JAMA: Patients admitted to hospital are more likely to discontinue meds
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“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,” Chaim M. Bell, MD, PhD, associate professor of medicine and health policy, management and evaluation, University of Toronto and St. Michael's Hospital in Ontario, and colleagues wrote. “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.”
During the study, Bell and colleagues set out to understand why unintentional discontinuation of medications following a hospital discharge occurs and what steps can be taken to help enhance medication adherence. The study looked at the unintentional discontinuation of medications as opposed to intentional discontinuation (i.e. the discontinuation of a blood thinner due to major bleeding in the hospital).
The researchers performed a retrospective study using population-based data of seniors in the province of Ontario between 1997 and 2009 to evaluate the medication adherence of five medication classes administered for chronic disease: statins, antiplatelet/anticoagulant agents, levothyroxine, respiratory inhalers and gastric acid–suppressing drugs.
The study cohort included 396,380 patients who were 66 years or older and were on continuous usage of at least one of the five evidence-based medications for at least one year. The researchers compared the rates of medication discontinuation between three groups: those admitted to the ICU, those hospitalized without an ICU admission and patients who were not hospitalized (control group). Of the 396,380 patients in the study, 187,912 were admitted to the hospital and 208,468 were not.
“We followed patients after they were discharged from the hospital and assessed whether or not they filled their prescription within three months after a hospital discharge,” Bell told Cardiovascular Business during an interview. “What we found was that patients admitted to the hospital had a higher risk of discontinued medical therapy,” Bell said. “Additionally, the baseline risk was even higher if patients were admitted to the ICU.”
For hospitalized patients, 19.4 percent discontinued antiplatelet/anticoagulants after discharge compared with 11.8 percent of controls. Additionally, 14.6 percent of patients admitted to the ICU discontinued statin therapy and 22.8 percent discontinued anticoagulants or antiplatelets.
Bell speculated that the high percentage of patients who did not fill their prescriptions could stem from the fact that hospital staff may not have received an adequate list of patients' medications prior to their admission into the hospital.
Medication usage is not well documented, Bell offered. “When patients are discharged from the hospital they are given a list of new prescriptions to take and often there is a lack of communication between the patient, the primary care physician and the hospital-based physician, which can lead to this unintentional discontinuation of medications upon leaving the hospital.
“There are quite a few hand-offs and transitions of care within the hospital,” Bell added. “Often times when a patient is leaving the hospital, the patient is uncertain of what medications they need to be on.”
However, the disconnect often occurs when the primary care physician (PCP) assumes that the patient made an intentional decision to discontinue medication, even though the case may be that the patient was uninformed. There are problems with information transfer and communication within the care continuum, Bell said.
Some turn to EHRs to help coordinate care, Bell said, but success may depend on the completeness and timeliness of the data. “When people think of EHRs, they think of this as the primary care physician gaining access to patient charts,” Bell noted. “That is not always the case; in fact, it is often the hospital-based physicians gaining access to the PCP’s chart.”
Bell said EHRs could be the answer if the community pharmacist, PCP and hospital-based physician all had access to updated medication lists.
Most important is good communication with patients and their families, he said. “These were a group of vulnerable patients with 75 percent taking nine or more prescribed medications,” Bell added. “When they leave the hospital it may be hard for them to realize what medications are missing.”
He offered that having an accurate list of medications and being able to communicate that list to patients will help close the gap of medication discontinuation after a patient gets discharged from the hospital.
Discontinuing these types of medications can have severe effects. For example, discontinuing a proton pump inhibitor could increase peptic ulcers and discontinuing warfarin could increase the risk of embolic stroke in atrial fibrillation patients. In an accompanying editorial, Jeremy M. Kahn, MD, MS, and Derek C. Angus, MD, MPH, both of the University of Pittsburgh in Pennsylvania, argued that the medication discontinuation during the current study could have been intentional.
“There are a number of valid reasons these medications may have been stopped during the index hospitalization,” Kahn and Angus wrote. “New contraindications may have arisen that were not captured in the investigators' administrative database. Physicians may have used the admission as an opportunity to rethink the original medication indication, deciding that the patient was better off without the medication.”
However, despite this fact, Kahn and Angus agreed with Bell and colleagues that “more powerful solutions are necessary to promote the overall medication quality, not just adherence to a checklist at discharge.”
Bell concluded that a better focus on medication reconciliation, along with better communication and collaboration, should be the first step.