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Pavon JM, Sloane RJ, Colón-Emeric CS, Pieper CF, Schmader K, Gallagher D, Hastings SN. Central nervous system medication use around hospitalization. J Am Geriatr Soc 2024; 72:1707-1716. [PMID: 38600620 DOI: 10.1111/jgs.18915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. METHODS Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). RESULTS Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. CONCLUSIONS CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.
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Affiliation(s)
- Juliessa M Pavon
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Richard J Sloane
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Cathleen S Colón-Emeric
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Carl F Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Kenneth Schmader
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - David Gallagher
- Department of Medicine/Division of General Internal Medicine/Hospital Medicine, Duke University, Durham, North Carolina, USA
| | - Susan N Hastings
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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Bortolani A, Fantin F, Giani A, Zivelonghi A, Pernice B, Bortolazzi E, Urbani S, Zoico E, Micciolo R, Zamboni M. Predictors of hospital readmission rate in geriatric patients. Aging Clin Exp Res 2024; 36:22. [PMID: 38321332 PMCID: PMC10847193 DOI: 10.1007/s40520-023-02664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/11/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Hospital readmissions among older adults are associated with progressive functional worsening, increased institutionalization and mortality. AIM Identify the main predictors of readmission in older adults. METHODS We examined readmission predictors in 777 hospitalized subjects (mean age 84.40 ± 6.77 years) assessed with Comprehensive Geriatric Assessment (CGA), clinical, anthropometric and biochemical evaluations. Comorbidity burden was estimated by Charlson Comorbidity Index (CCI). Median follow-up was 365 days. RESULTS 358 patients (46.1%) had a second admission within 365 days of discharge. Estimated probability of having a second admission was 0.119 (95%C.I. 0.095-0.141), 0.158 (95%C.I. 0.131-0.183), and 0.496 (95%C.I. 0.458-0.532) at 21, 30 and 356 days, respectively. Main predictors of readmission at 1 year were length of stay (LOS) > 14 days (p < 0.001), albumin level < 30 g/l (p 0.018), values of glomerular filtration rate (eGFR) < 40 ml/min (p < 0.001), systolic blood pressure < 115 mmHg (p < 0.001), CCI ≥ 6 (p < 0.001), and cardiovascular diagnoses. When the joint effects of selected prognostic variables were accounted for, LOS > 14 days, worse renal function, systolic blood pressure < 115 mmHg, higher comorbidity burden remained independently associated with higher readmission risk. DISCUSSION Selected predictors are associated with higher readmission risk, and the relationship evolves with time. CONCLUSIONS This study highlights the importance of performing an accurate CGA, since defined domains and variables contained in the CGA (i.e., LOS, lower albumin and systolic blood pressure, poor renal function, and greater comorbidity burden), when combined altogether, may offer a valid tool to identify the most fragile patients with clinical and functional impairment enhancing their risk of unplanned early and late readmission.
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Affiliation(s)
- Arianna Bortolani
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy.
| | - Francesco Fantin
- Section of Geriatric Medicine, Centre for Medical Sciences - CISMed, Department of Psychology and Cognitive Science, University of Trento, Rovereto (TN), Italy
| | - Anna Giani
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
| | - Alessandra Zivelonghi
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
| | - Bruno Pernice
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
| | - Elena Bortolazzi
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
| | - Silvia Urbani
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
| | - Elena Zoico
- Section of Geriatric Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Rocco Micciolo
- Centre for Medical Sciences, Department of Psychology and Cognitive Sciences, University of Trento, Trento, Italy
| | - Mauro Zamboni
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37126, Verona, Italy
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Schönenberger N, Meyer-Massetti C. Risk factors for medication-related short-term readmissions in adults - a scoping review. BMC Health Serv Res 2023; 23:1037. [PMID: 37770912 PMCID: PMC10536731 DOI: 10.1186/s12913-023-10028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Hospital readmissions due to medication-related problems occur frequently, burdening patients and caregivers emotionally and straining health care systems economically. In times of limited health care resources, interventions to mitigate the risk of medication-related readmissions should be prioritized to patients most likely to benefit. Focusing on general internal medicine patients, this scoping review aims to identify risk factors associated with drug-related 30-day hospital readmissions. METHODS We began by searching the Medline, Embase, and CINAHL databases from their inception dates to May 17, 2022 for studies reporting risk factors for 30-day drug-related readmissions. We included all peer-reviewed studies, while excluding literature reviews, conference abstracts, proceeding papers, editorials, and expert opinions. We also conducted backward citation searches of the included articles. Within the final sample, we analyzed the types and frequencies of risk factors mentioned. RESULTS After deduplication of the initial search results, 1159 titles and abstracts were screened for full-text adjudication. We read 101 full articles, of which we included 37. Thirteen more were collected via backward citation searches, resulting in a final sample of 50 articles. We identified five risk factor categories: (1) patient characteristics, (2) medication groups, (3) medication therapy problems, (4) adverse drug reactions, and (5) readmission diagnoses. The most commonly mentioned risk factors were polypharmacy, prescribing problems-especially underprescribing and suboptimal drug selection-and adherence issues. Medication groups associated with the highest risk of 30-day readmissions (mostly following adverse drug reactions) were antithrombotic agents, insulin, opioid analgesics, and diuretics. Preventable medication-related readmissions most often reflected prescribing problems and/or adherence issues. CONCLUSIONS This study's findings will help care teams prioritize patients for interventions to reduce medication-related hospital readmissions, which should increase patient safety. Further research is needed to analyze surrogate social parameters for the most common drug-related factors and their predictive value regarding medication-related readmissions.
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Affiliation(s)
- N Schönenberger
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - C Meyer-Massetti
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Healthcare (BIHAM), University of Bern, Bern, Switzerland
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Akkawi ME, Abd Aziz HH, Fata Nahas AR. The Impact of Potentially Inappropriate Medications and Polypharmacy on 3-Month Hospital Readmission among Older Patients: A Retrospective Cohort Study from Malaysia. Geriatrics (Basel) 2023; 8:geriatrics8030049. [PMID: 37218829 DOI: 10.3390/geriatrics8030049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Potentially inappropriate medications (PIMs) use and polypharmacy are two issues that are commonly encountered among older people. They are associated with several negative outcomes including adverse drug reactions and medication-related hospitalization. There are insufficient studies regarding the impact of both PIMs and polypharmacy on hospital readmission, especially in Malaysia. AIM To investigate the possible association between polypharmacy and prescribing PIMs at discharge and 3-month hospital readmission among older patients. MATERIALS AND METHOD A retrospective cohort study involved 600 patients ≥60 years discharged from the general medical wards in a Malaysian teaching hospital. The patients were divided into two equal groups: patients with or without PIMs. The main outcome was any readmission during the 3-month follow-up. The discharged medications were assessed for polypharmacy (≥five medications) and PIMs (using 2019 Beers' criteria). Chi-square test, Mann-Whitney test, and a multiple logistic regression were conducted to study the impact of PIMs/polypharmacy on 3-month hospital readmission. RESULTS The median number for discharge medications were six and five for PIMs and non-PIMs patients, respectively. The most frequently prescribed PIMs was aspirin as primary prevention of cardiovascular diseases (33.43%) followed by tramadol (13.25%). The number of medications at discharge and polypharmacy status were significantly associated with PIMs use. Overall, 152 (25.3%) patients were re-admitted. Polypharmacy and PIMs at discharge did not significantly impact the hospital readmission. After applying the logistic regression, only male gender was a predictor for 3-month hospital readmission (OR: 2.07, 95% CI: 1.022-4.225). CONCLUSION About one-quarter of the patients were admitted again within three months of discharge. PIMs and polypharmacy were not significantly associated with 3-month hospital readmissions while male gender was found to be an independent risk factor for readmission.
