Discontinuation of medications with proven efficacy for treating chronic diseases is a critical problem, especially during or following hospitalization. Research has suggested that transitions in care, specifically those that occur during an ICU admission, may be partly to blame because they can result in medical errors.

Examining Transitions in Care

In a study published in the August 2011 JAMA, Chaim M. Bell, MD, PhD, and colleagues set out to evaluate rates of unintentional discontinuation of medication following hospitalization. Rates of medication discontinuation were compared across three groups: 1) patients admitted to the ICU, 2) patients hospitalized without ICU admission, and 3) non-hospitalized patients (controls). “We evaluated the effect of hospitalization and ICU admission on discontinuation of five medication groups with strong benefit-to-risk ratios,” explains Dr. Bell. “This is also one of the first studies to our knowledge that assesses the impact of discontinuation on outcomes at 1 year after discharge.”

Dr. Bell’s population-based cohort study analyzed medical records on almost 400,000 elderly patients hospitalized between 1997 and 2009 who were taking at least one of five medications:

Statins.

Antiplatelet or anticoagulant agents.

Levothyroxine.

Respiratory inhalers.

Gastric acid–suppressing drugs.

Patients were required to demonstrate a minimum of 1 year of continuous use of the medication for study entry, thus minimizing the possibility of deliberate medication withdrawals. At 90 days after study participants were discharged, potentially unintentional discontinuation of medication was assessed. The authors also tracked deaths, hospitalizations, and ED visits up to 1 year after hospital discharge.

New Findings on Medication Discontinuation

In the JAMA article, the investigators found that hospitalization was associated with an increased risk of medication discontinuation following release from the hospital in all medication groups examined. The highest rate of medication discontinuation occurred in the antiplatelet or anticoagulant agent group (Table 1). Discontinuation rates were highest among patients who had been admitted to the ICU. “Patients treated in the ICU were less likely to resume their regular medication schedule after discharge,” Dr. Bell says. “This may be because there are many transitions of care to units within the hospital. Another potential factor for this finding is that many different care teams are involved.” Another major finding from Dr. Bell’s study was that patients who discontinued their medication who were prescribed to two of the five medication groups assessed, statins and anti-coagulants in particular, had a higher adjusted risk of adverse events. “These events included ED visits, readmissions, and death over the 1 year following discontinuation of the drugs,” says Dr. Bell (Table 2).

Potential Explanations for Discontinuation

Dr. Bell notes that while it is unclear why the medications assessed in the study are often stopped, previous research has shown that system-level errors can have an impact on adherence. “These errors may include deliberate suspension of medication during emergency situations and failure to re-start medications due to communication errors that occur during transitions in care.” Another issue that may have had an impact was the prevalence of polypharmacy in the study population. Patients were prescribed a median of 12 different medications in the year prior to hospitalization, and 75% were prescribed nine or more medications.

“These data suggest that prescription errors and medication discontinuation can persist after patients are discharged, and this can lead to adverse patient outcomes.”

“It may be that patients are expecting to be reminded that they need to keep taking medications after they leave the hospital,” says Dr. Bell. “Seniors are probably the most vulnerable patient group because they may be taking numerous medicines to manage chronic disease.” A standardized process of care, such as medication reconciliation, has been shown to minimize the rate of errors. Patient-level factors were also not assessed in this study, but numerous factors were adjusted for in the analysis, including demographics, number of drugs, and disease burden. “We tried to minimize potential patient-level adherence issues by evaluating patients with established adherence levels,” Dr. Bell says. “That is why we purposely selected individuals for this study who faithfully filled their prescriptions for at least 1 year before being hospitalized.”

Broad Implications

The findings from Dr. Bell’s analysis may have broad implications for clinical practice. “These data suggest that prescription errors and medication discontinuation can persist after patients are discharged, and this can lead to adverse patient outcomes,” says Dr. Bell. “These data should encourage hospitals and physicians to approach patient handoffs more systematically in what is often a hectic inpatient environment. Part of the solution is creating and maintaining an accurate prescription drug list.” He adds that future quality improvement strategies should utilize a multidisciplinary approach and more frequent follow-up to break down the wall between inpatient and outpatient care, thus minimizing errors and rates of medication discontinuation.

 

References

Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306:840-847. Available at: http://jama.ama-assn.org/content/306/8/840.full.pdf+html.

Bell CM, Rahimi-Darabad P, Orner AI. Discontinuity of chronic medications in patients discharged from the intensive care unit. J Gen Intern Med. 2006;21:937-941.

Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314-323.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841.

Landefeld CS. Improving health care for older persons. Ann Intern Med. 2003;139(pt 2):421-424.