Inpatient Medication Use Research Articles

#4594 INPATIENT POLYPHARMACY AND THE AGING KIDNEY

Abstract Background and Aims Individuals aged ≥80 years have been found to have some of the highest rates of polypharmacy. Nearly 50% of these people are likely to have significant renal impairment, either from chronic kidney disease or age-related decline. Since many drugs are renally excreted, reduced renal function will cause pharmacokinetic and pharmacodynamic changes. As a result, some medications are inappropriate and there is an increased risk of adverse effects which are dose-related or related to drug interactions. We aim to examine the prevalence of highly renally excreted and nephrotoxic medications taken by our oldest old medical inpatients. Method Data was obtained as part of an ongoing prospective cross-sectional observational study examining polypharmacy in elderly inpatients at Ballina Hospital, Australia. Data as of 03/01/2019 for participants aged ≥80 years were retrieved as part of this nested study involving acute medical inpatients with sufficient capacity to provide informed consent. Exclusion criteria comprised of people with insufficient working knowledge of English, cognitive impairment (including delirium) and those under the age of 80 years. Information with regards to inpatient medication use, co-morbidities and renal function (creatinine clearance, CrCl) were retrieved from inpatient medical records as part of routine clinical care. Renally excreted medications and potential nephrotoxic medications were identified via the Australian Medicines Handbook and Renal Drug Database. Cognition was assessed by the Montreal Cognitive Assessment, multimorbidity via the Charlson Co-morbidity Index and frailty using the Clinical Frailty Score. A polypharmacy questionnaire was used to further probe participant insight and aptitude towards medication use. Results One hundred and five inpatients, with mean age of 86.7 years (range 80.2 to 102.7) met the inclusion criteria and participated in the study. The patients were prescribed an average of 12 medications (range 3–26). They had multiple co-morbidities (mean CCI 6), 64% were assessed to have mild cognitive impairment and 62% were classified as frail. Also, 28% did not know the indication for their medication and 30% reported missing medications. The calculated CrCl ranged from 19–99ml/min, with the majority of patients falling between the range of 30–60ml/min (mean 49ml/min). On average, each patient was taking 1 medication that is ≥50% renally excreted unchanged (or their active metabolites), 1 medication that requires dose reduction when CrCl is 30–60ml/min, 2 medications that require dose reduction when CrCl is 10–30ml/min and 1 medication infrequently or commonly classed as nephrotoxic. The average total number of medications did not change significantly with decrease in CrCl, however, there was a non-significant increase in potentially nephrotoxic medication use. Patients experienced a similar anticholinergic or sedative load (as measured by the drug burden index) regardless of CrCl. Conclusion A substantal burden of medications was found in individuals of advanced age (>80years) with renal impairment. The risk of medication-related harm may be further compounded by age-related barriers and challenges to managing multi-drug regimens. Regular medication reviews are essential for this vulnerable patient group.

The effect of Patient\u2019s Own Medication use on patient\u2019s self-reported medication knowledge during hospitalisation: a pre-post intervention study

BackgroundImproving patient’s medication knowledge and consequently medication use is essential for optimal treatment outcomes. As patient knowledge about medication is currently suboptimal, interventions to optimise medication knowledge are necessary. Implementation of Patient’s Own Medication (POM) in which patients bring their outpatient medication to the hospital, and nurses administer these during admission, may increase medication knowledge. The aim of this study is to explore the impact of POM use on self-reported medication knowledge of hospitalised patients compared to standard care. Patient’s sense of medication safety, attitude to the provision of information, and to inpatient medication use were studied in both standard care and during POM use too.MethodIn this nationwide intervention study perceived medication knowledge was assessed with a questionnaire pre and post implementing POM use. The questionnaire assessed perceived medication knowledge at admission and discharge, medication safety during hospitalisation, the provision of information during hospitalisation and at discharge, and inpatient medication use during hospitalisation. Patients’ answers were categorised into positive and negative/neutral. The proportion of patients with adequate medication knowledge, in the standard care and POM use group at hospital admission and discharge, were calculated and compared with adjustment for potential confounders.ResultsAmong the 731 patients (393 received standard care and 338 POM) who completed the questionnaire (80.2%), POM use seemed to be positively associated with self-reported knowledge on how to use medication at discharge (adjusted OR: 3.22 [95% CI 2.01–5.16]). However, for the other two knowledge related statements POM use was not associated. Medication knowledge at admission was the most important variable associated with perceived medication knowledge at discharge. The majority perceived POM use to be safer (52.9% of standard care patients versus 74.0% POM users; P < 0.01), POM users knew better which medicines they still used during hospitalisation (85.8% versus 92.3% resp.; P = 0.01), and most patients preferred POM use regardless of having experienced it (68.2% versus 82.2% resp.; P < 0.01).ConclusionPOM use positively affects patient’s medication knowledge about how to use medication and patients’ perception of medication safety. With POM use more patients have a positive attitude towards the provision of information. The majority of patients prefer POM use. In conclusion, POM use seems a valuable intervention and requires further investigation.