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Affiliation(s)
- Muhammad Eid Akkawi
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan 25150, Malaysia
- Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan 25150, Malaysia
| | - Hani Hazirah Abd Aziz
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan 25150, Malaysia
| | - Abdul Rahman Fata Nahas
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan 25150, Malaysia
- Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan 25150, Malaysia
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What Is the Medication Iatrogenic Risk in Elderly Outpatients for Chronic Pain? Clin Neuropharmacol 2022; 45:65-71. [PMID: 35579486 DOI: 10.1097/wnf.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Medication iatrogeny is a major public health problem that increases as the population ages. Therapeutic escalation to control pain and associated disorders could increase polypharmacy and iatrogeny. This study aimed to characterize the medication iatrogenic risk of elderly outpatients with chronic pain. METHODS This was a prospective cohort study recruiting patients 65 years or older with chronic pain. A medication iatrogenic assessment was performed based on the best possible medication history to record risk of adverse drug events (Trivalle score), STOPP (Screening Tool of Older Person's Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria, and potentially inappropriate medications. RESULTS We recruited 100 patients with an average age of 71 years. The median number of medications before pain consultation was 8 (interquartile range = [7;11]). Trivalle score showed that 43% of patients were at moderate or high medication iatrogenic risk. Before consultation, 79% and 75% of patients had at least 1 STOPP or START criterion on their orders, respectively. One-third of orders mentioned benzodiazepine prescribed for more than 4 weeks. At least 1 potentially inappropriate medication was prescribed for 54% of the patients, with a median of 1 per patient (interquartile range = [0;1]). A combination of several anticholinergics was prescribed in 23% of patients. CONCLUSION Elderly patients with chronic pain are at risk of medication iatrogeny. Preventive measures as multidisciplinary medication review could reduce the iatrogenic risk in these outpatients.This study is registered at clinicaltrials.gov as NCT04006444 on July 3, 2019.
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El Abd A, Schwab C, Clementz A, Fernandez C, Hindlet P. Safety of Elderly Fallers: Identifying Associated Risk Factors for 30-Day Unplanned Readmissions Using a Clinical Data Warehouse. J Patient Saf 2022; 18:230-236. [PMID: 34419990 DOI: 10.1097/pts.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital readmissions are a major problem in the older people as they are frequent, costly, and life-threatening. Falls among older adults are the leading cause of injury, deaths, and emergency department visits for trauma. OBJECTIVE The main objective was to determine risk factors associated with a 30-day readmission after index hospital admission for fall-related injuries. METHODS A retrospective nested case-control study was conducted. Data from elderly patients initially hospitalized for fall-related injuries in 2019, in 11 of the Greater Paris University Hospitals and discharged home, were retrieved from the clinical data warehouse. Cases were admission of elderly patients who subsequently experienced a readmission within 30 days after discharge from the index admission. Controls were admission of elderly patients who were not readmitted to hospital. RESULTS Among 670 eligible index admissions, 127 (18.9%) were followed by readmission within 30 days after discharge. After multivariate analysis, men sex (odds ratio [OR] = 2.29, 95% confidence interval [CI] = 1.45-3.61), abnormal concentration of C-reactive protein, and anemia (OR = 2.22, 95% CI = 1.28-3.85; OR = 1.85, 95% CI = 1.11-3.11, respectively) were associated with a higher risk of readmission. Oppositely, having a traumatic injury at index admission decreased this risk (OR = 0.47, 95% CI = 0.28-0.81). CONCLUSIONS Reducing early unplanned readmission is crucial, especially in elderly patients susceptible to falls. Our results indicate that the probability of unplanned readmission is higher for patients with specific characteristics that should be taken into consideration in interventions designed to reduce this burden.
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Affiliation(s)
- Asmae El Abd
- From the GHU AP-HP.Sorbonne Université, Hôpital Saint Antoine, Service Pharmacie, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris
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7
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Mohanty SD, Lekan D, McCoy TP, Jenkins M, Manda P. Machine learning for predicting readmission risk among the frail: Explainable AI for healthcare. PATTERNS (NEW YORK, N.Y.) 2022; 3:100395. [PMID: 35079714 PMCID: PMC8767300 DOI: 10.1016/j.patter.2021.100395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/29/2021] [Accepted: 11/02/2021] [Indexed: 01/23/2023]
Abstract
Healthcare costs due to unplanned readmissions are high and negatively affect health and wellness of patients. Hospital readmission is an undesirable outcome for elderly patients. Here, we present readmission risk prediction using five machine learning approaches for predicting 30-day unplanned readmission for elderly patients (age ≥ 50 years). We use a comprehensive and curated set of variables that include frailty, comorbidities, high-risk medications, demographics, hospital, and insurance utilization to build these models. We conduct a large-scale study with electronic health record (her) data with over 145,000 observations from 76,000 patients. Findings indicate that the category boost (CatBoost) model outperforms other models with a mean area under the curve (AUC) of 0.79. We find that prior readmissions, discharge to a rehabilitation facility, length of stay, comorbidities, and frailty indicators were all strong predictors of 30-day readmission. We present in-depth insights using Shapley additive explanations (SHAP), the state of the art in machine learning explainability.
