Pharmacist Intervention Research Articles

Pharmacist Interventions and Medication Adherence of H. Pylori-Infected Patients: A Review of Randomized Controlled Studies

The Helicobacter pylori (H. Pylori) eradication regimen challenges patient medication adherence. Pharmacists play an essential role in supporting medication adherence to achieve treatment efficacy. This review aimed to evaluate the effect of pharmaceutical interventions on medication adherence in patients with H. Pylori infection taking eradication regimens. The literature was reviewed using Scopus, ScienceDirect, PubMed, and Google Scholar. Keywords included adherence, pharmacist intervention, H. Pylori, and eradication regimen. We collected original articles published in English from January 2002 to December 2022 describing pharmacist interventions to improve medication adherence in adult patients with H. Pylori infection We assessed adherence rates before and after the intervention. Two independent researchers extracted relevant data for the inclusion criteria and assessed the methodological quality of studies using the Joanna Briggs Institute Critical Appraisal Checklist Tools. A total of 413 articles were retrieved, of which six were eligible for review. The most common pharmacist intervention strategy was a combination of patient education with oral and written information provided. The findings suggest that pharmacist interventions support the improvement of medication adherence and highlight the role of pharmacist interventions in enhancing overall health outcomes. Further studies must assess the long-term effects and clinical outcomes of pharmacist interventions.

Value Assessment of Oncology Pharmacist Interventions.

A review of the published literature confirms the challenge in quantifying the value of oncology pharmacists. This editorial expands on a 2020 study by Meleis and colleagues published in the Journal of the Advanced Practitioner in Oncology and seeks to correlate pharmacist interventions to cost-saving and cost-avoidance measures to show the value of ambulatory oncology clinical pharmacists in patient care. A total of 4,686 interventions were reviewed. The 6-month intervention data demonstrate an annualized value of approximately $1.1 million dollars from nine ambulatory oncology clinical pharmacists showcasing the essential role of the clinical pharmacist in ambulatory oncology settings.

Pharmacist Intervention to Address Drug Related Problems in Patients with Decompensated Liver Cirrhosis

Background: Patients with decompensated cirrhosis are often given therapeutic and prophylactic drugs. Polypharmacy raises both the likelihood of prescription errors and the complications associated with drugs. Clinical pharmacists are excellent at recognizing, addressing, and preventing clinically significant drug-related problems. Objectives: Identification types of pharmacist interventions to address drug-related problems in patients with decompensated cirrhosis and assess the acceptance/implementation of these recommendations. And identify patient factors associated with accepting pharmacist recommendations. Subjects and Methods: Prospective, interventional, clinical study for 80 hospitalized decompensated cirrhosis patients was conducted at Baghdad Teaching Hospital and lasted for four months, from the first of December 2021 until the last of March 2022. The study involved two phases, the first one was observational to identify drug-related problems and classify them according to the Pharmaceutical Care Network Europe classification version 9.1, and the second phase was interventional to increase the awareness of patients and health care providers about those problems and to propose a proper solution for each one. Results: The most frequent pharmacist intervention was proposed to the prescriber (54.7%), followed by speaking to the caregiver (37.7%). Acceptance and full implementation were highly observed in 71.1% of the intervention. There is a significant association between occurring ascites and bleeding in patients and accepting/implementing pharmacist recommendations Conclusions: Patients with decompensated liver cirrhosis have a significant prevalence of drug-related problems. Clinical pharmacists are excellent at recognizing drug-related problems and reducing their incidence, and their interventions were well accepted.

A clinical pharmacist's intervention on interaction between meropenem and valproic acid in paediatric inpatient clinic: A case report

A clinical pharmacist's intervention on interaction between meropenem and valproic acid in paediatric inpatient clinic: A case report

국내 지역약국 약사의 약물관련문제에 관한 중재활동 현황

Community pharmacists have contributed to safe and effective drug treatment for patients by performing appropriate intervention activities to solve the drug-related problems (DRPs). This study aims to investigate the current status and evaluate interventions performed in community pharmacies. We evaluated DRP and pharmacist intervention activity (PIA) data obtained from a community pharmacy between August 9, 2021 and October 15, 2021 (10 weeks). Problems and causes of DRPs were classified according to Pharmaceutical Care Network Europe (PCNE) criteria, while PIAs were assessed by intervention types and conducted time-points. Economic outcomes from PIA were also estimated by cost avoidance and cost saving. During the ten-week period, a total of 6,576 prescriptions were submitted, and 754 cases of intervention were conducted. Among 754 PIA cases, 48.8% of them were performed via DUR alert, but 51.2% of PIAs were initiated via counseling or inspection by pharmacist without DUR alert. The acceptance rate of PIA by patients and prescription doctors reached to 93.4%. The net benefit cost converted to annual cost was estimated at ₩5,674,032. Various PIAs in community pharmacies run at various points from the moment the patient is prescribed to the end of treatment. To properly evaluate the clinical and cost-effective value for PIA of community pharmacy, constructing a database of information on DRPs and PIAs must be preceded.