317 Comparison of One-Day Combined Versus Staged Anterior and Posterior Cervical Decompression, Fixation and Fusion

INTRODUCTION: Current management of cervical stenosis at times can involve both anterior and posterior decompression, stabilization and fusion. Although these procedures can be done in a combined or staged fashion, there is a scarcity of literature on this topic. METHODS: A retrospective cohort analysis was conducted on consecutive patients at a single institution between July 2015 and April 2019 who underwent either single day combined or separate day staged surgeries. Demographics, comorbidities, length of stay, perioperative complications, and inpatient medication use were compared between cohorts. Multivariable analysis was used to adjust for differences in demographics and other confounding covariates. RESULTS: 80 patients were analyzed (combined = 58, staged = 22). Comparing combined versus staged, there were no differences in baseline demographics. The administration of morphine equivalents was similar comparing combined and staged (569 vs 681 morphine equivalents, P = 0.66). Staged patients had significantly longer time in the operating room (7.2 vs 8.5 hours, P &lt; 0.01) and longer duration of general anesthesia (6.7 vs 7.6 hours, P &lt; 0.01). Incidence of post-operation delirium was significantly higher in the staged group (13.2% vs 50.0%), with an adjusted odds ratio of 23.3 (95% CI: 2.6 – 212.1; P &lt; 0.01). Dysphagia was the most common post-operative complication seen in 43 patients (53.7%). Patients age &gt; 60 had total length of stay 39.1% ± 15.0% longer than those age = 60 (multivariable adjusted mean ± standard error; P = 0.02). CONCLUSION: Staging anterior and posterior cervical decompression, stabilization and fusion is associated with longer usage of the operating room, longer duration of general anesthesia, and increased incidence of perioperative complications.

Less Medication Use in Inpatients With Severe Mental Illness Receiving a Multidisciplinary Lifestyle Enhancing Treatment. The MULTI Study III.

Besides having an unhealthy lifestyle contributing to premature mortality, inpatients with severe mental illness (SMI) use high dosages of medication. Previous research has shown improved health after lifestyle improvements in SMI. In addition, we aimed to retrospectively study whether a multidisciplinary lifestyle enhancing treatment (MULTI) was associated with changes in medication use after 18 months, as compared with patients that continued treatment as usual (TAU) and explored mediation by a change in physical activity. We conducted an observational study within a cohort of inpatients with SMI, who received MULTI (N = 65) or continued TAU (N = 49). Data on their somatic and psychotropic medications were collected, converted into defined daily dose (DDD), and analyzed using linear multilevel regression, correcting for baseline value and differences between groups in age, diagnosis, and illness severity. Compared with TAU, the DDD for psychotropic medication significantly decreased with MULTI (B = −0.55, P = 0.02). Changes in total activity did not mediate this association, suggesting that multiple components of MULTI contributed. Corrected between-group analyses for subgroups of medication were not possible due to lack of power and skewed distributions. Within-group data showed a decreased proportion of users as well as median DDD in both groups for almost all medications. In addition to previously reported health improvements after 18 months of MULTI, we observed a significant decrease in dose of psychotropic medication in MULTI compared to TAU. This first study evaluating a wide range of medications indicates a possible effect of lifestyle improvements on medication use in inpatients with SMI. Findings need to be confirmed in future controlled studies, however.

Noncomfort Medication Use in Acute Care Inpatients Comanaged by Palliative Care Specialists Near the End of Life

To examine comfort medication (CM) and noncomfort (NC) medication use in inpatients comanaged by palliative care (PC) near the end of life. Chart review of inpatients comanaged by the PC service at 2 academic hospitals. Medications were categorized as CM and NC medication according to the published guidelines. Seventy patients met inclusion criteria. In the final week of life, inpatients were receiving a mean of 6 CM (40 doses) and 7 NC medications (41 doses). Four new NC medications were started per patient, but only 3 were discontinued. The NC medications were most frequently discontinued on the day of PC consult, but 14% were stopped on the day of death/PC unit transfer. Inpatients comanaged by PC continue to receive NC medications as they near the end of life.