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Affiliation(s)
- Somya D. Mohanty
- Department of Computer Science, University of North Carolina at Greensboro, Petty Building, Greensboro 27403, NC, USA
| | - Deborah Lekan
- School of Nursing, University of North Carolina at Greensboro, Petty Building, Greensboro 27403, NC, USA
| | - Thomas P. McCoy
- School of Nursing, University of North Carolina at Greensboro, Petty Building, Greensboro 27403, NC, USA
| | | | - Prashanti Manda
- Informatics and Analytics, University of North Carolina at Greensboro, 500 Forest Building, Greensboro 27403, NC, USA
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Hwang AB, Schuepfer G, Pietrini M, Boes S. External validation of EPIC's Risk of Unplanned Readmission model, the LACE+ index and SQLape as predictors of unplanned hospital readmissions: A monocentric, retrospective, diagnostic cohort study in Switzerland. PLoS One 2021; 16:e0258338. [PMID: 34767558 PMCID: PMC8589185 DOI: 10.1371/journal.pone.0258338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 09/24/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction Readmissions after an acute care hospitalization are relatively common, costly to the health care system, and are associated with significant burden for patients. As one way to reduce costs and simultaneously improve quality of care, hospital readmissions receive increasing interest from policy makers. It is only relatively recently that strategies were developed with the specific aim of reducing unplanned readmissions using prediction models to identify patients at risk. EPIC’s Risk of Unplanned Readmission model promises superior performance. However, it has only been validated for the US setting. Therefore, the main objective of this study is to externally validate the EPIC’s Risk of Unplanned Readmission model and to compare it to the internationally, widely used LACE+ index, and the SQLAPE® tool, a Swiss national quality of care indicator. Methods A monocentric, retrospective, diagnostic cohort study was conducted. The study included inpatients, who were discharged between the 1st of January 2018 and the 31st of December 2019 from the Lucerne Cantonal Hospital, a tertiary-care provider in Central Switzerland. The study endpoint was an unplanned 30-day readmission. Models were replicated using the original intercept and beta coefficients as reported. Otherwise, score generator provided by the developers were used. For external validation, discrimination of the scores under investigation were assessed by calculating the area under the receiver operating characteristics curves (AUC). Calibration was assessed with the Hosmer-Lemeshow X2 goodness-of-fit test This report adheres to the TRIPOD statement for reporting of prediction models. Results At least 23,116 records were included. For discrimination, the EPIC´s prediction model, the LACE+ index and the SQLape® had AUCs of 0.692 (95% CI 0.676–0.708), 0.703 (95% CI 0.687–0.719) and 0.705 (95% CI 0.690–0.720). The Hosmer-Lemeshow X2 tests had values of p<0.001. Conclusion In summary, the EPIC´s model showed less favorable performance than its comparators. It may be assumed with caution that the EPIC´s model complexity has hampered its wide generalizability—model updating is warranted.
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Affiliation(s)
- Aljoscha Benjamin Hwang
- Staff Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- * E-mail:
| | - Guido Schuepfer
- Staff Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Mario Pietrini
- Staff Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Mudumbai SC, Chung P, Nguyen N, Harris B, Clark JD, Wagner TH, Giori NJ, Stafford RS, Mariano ER. Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients. PAIN MEDICINE 2021; 21:595-603. [PMID: 31309970 DOI: 10.1093/pm/pnz154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? METHODS We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. RESULTS The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. CONCLUSIONS Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | | | | | | | - J David Clark
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Todd H Wagner
- Center for Innovation to Implementation.,Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Nicholas J Giori
- Orthopaedic Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Departments of Orthopaedic Surgery
| | - Randall S Stafford
- Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Klinge M, Aasbrenn M, Öztürk B, Christiansen CF, Suetta C, Pressel E, Nielsen FE. Readmission of older acutely admitted medical patients after short-term admissions in Denmark: a nationwide cohort study. BMC Geriatr 2020; 20:203. [PMID: 32527311 PMCID: PMC7291666 DOI: 10.1186/s12877-020-01599-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/01/2020] [Indexed: 12/02/2022] Open
Abstract
Background Knowledge of unplanned readmission rates and prognostic factors for readmission among older people after early discharge from emergency departments is sparse. The aims of this study were to examine the unplanned readmission rate among older patients after short-term admission, and to examine risk factors for readmission including demographic factors, comorbidity and admission diagnoses. Methods This cohort study included all medical patients aged ≥65 years acutely admitted to Danish hospitals between 1 January 2013 and 30 June 2014 and surviving a hospital stay of ≤24 h. Data on readmission within 30 days, comorbidity, demographic factors, discharge diagnoses and mortality were obtained from the Danish National Registry of Patients and the Danish Civil Registration System. We examined risk factors for readmission using a multivariable Cox regression to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for readmission. Results A total of 93,306 patients with a median age of 75 years were acutely admitted and discharged within 24 h, and 18,958 (20.3%; 95% CI 20.1 - 20.6%) were readmitted with a median time to readmission of 8 days (IQR 3 - 16 days). The majority were readmitted with a new diagnosis. Male sex (aHR 1.15; 1.11 - 1.18) and a Charlson Comorbidity Index ≥3 (aHR 2.28; 2.20 - 2.37) were associated with an increased risk of readmission. Discharge diagnoses associated with increased risk of readmission were heart failure (aHR 1.26; 1.12 - 1.41), chronic obstructive pulmonary disease (aHR 1.33; 1.25 - 1.43), dehydration (aHR 1.28; 1.17 - 1.39), constipation (aHR 1.26; 1.14 - 1.39), anemia (aHR 1.45; 1.38 - 1.54), pneumonia (aHR 1.15; 1.06 - 1.25), urinary tract infection (aHR 1.15; 1.07 - 1.24), suspicion of malignancy (aHR 1.51; 1.37 - 1.66), fever (aHR 1.52; 1.33 - 1.73) and abdominal pain (aHR 1.12; 1.05 - 1.19). Conclusions One fifth of acutely admitted medical patients aged ≥65 were readmitted within 30 days after early discharge. Male gender, the burden of comorbidity and several primary discharge diagnoses were risk factors for readmission.
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Affiliation(s)
- M Klinge
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - M Aasbrenn
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Öztürk
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - C F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - C Suetta
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Geriatric Research Unit, Department of Medicine, Herlev-Gentofte Hospitals, Copenhagen, Denmark.,CopenAge - Copenhagen Center for Clinical Age Research, University of Copenhagen, Copenhagen, Denmark
| | - E Pressel
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - F E Nielsen
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark. .,Department of Emergency Medicine, Slagelse Hospital, Bispebjerg and Frederiksberge, Denmark. .,Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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11
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Neville HL, Losier M, Pitman J, Gehrig M, Isenor JE, Minard LV, Penny E, Bowles SK. Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients. Can J Hosp Pharm 2020; 73:193-201. [PMID: 32616945 PMCID: PMC7308153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood. OBJECTIVES To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada. METHODS A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed. RESULTS Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001). CONCLUSIONS BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.
