Intensification of older adults’ outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

Anderson, Timothy S.; Wray, Charlie M; Jing, Bocheng; Fung, Kathy Z.; Ngo, Sarah; Xu, Edison; Shi, Ying; Steinman, Michael A.

doi:10.1136/bmj.k3503

Cited by 29 publications

(43 citation statements)

References 23 publications

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“…We identified intensifications based on a previously validated algorithm comparing medications in use prior to hospital admission with medications prescribed at hospital discharge. 3,15 We defined medications in use at hospital admission as the latest pharmacy fill being for a quantity sufficient to last until at least 60 days before admission. Discharge medications were defined as prescriptions filled by the outpatient VHA pharmacy between 2 days before and 2 days after discharge and prescriptions filled by the inpatient pharmacy on the day of discharge with a supply of at least 7 days.…”

Section: Identifying Medication Intensificationsmentioning

confidence: 99%

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

et al. 2020

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IMPORTANCE Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. OBJECTIVE To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. MAIN OUTCOMES AND MEASURES Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. RESULTS Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A 1c (HbA 1c) level less than 7.0%, and 1044 (6%) had an HbA 1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA 1c , while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA 1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA 1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. CONCLUSIONS AND RELEVANCE In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA 1c goal.

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Section: Identifying Medication Intensificationsmentioning

confidence: 99%

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

et al. 2020

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“…The second article discusses, the lack of anticoagulant prescribing when clinically indicated 16 . The third article highlights the high prevalence of ADEs in older adults, 24 and the fourth calls attention to intensifying antihypertensive medications 23 …”

Section: Discussionmentioning

confidence: 99%

“…This is one of the first studies to examine the clinical outcomes associated with intensification of antihypertensives at hospital discharge, finding an increased risk of readmission and serious adverse events with no improvement in blood pressure control. These findings have potentially significant clinical implications given that older adults are frequently discharged from hospital settings with intensified antihypertensive regimens 23 . While it may be necessary to adjust antihypertensive therapy during hospitalization, it is important for inpatient clinicians to consider their decisions based on outpatient hypertension control, medication adherence and previous medications prescribed.…”

Section: Summary Of Studiesmentioning

confidence: 99%

Medication Use Quality and Safety in Older Adults: 2019 Update

Ailabouni

Marcum

Schmader

et al. 2021

J American Geriatrics Society

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Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected highquality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital readmission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

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“…In the BMJ this week (doi:10.1136/bmj.k3503), Anderson and colleagues report a retrospective cohort analysis of older adults admitted to hospital, conducted using national inpatient and outpatient Veterans Affairs pharmacy data merged with Veterans Affairs and Medicare claims data 3. The study investigated the frequency of intensification of antihypertensive treatment at hospital discharge (a new or higher dose antihypertensive at discharge compared with treatment before admission).…”

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confidence: 99%