Following discharge from a hospital, patients are at an increased risk of unintentional discontinuation of commonly prescribed chronic disease medications, with this risk even greater for patients who were admitted to an intensive care unit, according to a study in the August 24/31 issue of JAMA.1
“Transitions in care are vulnerable periods for patients during hospitalization. Medical errors during this period can occur as a result of incomplete or inaccurate communication as responsibility shifts from one physician to another. At hospital discharge, patients may be susceptible to prescription errors of omission, including the unintentional discontinuation of medications with proven efficacy for treating chronic diseases. Treatment in the intensive care unit (ICU) may place patients at elevated risk for such errors of omission,” according to background information in the article.
Chaim M. Bell, M.D., Ph.D., of St. Michael's Hospital and the Institute for Clinical Evaluative Sciences, Toronto, and colleagues examined the rates of unintended discontinuation of common medications for chronic diseases after acute care hospitalization and ICU admission. For the study the researchers used administrative records from 1997 to 2009 of all hospitalizations and outpatient prescriptions in Ontario, Canada, which included 396,380 patients who were 66 years or age or older with continuous use of at least 1 of 5 evidence-based medication groups prescribed for long-term use: (1) statins, (2) antiplatelet/anticoagulant agents, (3) levothyroxine (medication for thyroid problems), (4) respiratory inhalers, and (5) gastric acid-suppressing drugs. Rates of medication discontinuation were compared across 3 groups: patients admitted to the ICU, patients hospitalized without ICU admission, and nonhospitalized patients (controls). The primary outcome measure was a patient’s failure to renew a prescription within 90 days after hospital discharge.
The study included 187,912 hospitalized patients and 208,468 controls. The researchers found that patients admitted to the hospital were more likely to experience potentially unintentional discontinuation of medications than controls across all medication groups examined. The highest rate of medication discontinuation occurred in the antiplatelet or anticoagulant agent group (n = 5,564; 19.4 percent). In this group, there were 552 patients (22.8 percent) with an ICU admission who discontinued these medications after hospital discharge. In contrast, of the patients in the control group who were receiving antiplatelet or anticoagulant medications, only 11.8 percent experienced medication discontinuation at 90 days. The respiratory inhaler group had the lowest rate of medication discontinuation (4.5 percent).
The authors also found that there was an increased risk of medication discontinuation in patients with an ICU admission compared with nonhospitalized patients. “Overall, the increased risk of medication discontinuation in patients with an ICU admission was statistically significant in 4 of the 5 medication groups compared with hospitalized patients without an ICU admission.”
One-year follow-up of patients who discontinued medications showed an elevated risk for the secondary composite outcome of death, emergency department visit, or emergent hospitalization in the statins group and in the antiplatelet/anticoagulant agents group.
“Better communication and a system-based method have been advocated as possible solutions to improve medication continuity and safety. These strategies can range from customized integrated hospital computer systems to simple preprinted forms. However, their success is contingent on including all relevant clinicians and the patients themselves. Formal programs such as medication reconciliation and standard discharge summaries can provide a means to improve interdisciplinary communication, including with primary care clinicians. Identification of high-risk patients and transfers in care may help improve program efficiency and focus valuable resources,” the authors write.
In an accompanying editorial, Jeremy M. Kahn, M.D., M.S., and Derek C. Angus, M.D., M.P.H., of the University of Pittsburgh, (Dr. Angus is also a Contributing Editor, JAMA), write that “more powerful solutions are necessary to promote overall medication quality, not just adherence to a checklist at discharge.”2
“Examples might include comprehensive electronic health records available to all clinicians within a system, or integrated health care organizations that encourage and incentivize communication across care sites. These types of large-scale organizational innovations offer promise not only to reduce the harms associated with care transitions, but also to leverage the opportunities for health care improvement inherent in the transition process. The time to begin implementing these programs is now, along with conducting demonstration projects evaluating other innovative ways to improve communication across care sites. The challenge is to design, test, and implement solutions that acknowledge the complexities of modern prescription medication management and facilitate optimal medication usage at every step of the process, so that a major opportunity to improve care will not be missed.”
1. (JAMA. 2011;306:840-847
2. (JAMA. 2011;306:878-879.