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Affiliation(s)
- Heather L Neville
- , BScPharm, MSc, FCSHP, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Mia Losier
- , BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with Horizon Health Network, Saint John, New Brunswick
| | - Jennifer Pitman
- , BScMedSc, BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with the Vancouver Island Health Authority, Victoria, British Columbia
| | - Melissa Gehrig
- , BSc(Hons), BScPharm, MSc, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Jennifer E Isenor
- , BScPharm, PharmD, is with the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
| | - Laura V Minard
- , BSc, BScPharm, ACPR, PhD, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Ellen Penny
- , BScPharm, PharmD, BCGP, is with the Nova Scotia Health Authority, Sydney, Nova Scotia
| | - Susan K Bowles
- , BScPhm, MSc, PharmD, FCSHP, is with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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12
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Predictors of hospital readmission among older adults with cancer. J Geriatr Oncol 2020; 11:1108-1114. [PMID: 32222347 DOI: 10.1016/j.jgo.2020.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/01/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Older adults with cancer are at higher risk for costly and potentially dangerous hospital readmissions. Identifying risk factors for readmission in this population is important for future prevention of readmission. MATERIALS AND METHODS Hospital discharges among patients ≥ 65 years with solid tumors on non-surgical services from 2006-2011 were reviewed in this matched case-control study. We abstracted patient/cancer characteristics; functional status; fall risk; chemotherapy line; comorbidities; laboratory values; discharge parameters; and miscellaneous information (Do Not Resuscitate Order, pain scores) from medical records. Conditional logistic regression was used for univariate and multivariable analysis. RESULTS This analysis included 184 case-patients readmitted within 30 days after discharge from the index admission and 184 sex- and age-matched control-patients discharged from index admission within three months of the cases with no readmission. Cases and controls had no differences in terms of primary cancer type, treatment, and index admission reason. Cases were more likely to have abnormal hemoglobin, albumin, sodium, and SGOT on discharge. Compared to those with ≤1 abnormal laboratory test, patients with 2 or more abnormal test results were 3 times more likely to be readmitted within 30 days. CONCLUSION This study demonstrated that older adults with cancer who had at least 2 abnormal laboratory results (hemoglobin, albumin, sodium, and SGOT) at discharge were 3 times more likely to be readmitted within 30 days compared to those with ≤1 abnormal results. These laboratory values may be predictive of the risk of readmission, and should be monitored before discharge to potentially prevent readmission.
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13
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Leffler ME, Elliott DP, Thompson S, Dean LS. Medication‐related readmission risk assessment in older adult patients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michaela E. Leffler
- Pharmacy Practice Department University of Charleston School of Pharmacy Charleston West Virginia
- Pharmacy Department Charleston Area Medical Center Charleston West Virginia
| | - David P. Elliott
- Charleston Division West Virginia University School of Pharmacy Charleston West Virginia
| | - Stephanie Thompson
- Charleston Area Medical Center (CAMC) Health Education and Research Institute Charleston West Virginia
| | - Leighton Scott Dean
- Charleston Area Medical Center (CAMC) Health Education and Research Institute Charleston West Virginia
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14
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Turbow S, Shah K, Penziner K, Knauss M. Evaluation of a Pharmacist-Based Intervention to Reduce Readmissions in Geriatric High-Utilizer Patients: A Pilot Study. Innov Pharm 2019; 10. [PMID: 34007551 PMCID: PMC7592867 DOI: 10.24926/iip.v10i2.1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose The goal of this study was to determine if a pharmacist-led intervention to improve medication safety at hospital discharge reduced the number of hospital readmissions among geriatric high-utilizer patients. This study is the first to test a pharmacist-based intervention in a high-utilizer population. Methods This was a quasi-experimental pilot study done at a safety-net hospital in the southeastern US. Fifty-seven patients 65 years old and older who were in the 95th percentile for number of hospital admissions in a year were included. On the day of discharge, one of the study pharmacists reviewed the discharge medication list and calculated the Medication Appropriateness Index (MAI) for each medication and reviewed for Beers Criteria. Any medication identified as potentially high-risk or inappropriate was flagged by the pharmacist and discussed with the team. The primary outcome was the number of admissions in the year following the intervention in the intervention group versus the control group. Results There were no statistically significant differences in the number of admissions, the MAI scores, or the number of medications meeting Beers Criteria between the two groups. Conclusion Although this study did not demonstrate a decrease in hospital admissions, it shows that pharmacist review of medications at discharge can identify potentially unnecessary medications that could lead to confusion or adverse events. Further research is necessary to identify interventions to prevent readmissions in this high-risk population.
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Affiliation(s)
- Sara Turbow
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kruti Shah
- Department of Pharmacy Services, Grady Health System, Atlanta, GA
| | | | - Michael Knauss
- Department of Pharmacy Services, Grady Health System, Atlanta, GA
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15
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Blanc AL, Fumeaux T, Stirnemann J, Dupuis Lozeron E, Ourhamoune A, Desmeules J, Chopard P, Perrier A, Schaad N, Bonnabry P. Development of a predictive score for potentially avoidable hospital readmissions for general internal medicine patients. PLoS One 2019; 14:e0219348. [PMID: 31306461 PMCID: PMC6629067 DOI: 10.1371/journal.pone.0219348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 06/21/2019] [Indexed: 11/26/2022] Open
Abstract
Background Identifying patients at high risk of hospital preventable readmission is an essential step towards selecting those who might benefit from specific transitional interventions. Objective Derive and validate a predictive risk score for potentially avoidable readmission (PAR) based on analysis of readmissions, with a focus on medication. Design/Setting/Participants Retrospective analysis of all hospital admissions to internal medicine wards between 2011 and 2014. Comparison between patients readmitted within 30 days and non-readmitted patients, as identified using a specially designed algorithm. Univariate and multivariate regression analyses of demographic data, clinical diagnoses, laboratory results, and the medication data of patients admitted during the first period (2011–2013), to identify factors associated with PAR. Using these, derive a predictive score with a regression coefficient-based scoring method. Subsequently, validate this score with a second cohort of patients admitted in 2013–2014. Variables were identified at hospital discharge. Results The derivation cohort included 7,317 hospital stays. Multivariate logistic regressions found significant associations with PAR for: [adjusted OR (95% CI)] hospital length of stay > 4 days [1.3 (1.1–1.7)], admission in previous 6 months [2.3 (1.9–2.8)], heart failure [1.3 (1.0–1.7)], chronic ischemic heart disease [1.7 (1.2–2.3)], diabetes with organ damage [2.2 (1.3–3.8)], cancer [1.4 (1.0–1.9)], metastatic carcinoma [1.9 (1.3–3.0)], anemia [1.2 (1.0–1.5)], hypertension [1.3 (1.1–1.7)], arrhythmia [1.3 (1.0–1.6)], hyperkalemia [1.4 (1.0–1.7)], opioid drug prescription [1.3 (1.1–1.6)], and acute myocardial infarction [0.6 (0.4–0.9)]. The PAR-Risk Score, derived from these results, demonstrated fair discriminatory and calibration power (C-statistic = 0.699; Brier Score = 0.069). The results for the validation cohort’s operating characteristics were similar (C-statistic = 0.687; Brier Score = 0.064). Conclusion This study identified routinely-available factors that were significantly associated with PAR. A predictive score was derived and internally validated.