Antiretroviral stewardship in a tertiary academic hospital: The need for a clinical pharmacist.

South Africa has the highest prevalence of people living with HIV globally. Although antiretroviral therapy provides solutions, evidence of antiretroviral resistance emerged, requiring the application of antiretroviral-stewardship programmes to curb medication-related problems. Identify and describe antiretroviral-stewardship pharmacist interventions in an active antiretroviral-stewardship programme. HIV-positive adults admitted to medical wards at a tertiary academic hospital in South Africa. A descriptive quantitative study was performed, utilising an antiretroviral-stewardship assessment tool to determine antiretroviral-related recommendations in the treatment of HIV-positive adults. The study employed purposive sampling. Treatment charts were evaluated to identify antiretroviral-stewardship recommendations. The number of recommendations highlighted the need for a clinical pharmacist in an active antiretroviral-stewardship programme. Descriptive data analysis with Pearson correlations was employed to display the data. Medication-related problems were identified in 100% of study patients (n = 41), with an average of 2.46 interventions per patient. One-hundred-and-one medication-related problems were identified by using the antiretroviral-stewardship assessment tool. The identified problems included a lack of viral load testing (41, 100%), lack of CD4 count monitoring (15; 36.6%) and lack of prophylactic treatment against opportunistic infections (10; 24.4%). Medication-related problems included the presence of clinically significant drug-drug interactions and serious side effects, CD4 count decline despite being on antiretroviral therapy, unnecessary treatment interruptions including risk for IRIS, inappropriate antiretroviral therapy regimen, non-adherence and absence of treating tuberculosis as co-morbidity. Present study demonstrates the need of an active antiretroviral-stewardship programme's benefits. The possible role of the clinical pharmacist as active participant and leader in this programme is highlighted. Highlight the role of clinical pharmacists in antiretroviral stewardship.

Impact of Medication Optimization and Recommendations by Clinical Pharmacists Embedded in a Memory Disorder Clinic (P3-7.005)

<h3>Objective:</h3> The purpose of this study is to determine the impact of pharmacist recommendations on reduction of potentially inappropriate medications (PIMs) in an older adult population with dementia or mild cognitive impairment (MCI). <h3>Background:</h3> Older adults with dementia or MCI are particularly vulnerable to adverse effects from PIMs. Many PIMs are anticholinergic medications which have been correlated with development of cognitive impairment in older adults. Previous studies have demonstrated that pharmacist interventions may reduce PIMs in older adults, but the impact of pharmacists embedded in an outpatient memory care clinic has not been adequately studied. <h3>Design/Methods:</h3> This prospective interventional study within an outpatient neurology center included patients at least 65 years old and diagnosed with dementia or MCI. Pharmacists utilized the American Geriatrics Society Beers Criteria, the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions, and the Anticholinergic Burden Scale (ACB) to identify PIMs and made recommendations to prescribers when appropriate based on clinical judgement. Primary outcomes included frequency and prevalence of PIMs before vs. after pharmacist intervention and rate of acceptance of pharmacy recommendations. Additional outcomes included ACB scores before vs. after intervention. <h3>Results:</h3> A total of 180 patients were included. Pharmacists made recommendations for 49% of patients. Common pharmacist recommendations included laboratory monitoring, medication discontinuations or substitutions. Out of 192 total pharmacist recommendations, 61 (32%) were accepted by providers within the neurology center’s memory clinic. After pharmacist intervention, the frequency and prevalence of PIMs as well as ACB scores were significantly reduced (p &lt; 0.01). <h3>Conclusions:</h3> Pharmacist intervention resulted in a significant reduction in PIMs and ACB scores in patients with dementia or MCI. Future studies should incorporate a prospective design to examine the clinical benefit of pharmacist intervention and explore additional methods to improve multidisciplinary collaboration between pharmacists and prescribers. <b>Disclosure:</b> Dr. Mattle has nothing to disclose. Miss Coli has nothing to disclose. Miss Lee has nothing to disclose. Dr. Aladeen has nothing to disclose. Dr. Ajtai has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen. Dr. Rainka has stock in Abbvie. Dr. Rainka has stock in acadia. Dr. Rainka has stock in alon. Dr. Rainka has stock in biogen. Dr. Rainka has stock in bristol myers squib. Dr. Rainka has stock in eisai. Dr. Rainka has stock in Lilly. Dr. Rainka has stock in novartis. Dr. Rainka has stock in pfizer. Dr. Rainka has stock in roche. Dr. Rainka has stock in Sage. Dr. Rainka has stock in alkermes.

