The January edition of ‘Eyes on Evidence’, the free monthly e-bulletin from NHS Evidence covering major new evidence as it emerges with an explanation about what it means for current practice, includes an expert commentary on new evidence from a population-based cohort study evaluating the rates of potentially unintentional discontinuation of medications following hospital or ICU admission.
The study included 396,380 people aged 66 or older who were prescribed at least one of five medical groups for long-term use (statins; antiplatelet/anticoagulant agents; levothyroxine; respiratory inhalers, and gastric acid suppressing drugs).
Patients who had a deliberate reason for stopping medication were excluded.
The study reported that people admitted to hospital were more likely to experience unintentional discontinuation of long-term medications for chronic diseases. Admission to an ICU was associated with an additional risk of medication discontinuation in four out of the five medication groups, compared to hospitalisations without an ICU admission.
According to the expert commentary, “This study demonstrates that transitions between health care locations increase the risk of discontinuities in care, measured as chronic prescription omissions. It shows that these discontinuities affect both the primary and secondary care interface and locations within hospital, that critical illness and intensive care admission add to the risk, and that the prescription omissions may cause patient harm.”
"The rate of discontinuation varied by drug class, but was as high as twice that of the control group. The large number of concurrent medications (median 12) demonstrates both the complexity of current medical practice, and the substantial opportunity for error which this creates. In a UK setting it is possible that a greater proportion of these omissions would eventually have been detected by a patient's GP, but this cannot be assumed. These findings provide further evidence that improving reliable delivery of best practice care is an important public health issue, and require a systems-wide approach.”
"Greater awareness of the problem must be fostered. Better documentation of the patient journey would be a good place to start – it is remarkably difficult to provide a clear visual representation of a patient's hospitalisation once this exceeds a week or so. Including a pharmacist in ward rounds, and reviewing patient prescriptions the day before hospital discharge, would also help. A list of pre-admission prescriptions compared with those at discharge would draw attention to omissions, whether intentional or inadvertent.”
"Electronic prescribing and patient information systems can incorporate prompts and reminders to support clinicians, and allow drugs to be suspended temporarily rather than discontinued. These systems can also be extended across the secondary-primary healthcare divide. The design of electronic systems requires the close involvement of end-users in a 'bottom-up' adaptive process, usually taking several years to attain maturity, and must also include the capacity for audit and performance feedback. In a research context, the Health Foundation is currently evaluating prescribing reliability through its Safer Clinical Systems programme, which will provide additional insights into barriers to and facilitators of best practice."
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