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Affiliation(s)
- Anne-Laure Blanc
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland
- Pharmacie Interhospitalière de la Côte, Morges, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- * E-mail:
| | - Thierry Fumeaux
- Groupement hospitalier de l’ouest lémanique (GHOL), Nyon, Switzerland
| | - Jérôme Stirnemann
- Department of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Elise Dupuis Lozeron
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Aimad Ourhamoune
- Department of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
- Division of Quality of Care, Medical and Quality Directorate, Geneva University Hospitals, Geneva, Switzerland
| | - Jules Desmeules
- Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Chopard
- Department of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
- Division of Quality of Care, Medical and Quality Directorate, Geneva University Hospitals, Geneva, Switzerland
| | - Arnaud Perrier
- Department of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Schaad
- Pharmacie Interhospitalière de la Côte, Morges, Switzerland
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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Ticinesi A, Nouvenne A, Prati B, Lauretani F, Morelli I, Tana C, Fabi M, Meschi T. Profiling the hospital-dependent patient in a large academic hospital: Observational study. Eur J Intern Med 2019; 64:41-47. [PMID: 30819605 DOI: 10.1016/j.ejim.2019.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND In older patients with acute illness, a condition of "hospital-dependence" may arise: patients get adapted to the hospital care and, once discharged, may experience health status decline, requiring repeated readmissions despite appropriate treatments. AIMS The objective of this case-series study was to describe the characteristics of 118 patients (72 F) aged ≥75 (mean 83.7 ± 4.9) who were urgently admitted to our institution at least 4 times in 2015. METHODS For each patient and admission, data on multimorbidity (Cumulative Illness Rating Scale Comorbidity Score and Severity Index), frailty (Rockwood Clinical Frailty Scale), functional dependence, functional status, polypharmacy, length of stay and interval between admissions were extrapolated from clinical records. Mortality during the years 2015 and 2016 was assessed on the institutional database. RESULTS At the first admission, patients had a high burden of polypharmacy (median number of drugs 8.5, IQR 6-11) and multimorbidity (Comorbidity Score 15.8 ± 4.1, Severity Index 2.9 ± 1.1). However, most (55.5%) were fit or pre-frail according to Clinical Frailty Scale (score 1-4). At multivariate models, Severity Index was significantly correlated with the length of stay (β ± SE 2.23 ± 0.89, p = .01) and readmission interval (β ± SE -22.49 ± 9.27, p = .02). Significantly increasing trends of multimorbidity and disability occurred across admissions. By the end of 2016, 66% of patients had died. Frailty (RR 2.005, 95%CI 1.054-3.814, p = .007) and cancer were the only predictors of mortality. CONCLUSIONS Hospital-dependent patients had severe multimorbidity, but exhibited an unexpectedly low prevalence of frailty/disability at baseline, though increasing across admissions. Trends of frailty and multimorbidity are paramount for profiling the hospital-dependence risk.
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Affiliation(s)
- Andrea Ticinesi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy.
| | - Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Fulvio Lauretani
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Ilaria Morelli
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Claudio Tana
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Massimo Fabi
- General Management, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Tiziana Meschi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
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17
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McAuliffe LH, Zullo AR, Dapaah-Afriyie R, Berard-Collins C. Development and validation of a transitions-of-care pharmacist tool to predict potentially avoidable 30-day readmissions. Am J Health Syst Pharm 2018; 75:111-119. [PMID: 29371191 DOI: 10.2146/ajhp170184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A practical tool for predicting the risk of 30-day readmissions using data readily available to pharmacists before hospital discharge is described. METHODS A retrospective cohort study to identify predictors of potentially avoidable 30-day readmissions was conducted using transitions-of-care pharmacy notes and electronic medical record data from a large health system. Through univariate and multivariable logistic regression analyses of factors associated with unplanned readmissions in the study cohort (n = 690) over a 22-month period, a risk prediction tool was developed. The tool's discriminative ability was assessed using the C statistic; its calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. RESULTS Three factors predictive of readmission risk were identified; these variables-medication count, comobidity count, and health insurance status at discharge-form the 3-predictor MEDCOINS score. Among patients identified as being at high risk for readmission using the MEDCOINS tool, the estimated readmission risk was 22.5%, as compared with an observed readmission rate of 21.9%. The discriminatory performance of MEDCOINS scoring was fair (C statistic = 0.65 [95% confidence interval, 0.60-0.70]), with good calibration (Hosmer-Lemeshow p = 0.99). CONCLUSION Among a cohort of patients who were seen by a transitions-of-care pharmacist during an inpatient hospitalization, comorbidity burden, number of medications, and health insurance coverage were most predictive of 30-day readmission. The MEDCOINS tool was found to have fair discriminative ability and good calibration.
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Affiliation(s)
| | - Andrew R Zullo
- Lifespan Corporation-Rhode Island Hospital, Providence, RI.,Department of Health Services, Policy, and Practice, Brown University, Providence, RI
| | | | - Christine Berard-Collins
- Lifespan Corporation-Rhode Island Hospital, The Miriam Hospital, Bradley Hospital, Lifespan Pharmacy, LLC, Providence, RI
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Izumi S(S, Basin B, Presley M, McCalmont J, Furuno JP, Noble B, Baggs JG, Curtis JR. Feasibility and Acceptability of Nurse-Led Primary Palliative Care for Older Adults with Chronic Conditions: A Pilot Study. J Palliat Med 2018; 21:1114-1121. [PMID: 29792733 PMCID: PMC6916529 DOI: 10.1089/jpm.2017.0666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many older adults live with serious illness for years before their death. Nurse-led primary palliative care could improve their quality of life and ability to stay in their community. OBJECTIVES To assess feasibility and acceptability of a nurse-led Transitional Palliative Care (TPC) program for older adults with serious illness. METHODS The study was a pilot trial of the TPC program in which registered nurses assisted patients with symptom management, communication with care providers, and advance care planning. Forty-one older adults with chronic conditions were enrolled in TPC or standard care groups. Feasibility was assessed through enrollment and attrition rates and degree of intervention execution. Acceptability was assessed through surveys and exit interviews with participants and intervention nurses. RESULTS Enrollment rate for those approached was 68%, and completion rate for those enrolled was 71%. The TPC group found the intervention acceptable and helpful and was more satisfied with care received than the control group. However, one-third of participants perceived that TPC was more than they needed, despite the number of symptoms they experienced and the burdensomeness of their symptoms. More than half of the participants had little to no difficulty participating in daily activities. CONCLUSION This study demonstrated that the nurse-led TPC program is feasible, acceptable, and perceived as helpful. However, further refinement is needed in selection criteria to identify the population who would most benefit from primary palliative care before future test of the efficacy of this intervention.