Pilot programme for screening perimenopausal women for cardiovascular risk from community pharmacy: MENOVASC Project

Cardiovascular diseases have been the leading cause of death in the world for more than 20 years. They are generally unusual in premenopausal women due to the cardiovascular protection of endogenous estrogens, so the cardiovascular risk in these has traditionally been underestimated. Establish a protocol for vascular risk screening in perimenopausal women from the community pharmacy. Descriptive study from an opportunistic sample in a community pharmacy of women between 45 and 55 years old. Participants were cited at the pharmacy and their cholesterol and blood pressure levels, weight, and height were taken. Information was collected on women's general and specific cardiovascular risk factors, medication they were taking and smoking. These data were used to estimate cardiovascular risk using SCORE tables. 18 forms were collected, with the average age of the applicants being 49 (SD 3) years old. 38.9% (CI95%: 17.3 a 64.3) had high blood pressure and 44.4% (CI95%: 21.5 a 69.2) had cholesterol levels equal to or higher than 190 mg/ml. 100% had some traditional or specific risk factor for women. The usefulness of vascular risk screening in perimenopausal women is confirmed. All this places value on the intervention of the community pharmacist in the detection and management of cardiovascular risk factors.

Impact of clinical pharmacist interventions in a bone and joint infection orthoseptic surgery unit

To assess the impact of interventions of a clinical pharmacist in a unit of orthopedic surgery specialized in bone and joint infections. Daily, in routine, a clinical pharmacist analyzed medication prescribed to inpatients via a computerized physician order entry (CPOE) (Phedra software). His attention was particularly focused on the impact of antibiotics on other medications. For this study, all of the pharmacist interventions (PI) have been retrospectively collected, then anonymized, and assessed over a two-month period. Thirty-eight patients were hospitalized during the study period, with a mean age of 63 years old. Forty-five interventions were identified which represents a mean of 1.18 pharmaceutical interventions per patient. Most of them concerned lack of follow-up (24%) and drug-drug interactions (22%) and widely non-anti-infectious medication (35 interventions) with levothyroxine (10 interventions) as the most involved non-anti-infectious molecule. Among antibiotics, with respectively 9 and 8 interventions, rifampicin and fluoroquinolones (6 interventions for moxifloxacin) were the most concerned notably for drug-drug interactions with usual treatment. In this observational retrospective study, 1.18 pharmacist interventions (PI) per patient were observed. Most of them are lack of follow-up and drug-drug interactions especially with usual treatment of patients. Moxifloxacin and rifampicin were the most antibiotics involved. Patients' characteristics (older, polypharmacy), long-term hospitalization and surgery are known to be predictive factors of medication errors and this study highlights the importance of the presence of clinical pharmacist in orthopedic surgery wards.

Pharmaceutical intervention in the usage of inhalers with COPD patients that have an appointment in a health center to do an spirometry

Background: the usage of inhalers is something complex. This work with COPD patients pretends that, after the pharmacist intervention, the correct usage of these drugs is guaranteed so as to improve the quality of life. Methods: the nurse set a date to do an spirometry to the patients. On the other hand, the pharmacist assessed the usage of the inhalers and carried out the adherence and quality of life tests. Three months after, the patients came back to the consultation and the pharmacist repeated the same procedure to detect any possible change after the intervention. Results: on those patients that attended both appointments, it was seen that there were statistically significant changes between the adherence punctuation regarding both appointments. The average of punctuation is higher in the second appointment (49.09) in respect to the first one (46.45), this is a significant difference with a p&lt;0.05. The quality of life was the same in both appointments and the errors average in the usage of inhalators in the second appointment decreased (1773) significantly in respect to the errors average in the first appointment (4727). Conclusion: the intervention of a pharmacist in a multidisciplinary team to the following of COPD patients is advantageous to these patients, mainly in relation to the usage of inhalers and the adherence to treatment.

