UB Study Shows Pharmacist-Physician Collaborations Reduce Hospital Readmissions, Save Money
Every year, more than 425,000 high-risk patients nationwide are released from the hospital, only to return within 30 days. This situation not only negatively affects patients but also saddles hospitals with $6 billion in annual costs—expenses that can be passed along to patients and impact their care.
Often, the medications prescribed to these patients— typically those suffering from heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia— contribute to these readmissions, according to David Jacobs, PharmD, PhD, associate professor in the Department of Pharmacy Practice at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences.
“Discrepancies in drugs, adverse drug reactions, and dangerous drug interactions all send these fragile patients back to the hospital,” said Jacobs, the lead author of a study exploring a solution to this revolving door: pharmacist-led interventions within primary care clinics during transitions of care (TOC).
A paper highlighting the study’s findings, titled "Clinical and Economic Effectiveness of a Pharmacy and Primary Care Collaborative Transition of Care Program," conducted by Jacobs and several UB pharmacy, medicine, and public health researchers, was selected as the 2025 American Pharmacists Association (APhA) Best Clinical Paper.
“Transitions of care refers to the movement of patients between health care practitioners and from other health care settings to home as their condition and care needs change,” Jacobs explained. “Primary care providers’ workload pressures continue to increase. A pharmacist-led TOC intervention can free up clinical time for the provider and improve patient care.”
For this study, researchers focused on hospital-to-home transitions, evaluating 300 adult patients between 2019 and 2021 at three primary care practices in Western New York.
After implementing a multifaceted pharmacy intervention—including medication reconciliation, comprehensive medication review, and provider and patient follow-up—they discovered that:
Hospital readmissions and emergency room visits dropped by 46%.
The net financial benefit was $9,078 per patient.
“There are so many changes in medication lists when a patient enters the hospital versus when they come home,” Jacobs said. “Our job as pharmacists is to work with the care team in the hospital and in primary care practices to ensure consistency and accuracy in the medication regimen. This means identifying and resolving any discrepancies, as well as addressing issues like omissions, duplication, incorrect dosages, and unintentional medication changes.”
To qualify for the study, patients needed to have conditions that put them at high risk of readmission and be regularly taking at least 15 prescription drugs. The study included an equal mix of male and female participants, ranging in age from 58 to 78, with an average age of 67.
The pharmacist-led intervention specifically included:
Reviewing the patient’s medication records at the primary care practice, including hospital notes and discharge summaries, and reconciling any discrepancies. Completing a comprehensive medication review, identifying medication-related issues such as adherence challenges and access barriers. Sending notes to the primary care provider via electronic health records, documenting any recommended interventions. Updating the patient’s medication records and delivering crucial information to the patient and caregiver in person or via phone whenever possible.
“Problems often arise when communication breaks down among health care providers, patients, and caregivers,” Jacobs said. “We aimed to eliminate those gaps through our interventions.”
The study also found strong support from physicians.
“I think you see that when pharmacy, medicine, and nursing professionals work together, health outcomes improve,” Jacobs noted.
Despite an increased national focus on care transitions—with health care shifting toward value-based care—Jacobs emphasized that no single TOC intervention has consistently improved post-discharge outcomes.
“There is no single component that fixes hospital readmissions,” Jacobs explained. “This is why we focused on a medication reconciliation component, a comprehensive medication review and evaluation, and consistent and ongoing communication. A multifaceted approach is what’s truly needed.”
Jacobs will receive the Best Clinical Paper Award on behalf of the research team at the APhA Annual Meeting and Exposition in Nashville, Tenn., in March 2025.
“It’s an honor and a privilege to be recognized for work like this in front of my national peers,” Jacobs said. “But this also reflects the collective efforts of an amazing team.”
“As pharmacists, we know we can make an impact on clinical care. By conducting studies like this and demonstrating both clinical and economic benefits, I hope we will continue to drive innovative approaches in Buffalo and beyond, ultimately improving patient care.”
Research Team Contributors The study was conducted by a multidisciplinary team, including faculty from the Department of Pharmacy Practice:
Erin Slazak, PharmD – Clinical Associate Professor Christopher Daly, PharmD – Clinical Associate Professor Collin Clark, PharmD – Clinical Assistant Professor William Prescott, PharmD – Chair and Clinical Professor Additional contributors included:
Ranjit Singh, MD – Associate Professor, Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences Gregory Wilding, PhD – Professor, Department of Biostatistics, School of Public Health and Health Professions Samantha Will, PharmD – Practicing Pharmacist, Buffalo Several graduate students.
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