Depressive Störungen im Kindes- und Jugendalter

The present analysis evaluates the prevalence and medication use in inpatients with depression during childhood and adolescence at the KinderAGATE hospitals in 2010. Also discussed are age and sex distribution. Since 2009 the following information has been recorded anonymously twice a year from each patient at the participating hospitals of KinderAGATE: age, sex, leading diagnosis, prescribed medication and dosage. The data obtained provide an excellent epidemiological basis for the observation of the prescription practice in child and adolescent psychiatry. In 2010, 8.4 % of the patients included were treated for a depressive disorder at the KinderAGATE hospitals. This is only a small portion compared to the rates found in adult psychiatry (25.8 % of patients). In our sample male patients diagnosed with depression (58 % DPat, mean age 13.8 years) were treated more often and earlier than female patients (42 % DPat, mean age 15.3 years). Fluoxetine and mirtazapine were the most frequently prescribed substances. Sertraline, escitalopram, and citalopram were also prescribed. A reserved medical treatment can be observed in child and adolescence psychiatry. Off-label use seems to be nearly unavoidable due to the lack of newly authorized medicine. Moreover, the numerous prescriptions for fluoxetine, the only SSRI currently approved for this age group in Germany, lead to the question of possible unauthorized alternatives.

Impact of thromboprophylaxis guidelines on clinical outcomes following total hip and total knee replacement

BackgroundThe American College of Chest Physicians (ACCP) guidelines recommends thromboprophylaxis for total hip replacement (THR) and total knee replacement (TKR) patients. We examined alignment with ACCP thromboprophylaxis guidelines among THR/TKR patients, and compared symptomatic venous thromboembolism (VTE), bleeding event rates and risk factors for VTE between patients receiving ACCP-recommended thromboprophylaxis (‘ACCP’) and those who did not (‘non-ACCP’). MethodsThis retrospective observational study used a large US health plan claims database that was linked to an inpatient database containing detailed inpatient medication use and a database containing date-of-death information. Patients who had THR/TKR surgery between April 01, 2004 and December 31, 2006 were included. Comparisons of VTE and bleeding events between ACCP and non-ACCP patients were analyzed using chi-squared tests and multivariate logistic regression. ResultsOf 3,497 linked patients, 1,395 (40%) received ACCP recommended thromboprophylaxis. Of the patients who received non-ACCP recommended prophylaxis the majority (81%) received shorter than the recommended minimum 10day prophylaxis and 118 (5.6%) of patients received no prophylaxis. Overall, non-ACCP patients were almost twice as likely to experience an incident DVT (3.76% versus 2.01%, p=0.003) and more than eight times as likely to experience an incident PE (1.19% versus 0.14%, p=0.001) relative to ACCP patients; there were no statistically significant difference in bleeding rates. Multivariate logistic regression indicated that the odds of a VTE event were significantly lower for ACCP patients (DVT: OR=0.54; p=0.006; PE: OR=0.12; p=0.004). ConclusionsThis study offers a unique perspective on ‘real-world’ thromboprophylaxis patterns and associated outcomes in THR and TKR patients in the US. It suggests that only 40% of THR/TKR patients receive ACCP-recommended thromboprophylaxis and that not receiving ACCP thromboprophylaxis is an independent risk factor for both DVT and PE.

Perioperative β-Blockade

The Atenolol study of 1996 provided evidence that perioperative β-blockade reduced postsurgical mortality. In 1998, the indications for perioperative β-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Affairs Medical Center. The current study tested the following hypothesis: Is there a difference in mortality rates between patients receiving perioperative atenolol and metoprolol? Epidemiologic analysis of the operations performed at the San Francisco Veterans Affairs Medical Center since 1996 was performed. High-risk inpatients with perioperative β-blockade were divided into two groups: patients who received perioperative atenolol only and those who received metoprolol only. Patients who switched between the two chronic oral β-blocker medications were excluded. IV administration of β-blockers was ignored. Propensity matching analysis was used to correct for population differences in risk factors. There were 38,779 operations performed from 1996 to 2008, with 24,739 inpatient procedures. Based on analysis of inpatient medication use, 3,787 patients received atenolol only (1,011) or metoprolol only (2,776). Thirty-day mortality (atenolol 1% vs. metoprolol 3%, P < 0.0008) and 1-yr mortality (atenolol 7% vs. metoprolol 13%, P < 0.0001) differed between the two β-blockers. Analysis based on inpatient and outpatient β-blocker use showed a similar pattern. Propensity matching that corrected for multiple cardiac risk factors found an odds ratio (OR) of 2.1 [95% CI 1.5-2.9], P < 0.0001 for increased 1-yr mortality with metoprolol for inpatient use. Perioperative β-blockade using atenolol is associated with reduced mortality compared with metoprolol.

