
  7. Eugene S Chu9,
  8. Stephanie K Mueller1,2,3,
  9. G Randy Smith Jr10,
  10. Mark V Williams11,
  11. Tosha B Wetterneck12,
  12. Jason Stein13,
  13. Anuj K Dalal1,2,3,
  14. Stephanie Labonville14,
  15. Anirudh Sridharan15,
  16. Deonni P Stolldorf6,16,
  17. Endel John Orav1,17,
  18. Marcus Gresham1,
  19. Jenna Goldstein4,
  20. Sara Platt4,
  21. Christopher Tugbéh Nyenpan4,
  22. Eric Howell18,19,
  23. Sunil Kripalani5,7
  24. MARQUIS2 Site Leaders for the MARQUIS2 Study Group
    1. 1 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
    2. 2 Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
    3. 3 Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
    4. 4 Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
    5. 5 Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    6. 6 Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
    7. 7 Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    8. 8 UCSF Health and Department of Medicine, Division of Hospital Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
    9. 9 Parkland Health and Hospital System and Hospital Medicine Service, Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, USA
    10. 10 Division of Hospital Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois, USA
    11. 11 Division of Hospital Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
    12. 12 Department of Medicine, Center for Quality and Productivity Improvement, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin, USA
    13. 13 Section of Hospital Medicine, Emory University Hospital and 1Unit, Atlanta, Georgia, USA
    14. 14 Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
    15. 15 Department of Medicine, Howard County General Hospital, Columbia, Maryland, USA
    16. 16 School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
    17. 17 Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
    18. 18 Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
    19. 19 Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
    1. Correspondence to Dr Jeffrey L Schnipper, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St, BC-3, Boston, MA 02120-1613, USA; jschnipper{at}


    Background The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.

    Methods This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2–5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.

    Results Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75–0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).

    Conclusion and relevance Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

    • medication reconciliation
    • medication safety
    • pharmacists
    • quality improvement

    Data availability statement

    Data are available upon reasonable request.

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    • Twitter @drjschnip, @harryreyesnieva, @DrStephMueller, @tweet_akdMD, @research_dee, @chrisnyenpan

    • Collaborators MARQUIS2 Site Leaders: Sanchita Sen, SamerBadr, Michelle Murphy, Corrie Vasilopoulos, Tara Vlasimsky, Christine Roussel, Olugbenga Arole, Loredana Diana Berescu, Arif Arifuddowla, Hattie Main, Susan Pickle, Cristy Singleton, Brenda Asplund, Andrea Delrue, Andrea Forgione, Colleen Shipman, Luigi Brunetti, Hina Ahmed, Adrian Gonzales, MithuMolla, Sarah Bojerek, Andrea Nguyen, Robert El-Kareh, Kyle Koenig, Loutfi Succari, Scott Kincaid, Pamela Proctor, Robert Pendleton, Amy Baughman, Kimberly Boothe, Katarzyna Szablowski, Olukemi Akande, Eric Tichy. MARQUIS2 Study Group: Chi Zheng, Ryan Centafont, Regina Jahrstorfer, Lisa Jaser, Isha John, Margaret Curtin, Jenna Swindler, Joe Marcus, Robert Osten, Tian Yaw, Zainulabdeen Al-Jammali, Nancy Doherty, Brandi Hamilton, Magdee Hugais, Samson Lee, Paul Sabatini, Eddie Eabisa, Jennifer Mello, Julianna Burton, Edward Fink, Anthony Biondo, Trina Huynh, Ken Kormorny, Adonice Khoury, Kathryn Ruf, Dwayne Pierce, Chadrick Lowther, Karli Edholm, Shantel Mullin, Nicole Murphy, Jeni Norstrom, Laura Driscoll, Maribeth Cabie, Andrew Cadorette, Sara John, Amy D’Silva and Lionel Picot-Vierra.

    • Contributors All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline, individually or as a group. JLS is the guarantor of the study, accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding This study was supported by the Agency for Healthcare Research and Quality (R18HS023757).

    • Competing interests JLS and ASM received remuneration from American Society of Health-System Pharmacists (ASHP) to develop their best possible medication history training curriculum. JLS received funding from Synapse Medicine for an investigator-initiated study to evaluate the effects of their medication decision support software on hospital pharmacists’ medication recommendations.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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