Structure and markers of appropriateness, quality and performance of drug treatment over a 1-year period after hospital discharge in a cohort of elderly patients with cardiovascular diseases from Germany

Abstract

In a group of elderly patients over 65 years of age with at least two cardiovascular diagnoses requiring chronic medication (n=424), drug therapy at hospital discharge and at home thereafter was followed for a 1-year period. Two home visits took place at 3 months and 12 months after initial discharge. A median of six prescriptions had already been given at the time of discharge; this number increased slightly during ambulatory follow-up. After 1 year, about 30% of the patients had to take more than ten dosing units per day. After discharge, about 50% of all prescriptions were subject to changes in the choice of the preparation (brand-generic) or the agent used [within a class of similar agents, e.g. angiotensin converting enzyme inhibitors (ACIs)]. The prescription of some problematic agents (benzodiazepines, non-steroidal anti-inflammatory agents) increased during the ambulatory follow-up, but pivotal medications for cardiovascular indications (e.g., ACI) given at discharge were maintained. Over-the-counter (OTC) drugs-which were not part of the discharge medication-contributed to 12% of all drugs taken at V4. The majority of the prescriptions (95% of about 2,000 prescriptions surveyed at each visit) was in agreement with the drug's approval status and was appropriate in terms of absence of contraindications. At home visits, therapy with ACI or beta-blocking agents was in agreement with clinical guidelines, although under-dosing was obvious. Blood pressure control (<140/90 mmHg) was achieved in 61% of the patients at discharge and deteriorated to 45% after 1 year; international normalized ratio control in patients with oral anticoagulation also declined (control rate 57% at discharge, 46% after 1 year). Statins as secondary prevention were given at discharge in only 60% of suitable patients, declining to about 50% in ambulatory visits. Diabetic control was not present in 35% of the patients at discharge or at home. Properties of or reason for their medication could be given for the majority (70-80%) of the prescriptions; these quotations were, however, cursory and almost nothing was known about medication risks. At home visits, non-compliance was admitted for approximately 8% of the prescriptions. In conclusion, for pivotal indications, family doctors widely followed the discharge recommendations, but deficits in ambulatory prescriptions and poor performance of the medication were in part already employed at the time of discharge from the hospital. The lack of a patient's knowledge about their own medication is precarious.

Statins for Secondary Prevention in Elderly Patients

“…There has been a global increase in statin utilization with the emergence of RCT evidence in the past 5 years (55-57) and a few regional increases with the use of knowledge translation programs and quality control initiatives (58 -60). However, recently reported utilization rates of 40% to 60% in elderly patients with active CHD remain suboptimal (5)(6)(7)(8). It is crucial to disseminate the evidence for statins in elderly patients with CHD to increase current utilization rates.…”

“…Coronary heart disease (CHD) is the leading cause of death among elderly patients, with Ͼ80% of coronary deaths occurring in patients over the age of 65 (1). Despite the See page 46 recommendation of the third National Cholesterol Education Program Adult Treatment Panel to intensively lower lipids in elderly patients with CHD (2)(3)(4), statin utilization continues to be 40% to 60% in elderly patients after myocardial infarction (MI) (5)(6)(7)(8). Utilization is suboptimal because evidence has not consistently shown that statins reduce mortality in elderly patients (9 -13).…”

Changes in drug therapy following hospital discharge for patients in a general practice: a German incident study

“…Himmel et al (2004) found changes of about 30% in antihypertensive and cardiac drugs after hospital admission independent of whether the patient was admitted because of cardiac disease or other medical problem. In a 1-year follow-up study, about 50% of all cardiovascular prescriptions were subject to changes in the choice of preparation (brand-generic) or within classes of similar agents prescribed (Harder et al 2005). In a study by Katz et al (1996), treatment changes were almost as common in patients admitted with stable cardiovascular disease as in those requiring rapid drug intervention.…”

Changes in secondary pharmacological prevention of acute coronary syndromes and stroke after hospital discharge: a 6-month follow-up study of German primary care patients

“…This may indicate that some of the attending physicians focused on symptomatic treatment of the medical condition. Patients with ACS took an average of six medications and patients with stroke took an average of five medications, which is in the upper range reported in the literature (Hach et al 2005;Harder et al 2005). It was also found that polypharmacy can be caused by treatment according to evidence-based therapeutic guidelines, which is particularly problematic for elderly and multi-morbid patients (Meinertz and Kähler 2005).…”