Estimating pediatric inpatient medication use in the United States

We demonstrated the feasibility of developing national estimates of pediatric inpatient medication use by analyzing data from a large administrative database. Pediatric inpatient data were extracted from Premier Perspective® database to calculate the prevalence of use of specific medications among hospitalized children in 2008. The database was validated by comparing characteristics to the HCUP KID sample of pediatric hospitalizations for 2006. Prevalence was calculated by categorizing patients as ever or never having received a specific drug. The 10 drugs administered in the most pediatric hospitalizations were acetaminophen, lidocaine, ampicillin, gentamicin, fentanyl, ibuprofen, morphine, ondansetron, ceftriaxone, and albuterol. Although the database is not a probability-based sample, it bears sufficient similarity to a probability-based sample of pediatric hospitalizations (HCUP KID) to serve as a starting point in developing national estimates of inpatient pediatric medication use. Over 500 drug entities were administered to hospitalized children, but most are used by small percentages of hospitalized patients. The small numbers of children using any one drug has implications for efforts to study efficacy and safety, describe off-label use, monitor adverse events, describe practice, and conduct comparative effectiveness research.

Quality Care for Children: Inpatient Medication Use in a Mid-Atlantic Hospital System 2000-2003

The authors report on a preliminary analysis of an electronic database that includes more than 32 000 pediatric hospitalizations during 2000-2003. They analyzed pediatric inpatient medication use in a defined geographic area, the catchment area for the Alfred I. duPont Hospital for Children, serving Delaware, Maryland, New Jersey, and Pennsylvania. The study population included 18 108 female and 14 375 male children. The authors calculated the percentages of children receiving at least 1 administration of each drug. More than 700 drugs were received by children in the study population; 9 were received by at least 10% of all patients. The probability of receiving specific medications varied with patient age, sex, and race, but much further work is needed to quantify the variations. The database has the potential to inform pediatric health services research and pediatric comparative effectiveness research, and it may be the first analysis of hospitalizations for a pediatric population comprising all ages from 0 to 18.

Alignment to ACCP Prophylaxis Guidelines and VTE Outcomes in THR and TKR Patients

Introduction: Venous thromboembolism (VTE) is a serious and sometimes fatal condition, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). Evidence suggests that major orthopaedic surgery, such as total hip replacement (THR) and total knee replacement (TKR), is associated with a high risk of postoperative VTE. Because of this risk, the American College of Chest Physicians (ACCP) guidelines recommend that these patients receive prophylaxis with anticoagulant therapy. However, the degree to which these guidelines are followed in routine practice is variable. In addition, few studies have documented the relationship between the variability in guideline alignment and VTE rates. Therefore, a retrospective database analysis was conducted todetermine the extent to which the ACCP guidelines for VTE prophylaxis are followed after THR/TKR andevaluate the incidence of VTE of those who received ACCP recommended prophylaxis according to the guidelines ('ACCP') and those who did not ('non-ACCP').Methods: In order to fully evaluate VTE prophylaxis patterns and outcomes, patients should be followed from the time of surgery through to hospital discharge and subsequently to care in the community. To our knowledge, a single database that captures this information for a specific patient in these three phases is not yet available. Therefore, a claims database associated with a large US health plan was linked to the Premier database, which provides details of inpatient medication use. Patients age ≥18 years undergoing TKR/THR between April 1, 2004 and December 31, 2007 and enrolled in the health plan 90 days prior to and 90 days following discharge from index hospitalization (or until death) were included in the analysis. Patients were considered to have received ACCP-guideline prophylaxis if they:initiated prophylaxis in hospital with LMWH, fondaparinux, or VKAinitiated prophylaxis within one day of surgery (for THR patients) andwere prescribed prophylaxis for a minimum of ten days, or until the occurrence of a bleeding event, a VTE-related event, or death.In addition, the number of DVTs and PEs occurring in ACCP and non-ACCP patients was recorded. Multivariate logistic regression was used to assess whether there was a significant relationship between ACCP guideline prophylaxis and the probability of a DVT or PE following THR/TKR.Results: Of the 30,644 eligible patients from the health plan, 3,497 patients could be linked to the inpatient database. Except for geographic indicators, there were no significant differences in patient demographics or baseline co-morbidities between those included and excluded from the final study sample. Of the 3,497 linked patients, 1,395 received ACCP guideline prophylaxis (40%). The number of DVTs occurring in the ACCP and non-ACCP groups were 27 and 62, respectively. Thus, 2.01% of ACCP and 3.76% of non-ACCP patients have a DVT following surgery and up to the end of 90-day followup (p=0.0521), suggesting that non-ACCP patients were almost twice as likely as ACCP patients to have a DVT. The number of PEs occurring in the ACCP and non-ACCP groups were 2 and 25, respectively. Thus, 0.14% of ACCP and 1.19% of non-ACCP patients experienced a PE following the date of surgery and up to the end of 90-day follow-up (p<0.0001), suggesting that non-ACCP patients were more than eight times more likely than ACCP patients to experience a PE. Multivariate logistic regression indicated that the probability of DVT and PE were significantly lower in patients receiving ACCP guideline prophylaxis (p=0.008 and p=0.03, respectively)Conclusions: By following patients from surgery through to care in the community, this study offers a unique perspective on ‘real-world’ prophylaxis patterns and clinical outcomes related to such patterns in THR and TKR patients. It suggests that:only 40% of THR/TKR patients receive prophylaxis that is in alignment with ACCP guidelines and thatpatients receiving prophylaxis according to the ACCP guidelines were less likely to have a DVT or PE than those not receiving ACCP guideline prophylaxis, the latter were almost twice as likely to have a DVT and more than eight times as likely to experience a PE.

