BACKGROUND: Prescribing of potentially harmful medications has not been well documented in hospitals. OBJECTIVE: The objective of the study was to determine the rate of and factors associated with potentially inappropriate medication (PIM) prescribing in a large inpatient sample. DESIGN: The study was a retrospective cohort of the period between September 1, 2002, and June 30, 2005. We used multivariable logistic regression to identify patient, physician, and hospital characteristics associated with PIM prescribing. SETTING: The study collected data from 384 US hospitals. PATIENTS: The sample was composed of patients aged ≥65 years admitted with 1 or more of 7 common medical diagnoses. MEASUREMENTS: The percentage of patients prescribed PIMs as defined using a modified Beers list was measured. Multivariable‐adjusted odds ratios for PIM use were computed. RESULTS: Of the 493,971 patients, 49% received at least 1 PIM, and 6% received 3 or more, most commonly promethazine, diphenhydramine, and propoxyphene. Patient, physician, and hospital characteristics were all associated with PIM use. Patients with myocardial infarction or heart failure were most likely (61% and 52% vs. 46% for pneumonia), men (47% vs. 49% for women) and those in managed care plans (44% vs. 49% for other plans) were less likely, and patients ≥85 years were least likely (42% vs. 53% for patients aged 65–74 years) to receive PIMs (P < .0001 for all comparisons). For high‐severity PIMs, internists and hospitalists had similar prescribing rates (33%), cardiologists had a higher rate (48%), and geriatricians had the lowest rate (24%). The proportion of elders receiving PIMs ranged from 34% in the Northeast to 55% in the South, and variation at the individual hospital level was extreme. At 7 hospitals, PIMs were never prescribed. CONCLUSIONS: Wide variation in the use of PIMs is associated with hospital and physician characteristics. Care may be improved by minimizing this non‐patient‐centered variation. Journal of Hospital Medicine 2008;3:91–102. © 2008 Society of Hospital Medicine.

Hypothesis: Among geriatric patients undergoing abdominal surgery who are at high risk for in-hospital delirium, clinical factors associated with delirium correlate with adverse outcomes. Design: Retrospective case series study. Setting: University-affiliated referral hospital. Patients: Among 228 consecutive patients 70 years or older who underwent major abdominal surgery from September 1, 2002, through December 31, 2003, 89 patients with risk factors for delirium were included in the study. Main Outcome Measures: Preoperative, intraoperative, and postoperative clinical factors known to affect the incidence of in-hospital delirium were tested for correlation with adverse outcomes. Incidence of delirium, mortality, and prolonged length of stay (LOS) of 14 days or longer were evaluated as adverse outcomes. Results: Postoperative delirium occurred in 60%, death in 20%, and prolonged LOS in 32% of patients. Multivariate analysis identified independent predictors of adverse outcomes. Poor preoperative functional and nutritional status correlated with postoperative delirium and mortality. Inadequate postoperative glycemic control also correlated with mortality. Complications in 2 or more organ systems and postoperative hypoalbuminemia (albumin level Ͻ3.0 mg/dL[Ͻ.003 g/dL; to convert to grams per liter, multiply by 10]) correlated with prolonged LOS. Suboptimal care was identified in the following clinical areas: use of precipitative medications, prolonged bedrest, uncontrolled pain, hypoxia, and glycemic control. Conclusions: In a subset of geriatric patients undergoing abdominal surgery who are at high risk for inhospital delirium, adverse outcomes correlated only with key clinical variables, such as hyperglycemia and poor nutritional and functional states. A high incidence of suboptimal care was observed in several clinical areas, suggesting opportunities for intervention.

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