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Affiliation(s)
| | - Basilia Basin
- Oregon Health and Science University School of Nursing, Portland, Oregon
| | - Margo Presley
- Department of Multnomah County Health, Portland, Oregon
| | | | - Jon P. Furuno
- Department of Pharmacy Practice, OSU/OHSU College of Pharmacy, Portland, Oregon
| | - Brie Noble
- Department of Pharmacy Practice, OSU/OHSU College of Pharmacy, Portland, Oregon
| | - Judith G. Baggs
- Oregon Health and Science University School of Nursing, Portland, Oregon
| | - J. Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
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Gers L, Petrovic M, Perkisas S, Vandewoude M. Antidepressant use in older inpatients: current situation and application of the revised STOPP criteria. Ther Adv Drug Saf 2018; 9:373-384. [PMID: 30364909 DOI: 10.1177/2042098618778974] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/01/2018] [Indexed: 11/15/2022] Open
Abstract
Objectives Antidepressant use increases as age rises. Moreover, older patients are more sensitive to side effects and drug interactions. This descriptive study aims to map antidepressant use among patients at the geriatrics department of a university hospital and to evaluate whether prescribing happens in an evidence-based manner. Methods Patients aged 75 years and over, admitted to the geriatrics department of the Middelheim Hospital in Antwerp between February and July 2017 were included. We checked whether they took antidepressants, which types and doses were prescribed, who prescribed the antidepressants, and whether prescribing was in concordance with the revised STOPP (Screening Tool of Older People's Prescriptions) criteria. Results Out of the 239 included patients, 61 were found to use antidepressants, with depression being the most important indication. General practitioners appeared to be the most frequent prescribers. Trazodone was the most prescribed antidepressant and was often used for sleeping disorders. Antidepressants were taken longer than recommended in almost one out of five cases. Patients with diabetes and renal insufficiency were prescribed antidepressants less frequently. Only 2.8% of the study participants were prescribed antidepressants for anxiety disorders. Conclusion We can conclude that prescription of antidepressants in older patients at the geriatrics department is often not evidence based. Clear guidelines may offer a solution; therefore more studies are needed on antidepressant use in older patients.
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Affiliation(s)
- Lynn Gers
- Department of Geriatric Medicine, University of Antwerp, Antwerp, Belgium
| | - Mirko Petrovic
- Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium
| | - Stany Perkisas
- Department of Geriatric Medicine, University of Antwerp, Antwerp, Belgium
| | - Maurits Vandewoude
- Department of Geriatric Medicine, University of Antwerp, ZNA Sint-Elisabeth, Leopoldstraat 26, Antwerp, Antwerp 2000, Belgium
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Schwab C, Korb-Savoldelli V, Escudie JB, Fernandez C, Durieux P, Saint-Jean O, Sabatier B. Iatrogenic risk factors associated with hospital readmission of elderly patients: A matched case-control study using a clinical data warehouse. J Clin Pharm Ther 2018; 43:393-400. [PMID: 29446115 DOI: 10.1111/jcpt.12670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/09/2018] [Indexed: 12/29/2022]
Abstract
WHAT IS KNOWN Hospital readmission within 30 days of patient discharge has become a standard to judge the quality of hospitalizations. It is estimated that 14% of the elderly, people over 75 years old or those over 65 with comorbidities, are at risk of readmission, of which 23% are avoidable. It may be possible to identify elderly patients at risk of readmission and implement steps to reduce avoidable readmissions. OBJECTIVE The aim of this study was to identify iatrogenic risk factors for readmission. The secondary objective was to evaluate the rate of drug-related readmissions (DRRs) among all readmissions and compare it to the rate of readmissions for other reasons. METHODS We conducted a retrospective, matched, case-control study to identify non-demographic risk factors for avoidable readmission, specifically DRRs. The study included patients hospitalized between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases consisted of patients readmitted to the emergency department within 30 days of initial discharge. Controls did not return to the emergency department within 30 days. Cases and controls were matched on sex and age because they are known as readmissions risk factors. After comparison of the mean or percentage between cases and controls for each variable, we conducted a conditional logistic regression. RESULTS The risk factors identified were an emergency admission at the index hospitalization, returning home after discharge, a history of unplanned readmissions and prescription of nervous system drugs. Otherwise, 11.4% of the readmissions were DRRs, of which 30% were caused by an overdose of antihypertensive. The number of drugs at readmission was higher, and potentially inappropriate medications were more widely prescribed for DRRs than for readmissions for other reasons. WHAT IS NEW AND CONCLUSION In this matched case-control retrospective study, after controlling for gender and age, we identified the typical profile of elderly patients at risk of readmission. These patients had an unplanned admission at the index hospitalization and prescribed nervous system drugs at discharge from the index admission; they have a history of unplanned readmission within 30 days and return home after discharge.
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Affiliation(s)
- C Schwab
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - V Korb-Savoldelli
- Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France.,Université Paris-Sud, Faculté de Pharmacie, Châtenay-Malabry, France
| | - J B Escudie
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Département de Santé Publique et Informatique Médicale, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - C Fernandez
- Université Paris-Sud, Faculté de Pharmacie, Châtenay-Malabry, France.,Service de Pharmacie, Hôpital Saint-Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, UMR-S 1136, Institut Pierre Louis D'Epidémiologie et de Santé Publique, Paris, France
| | - P Durieux
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Département de Santé Publique et Informatique Médicale, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - O Saint-Jean
- Faculté de Médecine, Université Paris-Descartes, Paris, France.,Service de Gériatrie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - B Sabatier
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
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Abstract
Hypnotics (sleeping pills) are prescribed widely, but the economic costs of the harm they have caused have been largely unrecognized. Randomized clinical trials have observed that hypnotics increase the incidence of infections. Likewise, hypnotics increase the incidence of major depression and cause emergency admissions for overdoses and deaths. Epidemiologically, hypnotic use is associated with cancer, falls, automobile accidents, and markedly increased overall mortality. This article considers the costs to hospitals and healthcare payers of hypnotic-induced infections and other severe consequences of hypnotic use. These are a probable cause of excessive hospital admissions, prolonged lengths of stay at increased costs, and increased readmissions. Accurate information is scanty, for in-hospital hypnotic benefits and risks have scarcely been studied -- certainly not the economic costs of inpatient adverse effects. Healthcare costs of outpatient adverse effects likewise need evaluation. In one example, use of hypnotics among depressed patients was strongly associated with higher healthcare costs and more short-term disability. A best estimate is that U.S. costs of hypnotic harms to healthcare systems are on the order of $55 billion, but conceivably might be as low as $10 billion or as high as $100 billion. More research is needed to more accurately assess unnecessary and excessive hypnotics costs to providers and insurers, as well as financial and health damages to the patients themselves.