The Direct Medical Costs Associated with Suspected and Confirmed Cases of Heparin-Induced Thrombocytopenia.

Introduction: Heparin-induced thrombocytopenia (HIT) is a serious adverse reaction associated with heparin exposure. Few studies have assessed the economic burden associated with HIT and none have assessed the costs of suspected HIT. The objective of our study was to identify and quantify the direct medical costs associated with suspected and confirmed cases of HIT from the Canadian hospital perspective.Methods: Over the last 7 years SHSC, a tertiary care adult academic hospital, experienced on average 125 cases of suspected HIT per year. A retrospective burden of illness analysis was conducted to examine the costs associated with suspected and confirmed cases of HIT at SHSC in 2005. Suspected HIT was defined by the performance of a HIT enzyme linked immunosorbent assay (ELISA) from January 1, 2005 to December 31, 2005. Confirmed HIT cases were defined as those who had a positive serotonin release assay (SRA) or a positive HIT ELISA plus a high clinical probability for HIT. In addition, HIT-related resource utilization variables were assessed by chart review and included:1.inpatient medication use;2.laboratory and imaging tests; and3.duration of hospital stay.Physician visits and post-discharge costs were not included in the cost analysis. The average cost per case of confirmed HIT, confirmed HIT with thrombosis (HITT), and negative HIT was calculated in 2007 Canadian dollars. Cost information was obtained from multiple sources, including the pharmacy database (WORx©) and Ontario Health Insurance Program (OHIP) Schedule of Benefits. For this analysis, we did not assume that length of stay (LOS) was prolonged by HIT unless the patient was readmitted with a HIT-related complication. The costs attributable to prolongation of LOS due to HIT or its treatment are being determined, although it is difficult to allocate some costs to the presence of HIT alone. The cost for a negative HIT case only includes the cost of inpatient medication use, laboratory and imaging tests.Results: There were 110 suspected HIT cases in 2005. We excluded 2 patients because their HIT status could not be determined after careful review. There were 88 HIT negative cases, 8 cases with confirmed HIT and 12 with HITT (Table). In this conservative analysis, patients with HITT incurred substantially greater costs than those with HIT. The average attributable cost of managing a HIT negative case was $116. Cardiovascular surgery (CVS) patients accounted for 48% of the suspected HIT cases and 65% of the confirmed cases. This represents 5% and 1% of the 960 CVS patients seen over the year.Conclusions: This is the first study to identify and quantify the direct medical costs associated both with confirmed HIT and HITT and also negative HIT cases. Clearly, if LOS is prolonged by HIT, as has been shown by others, the costs per case will escalate. Cardiovascular surgery cases are being analyzed separately.TableDemographics and Incremental Costs for Suspected HIT Cases (n=108)Negative HITConfirmed HITConfirmed HITTn88812CVS patients (%)44%75%58%Other Surgical patients (%)16%13%8%Medical patients (%)40%12%34%Mean Age ± SD (range)69 ± 13 (19–94)64 ± 12 (47–83)73 ± 7 (59–83)LOS ± SD (range)37 ± 44 (3–244)29 ± 21 (5–62)37 ± 35 (12–128)Average HIT-attributable Cost per Case$116$966$6,762