Meds for Chronic Illness Often Dropped After Hospital Stay

August 23, 2011

August 23, 2011 — Many patients taking medications for chronic illnesses stop taking them after a hospitalization, especially if they spent time in an intensive care unit (ICU), according to a study published online today in JAMA.

The consequences of nonadherence are serious. The study found that discontinuation of 2 cardiovascular medications after hospital discharge led to an increased risk for emergency department visits, hospitalization, and death.

The findings, write lead author Chaim Bell, MD, PhD, and coauthors, should spur hospitals and physicians to approach patient handoffs more systematically in a hectic inpatient environment. Part of the solution is creating and maintaining an accurate prescription drug list.

The authors combed through all hospitalizations and outpatient prescriptions in the Canadian province of Ontario from 1997 to 2009 to focus on 396,380 patients aged 66 years and older who were continuously taking at least 1 of 5 common medications for a chronic disease. The 5 categories consisted of statins, antiplatelet/anticoagulant agents, levothyroxine, respiratory inhalers, and gastric acid–suppressing medications.

One cohort of patients in the study was discharged after a hospitalization that included a trip to the ICU, and another was discharged without an ICU admission. Patients taking medications for chronic illnesses who were not hospitalized constituted a control group.

Excluded from the study were patients whose medications were deliberately halted during a hospital stay or afterward. An example, Dr. Bell told Medscape Medical News, would be a patient taken off his customary warfarin because he is bleeding internally. Dr. Bell, an associate professor of medicine at the University of Toronto, Canada, said his research team tried to minimize the possibility of deliberate medication withdrawals by picking agents that give inpatient clinicians very little reason to suspend their use by virtue of the superior safety characteristics.

A patient was classified as discontinuing a medication if the prescription was not renewed within 90 days after a hospital discharge.

Seniors Probably "Most Vulnerable Population"

In each of the 5 medication groups, patients were at an elevated risk of going off their chronic illness medications within 90 days of leaving a hospital. The adjusted odds ratio (AOR) of that happening compared with the AOR for nonhospitalized patients ranged from 1.18 for levothyroxine to 1.86 for antiplatelet/anticoagulant agents. For patients who spent time in an ICU, the AORs were even higher, ranging from 1.48 for statins to 2.31 for antiplatelet/anticoagulant agents.

The authors also looked at the AORs of patients dying, going to a hospital emergency department, or being hospitalized if they stopped taking their medications. That AOR was 1.07 for statins and 1.10 for antiplatelet/anticoagulant agents during the 12 months after the 90-day mark after a hospital discharge. For the other 3 drug groups, the AORs for this risk were statistically nonsignificant.

Dr. Bell told Medscape Medical News that the disruptions to drug regimens typically involve a faulty drug list for the patient. Clinicians may fail to obtain an accurate list when the patient is admitted or to maintain its accuracy as a patient moves from the ICU to a hospital ward, or from the hospital ward to discharge. Such slip-ups are understandable, given the focus on the patient's acute condition, as opposed to long-term health needs.

Patients might be expected to remind clinicians that they should keep taking a statin or anticoagulant after they leave the hospital, but Dr. Bell said that is less likely with seniors.

"They're probably the most vulnerable population," he said. "They may be taking 9 or 10 medicines to begin with, and they may forget to take one. Maybe they don't retain [instructions] as well. Sometimes we don't do a great job educating people."

Electronic health record technology can help maintain a precise medication list, but Dr. Bell and coauthors write that improved patient handoffs also depend on "including all relevant clinicians and the patients themselves" in the communication loop.

"An accurate pharmaceutical history should be available not only to hospital physicians and primary care physicians but also to pharmacists and home care nurses," said Dr. Bell.

The study was funded by a grant from the Canadian Institutes of Health Research. It was supported by the Institute for Clinical Evaluative Sciences, which is funded by the Ontario Ministry of Health and Long-Term Care. Dr. Bell and Dr. Scales received funding as Canadian Institutes of Health Research New Investigators. Dr. Bell now holds a Canadian Institutes of Health Research/Canadian Patient Safety Institute Chair in Patient Safety and Continuity of Care. Coauthor Jana Bajcar, BScPhm, MScPhm, EdD, reported that she has been a consultant to Merck Frosst Canada and AstraZeneca, has received payment from sanofi-aventis for lectures, and has received payment from AstraZeneca for manuscript preparation. Coauthor Merrick Zwarenstein, MBBCh, MSc, reported that he has been a consultant on trial design for Johnson & Johnson and has received financial support from the Centre for Medical Technology Policy for teaching pragmatic trial design.

JAMA. 2011;306:840-847. Abstract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.