Impact of in-hospital medication changes on clinical outcomes in older inpatients: the journey and destination

Abstract

Background Medication review is integral in the pharmacological management of older inpatients. Objective To assess the association of in-hospital medication changes with 28-day postdischarge clinical outcomes. Methods Retrospective cohort of 2000 inpatients aged ≥75 years. Medication changes included the number of increases (medications started or dose-increased) and decreases (medications stopped or dose-decreased) for (i) all medications, (ii) Drug Burden Index (DBI)–contributing medications and (iii) Beers Criteria 2015 medications (potentially inappropriate medications, PIMs). Changes also included differences in (i) the number of medications, (ii) the number of PIMs and (iii) DBI score, at discharge versus admission. Associations with clinical outcomes (28-day ED visit, readmission and mortality) were ascertained using logistic regression, adjusted for age, gender and principal diagnosis. For mortality, sensitivity analysis excluded end-of-life patients due to higher death risk. Patients were stratified into : (i) ≤4, (ii) 5–9 and (iii) ≥10 discharge medications. Results The mean age was 86 years (SD = 5.8), with 59.1% female. Medication changes reduced ED visits and readmission risk for patients prescribed five to nine discharge medications, with no associations in patients prescribed ≤4 and ≥ 10 medications. In the five to nine medications group, decreasing PIMs reduced risks of ED visit (adjusted odds ratio, aOR 0.55, 95% CI 0.34–0.91, P = .02) and readmission (aOR 0.62, 95% CI 0.38–0.99, P = .04). Decreasing DBI-contributing medications reduced readmission risk (aOR 0.71, 95% CI 0.51–0.99, P = .04). Differences in PIMs reduced ED visit risk (aOR 0.65, 95% CI 0.43–0.99, P = .04). There were no associations with mortality in sensitivity analyses in all groups. Discussion Medication changes were associated with reduced ED visits and readmission for patients prescribed five to nine discharge medications.