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Patients at risk of stopping medication after ICU stay

Friday August 26, 2011
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Following discharge from a hospital, patients are at an increased risk of unintentional discontinuation of commonly prescribed chronic disease medications, according to a Canadian study. The risk is even greater for patients who were admitted to an ICU.

"Transitions in care are vulnerable periods for patients during hospitalization," the authors wrote in the Aug. 24/31 issue of JAMA. "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 ICU may place patients at elevated risk for such errors of omission."

Chaim M. Bell, MD, PhD, and colleagues with St. Michael's Hospital and the Institute for Clinical Evaluative Sciences in Toronto 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 age 66 or older with continuous use of at least one of five evidence-based medication groups prescribed for long-term use: statins, antiplatelet/anticoagulant agents, levothyroxine, respiratory inhalers and gastric acid-suppressing drugs.

Rates of medication discontinuation were compared across three 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 potential, 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 (19.4%). In this group, there were 552 patients (22.8%) 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% experienced medication discontinuation at 90 days. The respiratory inhaler group had the lowest rate of medication discontinuation (4.5%).

"Overall, the increased risk of medication discontinuation in patients with an ICU admission was statistically significant in four of the five medication groups compared with hospitalized patients without an ICU admission," the authors wrote.

A one-year follow-up of patients who discontinued medications showed an elevated risk for the secondary composite outcome of death, ED 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," the authors wrote. "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."


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