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Affiliation(s)
- Daniel F Kripke
- University of California San Diego, La Jolla, CA, 92037-2226, USA
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22
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Pek EA, Remfry A, Pendrith C, Fan-Lun C, Bhatia RS, Soong C. High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among Hospitalized Older Adults. J Hosp Med 2017; 12:310-316. [PMID: 28459898 DOI: 10.12788/jhm.2739] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions. OBJECTIVE To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions. DESIGN Single-center retrospective observational study. SETTING Urban academic medical center. PARTICIPANTS Medical-surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone. MEASUREMENTS Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random-intercept logistic regression model to identify patient- and prescriber-level variables that were associated with potentially inappropriate prescriptions. RESULTS Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70-16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first-year trainees (OR, 0.28; 95% CI, 0.08-0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21-9.06). CONCLUSIONS The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first-year trainees.Journal of Hospital Medicine 2017;12:310-316.
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Affiliation(s)
| | - Andrew Remfry
- Department of Medicine, University of Toronto, Ontario
| | - Ciara Pendrith
- Institute of Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario
| | - Chris Fan-Lun
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Ontario; Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario; Division of Cardiology, Women's College Hospital and University Health Network, Toronto, Ontario; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Christine Soong
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario; Division of General Internal Medicine, Sinai Health System, Toronto, Ontario; Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario
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Li H, Guffey W, Honeycutt L, Pasquale T, Rozario NL, Veverka A. Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot. Hosp Pharm 2016; 51:744-751. [PMID: 27803504 DOI: 10.1310/hpj5109-744] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To evaluate the impact of a multifaceted, pharmacy-driven, unit-based transitions of care (TOC) program on all-cause 30-day readmission rates and to assess readmission rates in predefined subgroup patient populations. Methods: This prospective study included adult patients who were discharged from the pilot unit from January 5 to January 30, 2015. Patients who expired during hospitalization, left the hospital against medical advice, or transferred to another unit or nonaffiliated hospital were excluded. Possible pharmacist interventions included daily medication profile review, delivery of discharge medications to the bedside, counseling, and communication of a discharge medication list to follow-up providers. Patients had a 30-day follow-up period from the date of discharge to assess for readmission. Results: A total of 131 patients were screened and 94 patients were included. The primary outcome evaluating 30-day readmission rates occurred in 12.8% of patients in the pilot group versus 18.8% of patients in the historical control group (p = .26). None of the patients who received all possible pharmacist interventions were readmitted. Secondary outcomes assessing readmission rates in predefined subgroup populations as well as length of stay were comparable between the 2 groups. All identified medication discrepancies were resolved prior to discharge. Conclusion: Readmission rates during the pilot were numerically lower but not statistically significant when compared with historical data. Enhancement of the pharmacy-driven TOC services through allocation of additional resources is in progress. Further investigation is warranted to determine the impact of a TOC pharmacist after the service is sustained.
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Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res 2016; 5:918. [PMID: 27303633 PMCID: PMC4890308 DOI: 10.12688/f1000research.8729.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 09/02/2023] Open
Abstract
This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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25
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Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res 2016; 5:918. [PMID: 27303633 PMCID: PMC4890308 DOI: 10.12688/f1000research.8729.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 12/14/2022] Open
Abstract
This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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26
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Abstract
This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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27
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Blagburn J, Kelly-Fatemi B, Akhter N, Husband A. Person-centred pharmaceutical care reduces emergency readmissions. Eur J Hosp Pharm 2015; 23:80-85. [PMID: 27019710 PMCID: PMC4789703 DOI: 10.1136/ejhpharm-2015-000736] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/06/2015] [Accepted: 08/12/2015] [Indexed: 11/07/2022] Open
Abstract
Background Unplanned readmissions to hospital are used in many healthcare systems as a quality indicator of care. Identifying patients at risk of readmission is difficult; existing prediction tools are only moderately sensitive. Correlations exist between certain medicines and emergency readmission, but it is not known whether the association is direct or indirect. Objectives To determine whether person-centred pharmaceutical care bundles, comprising individualised medicines information, risk management and/or support in taking medicines, might prevent unplanned readmissions by improving adherence and reducing avoidable harm from prescribed medications. Methods We designed and implemented person-centred pharmaceutical care bundles for patients who were socially isolated and/or on high-risk medicines on one older people's medical ward for 1 year from February 2013. Another ward with similar patient demographics, service characteristics and a standard clinical pharmacy service was used as a comparator in a prospective cohort study. Readmission rates were retrospectively studied for 12 months before the intervention and during the 12-month intervention period. Results The readmission rates for the intervention and control wards in the 12 months before the intervention were not significantly different. During the intervention period, the readmission rate was significantly lower on the intervention ward (69/418) than on the control ward (107/490; 17% vs 22%, p<0.05, z=2.05, two-sample z test for difference in proportions of unrelated samples). Conclusions Person-centred pharmaceutical care bundles were significantly associated with reduced risk of emergency hospital readmission in this study. Further evaluation of the model is warranted.
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Affiliation(s)
- Julia Blagburn
- Pharmacy Department , Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Freeman Hospital , Newcastle-upon-Tyne , UK
| | - Ben Kelly-Fatemi
- Pharmacy Department , Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Freeman Hospital , Newcastle-upon-Tyne , UK
| | - Nasima Akhter
- Wolfson Research Institute for Health and Wellbeing, Durham University, Queen's Campus, University Boulevard , Thornaby-On-Tees , UK
| | - Andy Husband
- Division of Pharmacy , School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard , Thornaby-On-Tees , UK
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28
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Chiang LY, Liu J, Flood KL, Carroll MB, Piccirillo JF, Stark S, Wang A, Wildes TM. Geriatric assessment as predictors of hospital readmission in older adults with cancer. J Geriatr Oncol 2015; 6:254-61. [PMID: 25976445 PMCID: PMC4536088 DOI: 10.1016/j.jgo.2015.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/31/2015] [Accepted: 04/21/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hospital readmission is a common, costly problem. Little is known regarding risk factors for readmission in older adults with cancer. This study aims to identify factors associated with 30-day readmission in a cohort of older medical oncology patients. SETTING/PARTICIPANTS Adults age 65 and over hospitalized to an Oncology Acute Care for Elders Unit at Barnes-Jewish Hospital. MEASUREMENTS Standard geriatric screening tests were administered in routine clinical care. Clinical data and 30-day readmission status were obtained through medical record review. RESULTS 677 patients met the inclusion criteria. 77% were white and 53% were male. Thoracic (32%), hematologic (20%), and gastrointestinal (18%) malignancies were most common. The 30-day unplanned readmission rate was 35.2%. Multivariable analyses identified complete dependence in feeding (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.29-10.65), and some dependence (1.58, 1.04-2.41) and complete dependence (2.64, 1.70-4.12) in housekeeping, prior to admission, as associated with higher odds of readmission. Age<75 (1.49, 1.04-2.14), African-American race (1.59, 1.06-2.39), potentially inappropriate medications (1.36, 0.94-1.99), and higher-risk reasons for index admission (1.93, 1.34-2.78) also increased odds of readmission. These factors were organized into a prognostic index. CONCLUSION Hospital readmission was common and higher than previously reported rates in general medical populations. We identified several previously unrecognized factors associated with increased risk for readmission, including some geriatric assessment parameters, and developed a practical tool that can be used by clinicians to assess risk of 30-day readmission.
