ObjectivesTo investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs).DesignCohort study.SettingPatients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients’ GPs 4–5 months after patient discharge and recorded any additional drug regimen changes.ResultsIn total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0–16) and 7.6 drugs at discharge (range 1–17). On average, 4.4 drug changes per patient (SD 2.7, range 1–16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0–14) within 4–5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0–13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days.ConclusionsIn addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

The hospital physicians chose anticoagulants based on patient conditions as renal function, bleeding risks, and drug interactions being the most common taken into account. They could not say which NOAC was best, and wish that future studies could compare the different NOACs, and not just compare with warfarin.

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