Unintentional Continuation of Medications Intended for Acute Illness After Hospital Discharge: A Population-Based Cohort Study

Abstract

BACKGROUND:Patients are vulnerable to medicationrelated errors during transitions in care. Patients discharged from acute care hospitals may be at an elevated risk for the unintentional continuation of medications prescribed to prevent or treat complications that are associated with acute illness but are no longer indicated. We sought to evaluate rates of (primary objective) and risk factors for (secondary objective) potentially unintentional medication continuation following hospitalization. METHODS: A population-based cohort study of more than one million patients 66 years of age or older who were hospitalized in Ontario, Canada, between 2003 and 2011 and followed for 1 year (2004 to 2012). We created distinct cohorts by identifying seniors not previously receiving four classes of medications typically used to treat or prevent complications of acute illness: (1) antipsychotic medications, (2) gastric acid suppressants (histamine-2 blockers and proton pump inhibitors), (3) benzodiazepines, and (4) inhaled bronchodilators and steroids. After excluding documented indications, we followed patients to ascertain whether these medications were continued after hospital discharge, and assessed risk factors for their continuation using generalized estimating equations. The primary outcome was the new dispensation of any of the selected medications within 7 days of hospital discharge. RESULTS: Prescription without documented indication occurred across all medication classes, from 12,209 patients (1.4 %) for antipsychotic medications to 34,140 patients (6.1 %) for gastric acid suppressants. Risk factors for unintentional continuation varied across medication groups, but rates were consistently higher for older patients, those with multiple comorbidities, and emergency hospitalizations. The largest absolute risk factor across all medications was a hospitalization>7 days [OR 2.03 (95 % CI 1.94-2.11) for respiratory inhalers, 6.35 (95 % CI 5.91-6.82) for antipsychotic medications]. These medications were often continued at 1 year of follow-up, and accounted for a total additional medication cost of over CAD$18 million for the study population. CONCLUSION: Discharged patients are at risk of being prescribed and dispensed medications that are typically intended to prevent or treat complications of acute illness, despite having no documented indication for chronic use.

Antipsychotic prescribing patterns during and after critical illness: a prospective cohort study

“…Antipsychotics are not the only class of medications that are prescribed at discharge despite being no longer indicated at that time. Scales and colleagues [31] examined four medication classes, for example, and found that all four were prescribed at hospital discharge without a documented indication. We specifically focused on antipsychotics in the current study because, unlike some medications (e.g., gastric acid suppressants), antipsychotics have never been proven efficacious in the ICU setting and their adverse effects during chronic use are well documented.…”

Medication adherence 1 month after hospital discharge in medical inpatients

“…There are many instances where patients intentionally altering their medications may be beneficial. For example, large number of patients are prescribed a gastric acid suppressant intended for short‐term use, which may be continued long term without review . If patients themselves identify that a medication is unnecessary where the doctor has failed to do so, then this is likely to be a positive outcome.…”

“…For example, large number of patients are prescribed a gastric acid suppressant intended for short-term use, which may be continued long term without review. 23 If patients themselves identify that a medication is unnecessary where the doctor has failed to do so, then this is likely to be a positive outcome. Ideally, it should prompt discussion with their physician and regular review of their medications, rather than self-management of medications.…”

Caring for the critically ill patients over 80: a narrative review

“…Medications typically intended for short-term use during acute illness are sometimes continued after discharge without a documented indication [ 47 ]. While it is possible that these drugs were appropriately started during an acute illness in the ICU, most should have been discontinued at ICU or hospital discharge [ 48 ].…”