Unneeded Meds at Discharge Could Cause Harm

Ingrid Hein

October 23, 2020

A significant number of patients leave the hospital with inappropriate drugs because of a lack of medication reconciliation at discharge, new research shows.

Proton pump inhibitors — known to have adverse effects, such as fractures, osteoporosis, and progressive kidney disease — make up 30% of inappropriate prescriptions at discharge.

Harsh Patel

"These medications can have a significant toxic effect, especially in the long term," said Harsh Patel, MD, from Medical City Healthcare in Fort Worth, Texas.

And "when we interviewed patients, they were unable to recall ever partaking in a pulmonary function test or endoscopy to warrant the medications," he told Medscape Medical News.

For their retrospective chart review, Patel and his colleagues assessed patients admitted to the ICU in 13 hospitals over a 6-month period in North Texas. Of the 12,930 patients, 2557 had not previously received but were prescribed during their hospital stay a bronchodilator, a proton pump inhibitor, or an H₂ receptor agonist.

Of those 2557 patients, 26.8% were discharged on a proton pump inhibitor, 8.4% on an H₂ receptor agonist, and 5.49% on a bronchodilator.

There were no corresponding diseases or diagnoses to justify continued use, Patel said during his presentation at CHEST 2020.

Button Fatigue

The problem stems from a technology disconnect when patients are transferred from the ICU to the general population.

Doctors expect that the medications will be reconciled at discharge, said one of the study investigators, Prashanth Reddy, MD, from Medical City Las Colinas in Texas.

But in some instances, clinicians unfamiliar with the case click through the electronic health record to get the patient "out of the ICU to the floor," he explained. "They don't always know what medications to keep."

"They may have button fatigue, so they just accept and continue," Reddy told Medscape Medical News.

In light of these findings, the team has kick-started a project to improve transition out of the ICU and minimize overprescription at discharge.

"This is the kind of a problem where we thought we could have some influence," said Reddy.

One solution would be to put "stop orders" on potentially harmful medications. "But we don't want to increase button fatigue even more, so we have to find a happy medium," he said. "It's going to take a while to formulate the best path on this."

Patients are always happy to hear we're taking them off a drug.

The inclusion of pharmacy residents in rounds could make a difference. "When we rounded with pharmacy residents, these issues got addressed," Patel said. The pharmacy residents often asked: "Can we go over the meds? Does this person really need all this?"

Medication reconciliations not only have a positive effect on a patient's health, they can also cut costs by eliminating unneeded drugs. And "patients are always happy to hear we're taking them off a drug," Patel added.

He said he remembers one of his mentors telling him that if he could get his patients down to five medications, "then you've achieved success as a physician."

"I'm still working toward that," he said. "The end goal should sometimes be, less is more."

COPD Patients Overprescribed Home Oxygen

In addition to medications, home oxygen therapy is often prescribed when patients are discharged from the hospital.

A study of 69 patients who were continued on home oxygen therapy after hospitalization for an exacerbation of chronic obstructive pulmonary disease (COPD) was presented by Analisa Taylor, MD, from the University of Illinois College of Medicine in Chicago.

Despite guideline recommendations that patients be reassessed within 90 days of discharge, only 38 patients in the cohort were reassessed, and "28 were considered eligible for discontinuation," she said during her presentation at CHEST 2020.

However, "of those, only four were ultimately discontinued," she reported.

The reason for this gap needs to be examined, noted Taylor, suggesting that "perhaps clinical inertia plays a role in the continuation of previously prescribed therapy despite a lack of ongoing clinical benefit."

CHEST 2020: American College of Chest Physicians Annual Meeting: Posters P1569 and P1502.

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