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Patients are at high-risk of inadvertent interruption of home medication when transitioning from hospitalization back to the home setting.1,2 Medications for chronic conditions are often discontinued for valid reasons during a brief hospitalization. These medications may be overlooked when it comes time for discharge planning. Omissions of these medications can lead to potentially serious outcomes for the patient.

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Bell and colleagues1 conducted a population-based cohort study of over 396,000 elderly, hospitalized patients in Canada who were on long-term drug therapy for a chronic condition prior to hospitalization. The study included prescription and hospitalization data from 1997 to 2009. The hospitalized patients were compared to a control group of patients who did not have a hospitalization during a one-year period. All patients included in the study were being treated with one of the following classes of medication for at least one year prior to the hospitalization (or randomly selected index date for the control group): statins, levothyroxine, antiplatelet/anticoagulant, respiratory inhalers, or gastric-acid suppression drugs. Discontinuation of medication was defined as no refill for the same medication, or for a medication in the same class, within 90 days of discharge from the hospital.

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On average, the patients included in each group were about 75 years of age. The study showed a significant difference in the number of patients resuming the necessary drug therapy after discharge as compared to the control group. Almost 20% of patients on antiplatelet/anticoagulation therapy discontinued their medication within 90 days following their hospital stay. Patients admitted to the ICU during their hospitalization experienced an even higher discontinuation rate (almost 23%) as compared to only 12% in the control group. Patients who were taking levothyroxine experienced interruption of medication at a rate of 12.3% and 15% after acute and ICU admission respectively as compared to 11% in the control group. Statin therapy and medication for the suppression of gastric-acid were not continued at approximately the same rates. Inhaled respiratory medications were also vulnerable to discontinuation, although at much lower rates (4.5% for acute admission and 5.4% for ICU admission as compared to 3% for the control group.) Table 1 presents the adjusted odds ratio for the five medication classes.

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Pharmacists can play an important role in the transition period between hospitalization and home for patients needing chronic drug therapy. A thorough medication history upon intake is an opportunity to review a patient's medication profile and establish a medication baseline that can be used as a reference for discharge counseling.3,4 Discharge counseling on all medications is an ideal way to emphasize the importance of continuing chronic medication and protect the patient from adverse outcomes.

1. 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(8):840-847.   [PubMed: 21862745]
2. Bell CM, Bajcar J, Beirman A, et al. Potentially unintended discontinuation of long-term medication use after elective surgical procedures. Arch Intern Med. 2006;166:2525-2531.   [PubMed: 17159020]
3. Kahn ...

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