A Long-Term Study of the Reduction in Drug-Related Incident Reports and the Impact on Patients by Pharmacist Intervention in the Emergency Department.

In Japan, pharmacists have begun working in emergency departments (ED) over the last decade. However, no reports exist on the contribution of pharmacists' activities in the ED to patient safety. We investigated whether pharmacists' long-term duties influence the number of incident reports in the ED. Of the 862 incidents reported, 152 (17.6%) were drug-related reports. Further investigations revealed that 42 cases occurred during pharmacists' usual working hours, four cases (9.5%) occurred when a pharmacist was present in the ED, and 38 cases (90.5%) occurred in the absence of a pharmacist in the ED. The number of incident reports was significantly reduced by pharmacists optimizing pharmacotherapy in the ED (p=0.002). There was a decrease in the degree of impact on patients through pharmacist duties compared to pharmacist absence (intercepting errors prior to patient administration: 4.8 vs. 31%; medication misadministration: 4.8 vs. 59.4%). Medical staff-associated factors and time of patient arrival at the ED did not have a significant impact on incident reports for any time. Long-term pharmacist duties in the ED can reduce the number of incident reports and contribute to safe medication care in the ED.

(1152) Transplant Pharmacist Intervention During Transplant Center Transfer Among Pediatric Patients

(1152) Transplant Pharmacist Intervention During Transplant Center Transfer Among Pediatric Patients

Abstracts 13th PCNE Working Conference “Pharmacies' new roles in pharmaceutical care: bridging research and practice”

Abstracts 13th PCNE Working Conference “Pharmacies' new roles in pharmaceutical care: bridging research and practice”

The Impact of Clinical Pharmacy Services on Direct Oral Anticoagulant Medication Selection and Dosing in the Ambulatory Care Setting

Background: Off-label dosing of direct oral anticoagulants (DOACs) is both common and associated with adverse patient outcomes. Evidence describing best practices to support optimal direct oral anticoagulant (DOAC) dosing is limited. Objective: To describe the impact of clinical pharmacist intervention on DOAC prescribing. Methods: This retrospective study was a descriptive analysis conducted within an integrated healthcare system with a centralized, pharmacist-led Anticoagulation Management Service (AMS). Patients prescribed a DOAC between January 1, 2020 and December 31, 2020 were included. Pharmacy dispensing reports were generated for pharmacist review and anticoagulant drug therapy changes were recommended to physicians where appropriate. The primary objective was to describe the number and type of recommendations made. Secondary objectives were to determine the provider acceptance rate based on the intervention type and on clinical vs formulary recommendations. Results: Clinical pharmacists made 147 recommendations for 2331 unique patients included in the analysis. Twenty-three recommendations (16%) were to decrease the dose, 46 (31%) were to increase the dose, 14 (10%) were to change the medication due to clinical scenario, 62 (42%) were to change the medication due to cost, and 2 (1%) were another issue. One hundred twenty-three (84%) recommendations were accepted. The provider acceptance rate was similar for clinical and formulary recommendations (85% and 82% respectively). Conclusion: Implementation of report-driven clinical pharmacist intervention led to an improvement in appropriate DOAC medication selection and dosing.

Value of the clinical pharmacist interventions in the application of the American College of Cardiology (ACC/AHA) 2018 guideline for cholesterol management.

The study aims to examine the extent to which the updated ACC/AHA management of blood cholesterol guideline (2018) is implemented in practice and to assess the value of the clinical pharmacist interventions in improving physicians' adherence the guidelines recommendations. We utilized in this study an interventional before-after design. The study was conducted on 272 adult patients who visited the study site internal medicine clinics and were candidates for statin therapy based on the 2018 ACC/AHA guidelines for cholesterol management. Adherence to guideline recommendations was measured before and after clinical pharmacists' interventions by calculating the percentage of patients receiving statin therapy as per guideline recommendation, the type and intensity (moderate or high intensity) of statin therapy used, and the need for additional non-statin therapy. Adherence with guideline recommendations was significantly improved from 60.3% to 92.6% (X2 = 79.1, p = 0.0001) after clinical pharmacist interventions. Among patients who were on statin therapy, the percentage of those who were on proper statin intensity increased significantly from 47.6% to 94.4% (X2 = 72.5, p = 0.0001). The combination of statins with non-statin therapies such as ezetimibe and PCSK9 inhibitors increased from 8.5% to 30.6% (X2 = 95, p<0.0001) and from 0.0% to 1.6% (X2 = 6, p = 0.014), respectively. The use of other lipid-lowering agents was diminished from 14.6% to 3.2% (X2 = 19.2, p<0.0001). Collaboration between physicians and clinical pharmacists is a crucial strategy to improve patients' treatment and hence, achieve better health outcomes among patients suffering from dyslipidemia.

Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

AbstractBackgroundA gap in vancomycin therapeutic drug monitoring (TDM) electronic documentation, management, and related clinical pharmacist activities was identified by our clinical pharmacy team. In response, an electronic TDM (eTDM) template was planned, designed, and implemented by the pharmacy department team in collaboration with the electronic medical records team (EMR) and documentation committee.AimTo assess the impact of an electronic therapeutic drug monitoring (eTDM) template to measure the impact of adherence to vancomycin guidelines. Guideline adherence indicators include the number of vancomycin levels within the therapeutic range and the number of appropriate concentrations taken.MethodAn interventional, single‐centre study of vancomycin therapy in adult patients was performed from 2019–2021. Data were extracted from the electronic medical records and TDM paper‐based forms completed by clinical pharmacists. The number of concentrations within the therapeutic range and the number of appropriately taken levels were analysed by the chi‐square test. This study received an exemption from the Peninsula Health Human Research Ethics Commitee (QA/60523/PH‐2019/197291).ResultsThere was a total of 198 concentrations collected in the ‘before’ period and 125 concentrations collected in the ‘after’ period. The number of concentrations in therapeutic range increased from 34.8% to 43.2% (p = 0.132), not statistically significant. The number of concentrations taken appropriately increased from 33.8% to 55.2% (p &lt; 0.001). The proportion of patients with pharmacist involvement increased from 43.0% to 57.0% (p = 0.868).ConclusionThe study shows that implementation of an electronic vancomycin monitoring template improved the proportion of appropriate levels taken and is the preferred method of documentation by clinical pharmacists. Future projects may benefit from analysing the cost associated with unnecessary vancomycin serum levels ordered or inclusion of pharmacists in the TDM of other narrow therapeutic medications.

Clinical Pharmacist Led Approach on Enhancement of Medication Adherence Resolving the Drug Related Problems with Selective Serotonin Reuptake Inhibitors among the Patients with Psychiatric Illness. A Prospective, Pre and Post Non-Randomised Interventional

Abstract: Introduction: Non-adherence is one of the most common barriers to the successful completion of treatment and it can be worst in psychiatric patients. Objectives: To assess, compare and resolve drug-related problems and medication adherence among psychiatric patients with SSRI and to assess the association between non-adherence and drug-related problems. Materials and Methods: In this prospective, non-randomized interventional study 90 psychiatry patients which were on SSRI treatment of both gender, aged more than 18 years were included. Written informed consent was obtained from the patient prior to enrol in the study. Results: Out of 90 patients enrolled, 51 (56.7%) patients reported DRPs and after pharmacist intervention, it was reduced to 26 (28.9%). Results showed a significant association between drug-related problems and medication adherence. Baseline and follow-up MARS scores are compared and found that there is a significant increase in the adherence score of patients after pharmacist intervention. Conclusion: This study results show that through proper patient education it is possible to improve medication adherence and to optimize medication use, which may reduce the DRPs. It will help eventually help to decrease drug-related morbidity and mortality. Keywords: Medication adherence, Drug Related Problems, SSRI, Mood disorders, MARS.

Cost savings and cost avoidance with the inpatient clinical pharmacist interventions in a tertiary cancer care hospital.