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Affiliation(s)
- Leslie Y Chiang
- Washington University School of Medicine, St. Louis, United States
| | - Jingxia Liu
- Washington University School of Medicine, St. Louis, United States
| | | | - Maria B Carroll
- Washington University School of Medicine, St. Louis, United States
| | - Jay F Piccirillo
- Washington University School of Medicine, St. Louis, United States
| | - Susan Stark
- Washington University School of Medicine, St. Louis, United States
| | - Adam Wang
- Washington University School of Medicine, St. Louis, United States
| | - Tanya M Wildes
- Washington University School of Medicine, St. Louis, United States.
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Pace R, Spevack R, Menendez C, Kouriambalis M, Green L, Jayaraman D. Ability of nurse clinicians to predict unplanned returns to hospital within thirty days of discharge. Hosp Pract (1995) 2014; 42:62-8. [PMID: 25485918 DOI: 10.3810/hp.2014.12.1159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the ability of nurse clinician discharge flow coordinators (DFCs) to identify medical patients at risk of unplanned return to the hospital emergency department within 30 days of discharge and whether a higher predicted risk of return was correlated with preventability. DESIGN Prospective cohort study of patients discharged from medical wards at 2 hospital sites of the McGill University Health Center between September 1, 2011, and January 1, 2012. METHODS Univariate and multivariate analyses of factors including the ability of DFCs to predict 30-day unplanned returns to the hospital. Assessment of the preventability of returns to the hospital was performed by chart review using prespecified criteria. The ability of DFCs to predict returns was compared to the LACE criteria (length of stay, acute admission through the emergency department, comorbidities, and emergency department visits in the past 6 months). RESULTS We found that 25.0% (95% CI, 21.3-28.5) of our patients returned to the emergency department within 30 days. The DFC predictions were found to be significant in both univariate and multivariate analysis. Patient age, sex, and length of stay were not significant predictors in univariate or multivariate analysis; 13.9% (95% CI, 8.2-19.6) of returns were preventable and a further 25.8% (95% CI, 18.1-33.5) were potentially preventable with added services in the community. There was a trend toward more preventable or potentially preventable returns with higher predicted probability of return. In contrast the LACE criteria did not have a good predictive capacity in our patient population. CONCLUSION In a large urban center, experienced nurse clinician DFCs were able to predict 30-day emergency department returns with reasonable accuracy. They were also able to identify the returns to the hospital that were most likely to be preventable. Our data suggests that DFCs can be used to target patients identified as having an increased probability of return with interventions that may be able to reduce the burden of return to hospital.
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Affiliation(s)
- Romina Pace
- Department of Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Garrido MM, Prigerson HG, Penrod JD, Jones SC, Boockvar KS. Benzodiazepine and sedative-hypnotic use among older seriously Ill veterans: choosing wisely? Clin Ther 2014; 36:1547-54. [PMID: 25453732 DOI: 10.1016/j.clinthera.2014.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/09/2014] [Accepted: 10/10/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE The 2014 American Geriatrics Society's Choosing Wisely list cautions against the use of any benzodiazepines or other sedative-hypnotics (BSHs) as initial treatments for agitation, insomnia, or delirium in older adults. Because these symptoms are prevalent among hospitalized patients, seriously ill older adults are at risk of receiving these potentially inappropriate medications. The objectives of this study were to understand the extent to which potentially inappropriate BSHs are being used in hospitalized, seriously ill, older veterans and to understand what clinical and sociodemographic characteristics are associated with potentially inappropriate BSH use. METHODS We reviewed medical records of 222 veterans aged ≥65 years who were hospitalized in an acute care facility in the New York-New Jersey metropolitan region in fiscal years 2009 and 2010. Veterans had diagnoses of advanced cancer, chronic obstructive pulmonary disease, congestive heart failure, and/or HIV/AIDS and received inpatient palliative care. Associations among potentially inappropriate BSH use (BSHs for indications other than alcohol withdrawal and current generalized anxiety disorder or one-time use before a medical procedure) and clinical and sociodemographic characteristics were examined with multivariable logistic regression. FINDINGS One-fifth of the sample was prescribed a potentially inappropriate BSH during the index hospitalization during the study period (n = 47). The most commonly prescribed potentially inappropriate medications were zolpidem (n = 26 [11.7%]) and lorazepam (n = 19 [8.9%]). Hispanic ethnicity was significantly associated with prescription of potentially inappropriate BSHs among the entire sample (adjusted odds ratio [AOR] = 3.79; 95% CI, 1.32-10.88) and among patients who survived until discharge (n = 164; AOR = 5.28; 95% CI, 1.64-17.07). Among patients who survived until discharge, black patients were less likely to be prescribed potentially inappropriate BSHs than white patients (AOR = 0.35; 95% CI, 0.13-0.997), and patients who had past-year BSH prescriptions were more likely to be prescribed a potentially inappropriate BSH than patients without past-year BSH use. IMPLICATIONS The potentially inappropriate BSHs documented in our sample included short- and intermediate-acting benzodiazepines, medications that were not identified as potentially inappropriate for older adults until after these data were collected. Few long-acting benzodiazepines were recorded, suggesting that the older veterans in our sample were receiving medications according to the guidelines in place at the time of hospitalization. Clinicians may be able to reduce prescriptions of newly identified inappropriate BSHs by being aware of medications patients received before hospitalization and by being cognizant of racial/ethnic disparities in symptom management. Future studies should explore reasons for disparities in BSH prescriptions.
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Affiliation(s)
- Melissa M Garrido
- James J. Peters Veterans Affairs Medical Center, Bronx, New York; Icahn School of Medicine at Mount Sinai, New York, New York.
| | | | - Joan D Penrod
- James J. Peters Veterans Affairs Medical Center, Bronx, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shatice C Jones
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Kenneth S Boockvar
- James J. Peters Veterans Affairs Medical Center, Bronx, New York; Icahn School of Medicine at Mount Sinai, New York, New York; Jewish Home Lifecare, New York, New York
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