UB researchers’ paper on transitions of care wins national award

BUFFALO, N.Y. —  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 the patients, but it also saddles hospitals with $6 billion in annual costs that can be passed along to patients and affect their care.

Often, it’s the medications prescribed to these patients — typically those suffering from heart failure, chronic obstructive pulmonary disease (COPD) or pneumonia — that contribute to the 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,” which Jacobs conducted with 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 said. “Primary care providers’ workload pressures continue to increase. A pharmacist-led TOC intervention can free clinical time for the provider and improve patient care.”

For this study, the researchers focused on hospital-to-home transitions. They evaluated 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% and the net financial benefit was $9,078.

“There are so many changes in medication lists when a patient enters the hospital vs. when they come home,” Jacobs said. “Our job as pharmacists is to work with the care team in the hospital and in the primary care practice to ensure consistency and accuracy with the medication regimen. This means identifying and resolving any discrepancies and addressing issues like omissions, duplication, incorrect dosage and unintentional medication changes.”

Medication reconciliation and review

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. An almost equal mix of males and females were represented. They were between the ages of 58 and 78, with an average age of 67.

The intervention specifically included:

• reviewing the patient’s medication records at the practice, including the hospital notes and discharge summary, and reconciling any differences,
• completing a comprehensive medication review, which identifies any medication-related problems such as potential medication adherence and access issues,
• sending notes to the primary care provider via electronic health records, noting any recommended interventions for the patient,
• documenting final updates to the patient’s medication records and delivering important information to the patient and their caregiver in person or via phone whenever possible.

“Problems often arise when communication breaks down among health care providers, patients and their caregivers,” Jacobs said. “We tried to eradicate that through our interventions.”

The physicians, he noted, were extremely interested in participating in the study and working collaboratively.

“I think you see that when you have these different groups, whether it be pharmacy, medicine or nursing, working together, you can improve health outcomes,” he said.

Despite an increased focus on care transitions nationwide with health care shifting toward value-based care, no single TOC intervention has consistently been shown to improve the post-discharge outcomes, Jacobs said.

“What we know is that there is no single component that fixes hospital readmissions,” Jacobs said. “This is why we focused on a medication reconciliation component, a comprehensive medication review and evaluation, and consistent and ongoing communication. It’s this multifaceted approach that’s really needed.”

Collective effort

Jacobs will receive the award for best clinical paper on behalf of the research team at the APhA Annual Meeting and Exposition in Nashville, Tenn., in March.

“It’s an honor and a privilege to be recognized for work like this in front of my national peers, but it also reflects the collective efforts of an amazing team,” he said. “We know as pharmacists that we can make an impact on clinical care. By doing these type of studies and showing a clinical and economic benefit, I hope we will continue to drive innovative approaches in Buffalo and elsewhere, and ultimately, improve patient care.”

The other researchers who contributed to the study and the paper included faculty within the Department of Pharmacy Practice: Erin Slazak, PharmD, clinical associate professor; Christopher Daly, PharmD, clinical associate professor; Collin Clark, PharmD, clinical assistant professor; and William Prescott, PharmD, chair and clinical professor.

Outside the pharmacy school, Ranjit Singh, MD, associate professor in the Department of Family Medicine in the Jacobs School of Medicine and Biomedical Sciences; Gregory Wilding, PhD, professor in the Department of Biostatistics, School of Public Health and Health Professions; and Samatha Will, a practicing pharmacist in Buffalo, along with several graduate students, also contributed.