The economic benefit of the clinical pharmacist's role in ensuring the optimum use of medicines is potentially considerable, particularly when it comes to cancer management. We sought to evaluate the overall economic impact of clinical pharmacist interventions in the main cancer setting in Qatar. The total economic benefit of the clinical pharmacy interventions were analyzed from the public hospital perspective. Patient records in March 2018, July/August 2018, and January 2019 were retrospectively reviewed at the National Center for Cancer Care and Research, Qatar. The total benefit from interventions was the total cost avoidance due to preventable adverse drug events plus any cost savings associated with therapeutic-based resource use. Sensitivity analyses confirmed the results' robustness and increased generalizability. A total of 1352 interventions based on 281 patients were analyzed. The majority of the drug-related problems were related to the appropriateness of therapy, followed by dosing and administration. The total population benefit over the 3-months study period was QAR 4,879,185 (USD 1,336,763), constituting cost avoidance of QAR 4,234,012 (USD 1,160,003) and negative resource-use cost savings of -QAR 645,174 (-USD 176,760). Projected annual overall benefit was QAR 14,355,354 (USD 3,932,974). The increase in resource use with therapies was mostly because of the addition of other medications. Cost avoidance was mostly driven by recommending additional medications and discontinuation of medications. The uncertainty analysis demonstrated the robustness of outcomes. The clinical pharmacist intervention increased resource use and its cost. In overall, however, taking avoided cost of adverse drug events in consideration, it is an economically beneficial practice in the National Center for Cancer Care and Research setting, associated with adverse drug events prevention and substantial economic benefits.

Characterization of drug‐related problems and evaluation of pharmacist interventions in the cardiovascular intensive care settings in Thailand

AbstractIntroductionData regarding drug‐related problems (DRPs) and pharmacist's role in the cardiovascular intensive care units (CICU) from low‐ to middle‐income countries (LMIC) are limited.ObjectiveThe study aimed to characterize the DRP and interventions provided by clinical pharmacists in the CICU settings.MethodA retrospective, cross‐sectional study was conducted in patients admitted to CICU of a tertiary‐care hospital in Thailand during January 2021 to March 2022 was performed. Data were collected from patient's medical records and pharmacy service records. DRPs were categorized according to the Pharmaceutical Care Network Europe classification. Two board‐certified pharmacotherapy specialists, pharmacy residents, and trained clinical pharmacists staffed the units 5 days a week. The pharmacist team conducted a medication review and provided interventions to the cardiology team either verbally during the ward round or in writing, as appropriate. Pharmacist interventions were categorized into two groups including retrospective intervention (interventions made to resolve DRPs after an order was made) and prospective interventions (interventions made prior to ordering process). Outcome measures were (1) number of DRPs identified; (2) category of DRPs; (3) number interventions; and (4) acceptance rate of interventions by the medical team.ResultsAmong 576 patients admitted to the CICU, 345 DRPs were identified in 203 patients. The pharmacist team provided a total of 790 interventions including 345 retrospective interventions to resolve DRPs and 445 prospective interventions to guide medication use prior to the ordering process. The most frequent intervention was related to dosage adjustment, drug administration, adding drugs for existing conditions, and suggesting laboratory monitoring. The acceptance rate of the pharmacist intervention was 97.4%, most of which led to changes in drug therapy.ConclusionDRPs in CICU settings are common. Trained clinical pharmacists can effectively resolve DRPs and provide recommendations to improve quality of care through both clinical and distribution functions.

Implementing Transitions of Care Services in a Primary Care Clinic: Role of the Pharmacist

Introduction Pharmacists in primary care clinics improve medication adherence and reduce medication errors but these require further investigation to determine its potential impact on health care readmission rates. Methods: This review assessed the addition of a clinical pharmacist to the primary care provider’s transitions of care appointment. The primary outcome of this review was the change in acute health care encounters (hospital readmissions and/or Emergency Department visits) in the 6-month period before to the 6 months following initial clinical pharmacist intervention. Each patient served as their own control. Secondary outcomes included the number and types of pharmacist interventions, percentage of pharmacist recommendations accepted, number and categories of drug-related problems (DRPs), nonadherence reasons, 30-day hospital readmission rate, 30-day Emergency Department (ED) rate, time to first hospital readmission, time to first ED readmission, and preventable readmission rate. Results: The total number of combined acute health care encounters in 6 months decreased by 15% from 280 at baseline to 238 after pharmacist intervention (P = .087) for the 206 patients included in the final analysis. The 30-day hospital readmission rate was 9.7% and the median time between first hospital readmission was 54.5 days (IQR 63.5). We identified a total number of 310 DRPs with a mean of 1.5 DRPs (SD 1.3) identified per patient. The providers accepted 88% of the pharmacists’ recommendations. Conclusions: Clinical pharmacists embedded in a primary care setting demonstrated improved patient care during transitions of care by identifying and resolving drug-related problems, with a trend in decreasing acute health care utilization.