A new study in the August 24/31 issue of JAMA has found that patients are at a higher risk, after being discharged from hospital, of unintentional discontinuation of common medications prescribed for chronic diseases. Intensive care unit patients are at an even greater risk.

The article provided insightful background information on the matter.

The authors wrote:

“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,”

Assessments were made by Chaim M. Bell, M.D., Ph.D., of St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences, Toronto, and colleagues, on the rates of unintended discontinuation of medications for chronic diseases after ICU admission and acute care hospitalization. They looked at records of all hospitalizations and outpatient prescriptions in Ontario, Canada, between the years 1997 and 2009. Included were a total of 396,380 patients, all at least 66 years old, with consistent long-term use of at least 1 of 5 evidence-based medication groups.

Below are the drugs involved in this study:

  • Statins
  • Antiplatelet/anticoagulant agents
  • Levothyroxine (medication for thyroid problems)
  • Respiratory inhalers
  • Gastric acid-suppressing drugs

Three groups were compared in the study for their rates of medication discontinuation. The first group had patients hospitalized without ICU admission, the second group had patients admitted to the ICU and the third group had nonhospitalized patients (controls). Patient failure, within 90 days after hospital discharge, to renew a prescription was looked at as the primary outcome measure.

There were a total of 208,468 controls and 187,912 hospitalized patients in the study. They found that hospitalized patients had a higher rate of unintentional discontinuation in all medication groups observed, compared to the controls.

The antiplatelet or anticoagulant agent group had the highest rate of medication discontinuation (n = 5,564; 19.4 percent) of all medication groups. Within the group 552 of the patients (22.8 percent) had an ICU admission and after being discharged from their hospital, stopped taking their medication. Only 11.8% of patients in the control group, who were on the same medications, discontinued their medication after 90 days. The group with the lowest rate of medication discontinuation, at 4.5%, was the respiratory inhaler group.

Patients with an ICU admission were found to have a higher risk of medication discontinuation than non-hospitalized patients.

The authors said:

“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.”

The study found that the discontinuation of medications among patients led to an increased risk for emergency department visits, or emergency hospitalization. This was in the antiplatelet/anticoagulant agents group and statins group.

The authors concluded:

“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 necessity of implementing a more efficient program to regulate overall medication quality has been raised in an editorial by Jeremy M. Kahn, M.D., M.S., and Derek C. Angus, M.D., M.P.H., of the University of Pittsburgh. The writers urge that there are better ways of promoting medication quality than just adherence to a checklist at discharge.

They provided a few examples of solutions, such as the ability for clinicians to have complete access to electronic health records and the idea of integrated health care organizations that advocate communication among care sites.

The authors wrote:

“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 editorial stresses the need to begin designing, testing and implementing new programs that focus on optimal medication usage as soon as possible, and acknowledge the complexities involved with modern prescription medication management, so as not to miss an opportunity to improve care.

They added:

“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”

Written by Joseph Nordqvist