Medication omission at discharge is the most common type of medication discrepancy.
Medication omission at discharge is the most common type of medication discrepancy.
Patients who are hospitalized on one drug regimen are often discharged on an entirely different set of medications. Medication additions, deletions, or modifications are usually necessary to address the precipitating event and fine-tune the patient’s medications, because treating new conditions creates new potential drug interactions. However, several studies indicate that medication omission at discharge—simply forgetting to include medication(s)— is the most common type of medication discrepancy.1,2
Medications associated with endocrine conditions are among the most frequently omitted.1 People with diabetes and/or who have a myocardial infarction (MI) are at risk for 3 reasons. First, patients who experience an MI often have an elevated blood glucose level, regardless of whether they had been diagnosed with diabetes before the MI. They may continue to have an elevated blood glucose level after the MI, and may receive a diagnosis of diabetes. Second, patients with diabetes are at elevated risk for cardiovascular disease. Third, research has found that approximately 12% of patients with diabetes admitted to a hospital for MI were discharged without antihyperglycemic therapy (AHT). This increased the 1-year mortality rate in untreated patients.3
We need to heighten awareness of the need to resume or continue AHT after MI.
Holding AHT in the Hospital: It’s Reasonable
Clinical guidelines frequently recommend holding AHT (especially oral agents) during hospitalization, as insulin therapy is preferred.4 In lieu of oral therapy, the American Diabetes Association (ADA) recommends5:
Although there are other legitimate reasons for discontinuing AHT (Table 15), it’s often difficult to determine why medications are held or discontinued. A recent study found that in 327 records of patients whose AHT had been discontinued during hospitalization, 96% contained no explanation.6 Patients also tend to be discharged without standard cardiovascular therapies (aspirin, beta-blockers, 3-hydroxy-3-methylglutaryl- CoA reductase inhibitor) following acute MI. This indicates poor overall discharge planning, not just poor diabetes care. Clinicians shouldn’t assume that patients will continue their AHT after discharge, or that health care professionals involved in outpatient follow-up will handle AHT.
The Insulin-MI Conundrum
There is wide variation in the way hospitals approach hyperglycemia after MI.7 Pharmacists should note that, despite recommendations in most clinical guidelines to treat hyperglycemia in MI patients, clinicians have been hesitant to implement intensive glucose control because clinical trials have reported conflicting results. Observational studies indicate that hyperglycemia is common and increases mortality and complications. These studies show that tighter glucose control improves outcomes in hospitalized MI patients.8-14
More structured clinical trials examining targeted glucose control among MI patients have had recruitment and methodological problems, and have yielded conflicting results.15-17Further, a large recent study compared aggressive glucose control with more conservative control, finding that patients in the aggressive treatment arm were at greater risk for death.18 It’s confusing. Regardless, patients whose diabetes predates their MI will most likely receive insulin during hospitalization and will need continuing AHT at discharge.
Once MI patients who have received insulin are stabilized and are able to eat regularly, the hospital team should consider reinstituting oral and injectable noninsulin therapies. It’s also appropriate to restart them in anticipation of discharge. The ADA cautions that clinicians should start metformin only if the patient has no evidence of renal insufficiency, an unstable hemodynamic status, or a need for an imaging study that requires a radiocontrast dye.5
At Discharge: Pay Attention
It’s difficult to know if AHT is discontinued because prescribers forget to restart it or decide it’s not needed. To reduce mortality, good data support continuing AHT in older patients who have had a recent acute MI.3 Although the question of whether long-term glycemic control prevents future cardiovascular events is unanswered, the effects of hyperglycemia are generally believed to be more pronounced in patients who are older, have a longer duration of diabetes, or have comorbidities.5 The Agency for Healthcare Research and Quality has made recommendations concerning discharge (Online Table 219).
Table 2: Agency for Healthcare Research and Quality Hospital Discharge Recommendations
Complete all of the following before patients are discharged:
· Medication reconciliation: Perform a crosscheck to ensure that (1) no long-term but still necessary medications were stopped inadvertently and (2) new prescriptions will be safe in the outpatient setting and with the patient’s other medications.
· Give patients and their caretakers the opportunity to fill and review new or changed medications before discharge.
· Provide accurate, structured discharge communication to each patient’s health care providers regarding medication changes, pending tests and studies, and follow-up needs.
· Transmit discharge summaries to the patient’s primary physician as soon as possible after discharge.
· Schedule outpatient medical follow-up appointments with primary care providers, endocrinologists, and diabetes educators, which improve appointment-keeping behavior and medical outcomes.
Adapted from reference 19.
In the Ambulatory Setting
Ambulatory care pharmacists can help at care transitions. The simple act of asking patients about recent hospitalizations and reviewing their medications with them can help identify gaps and omissions. Educating patients about their medications and their disease also helps. Increasingly, ambulatory care pharmacies are offering medication therapy management, and helping their pharmacists expand their expertise in diabetes and cardiac care. As pharmacists move toward recognition as providers, they will need to improve their documentation skills and act assertively when they see medication problems.20
Virginia Bartok is a pharmacist whose primary practice was in indigent care. She currently provides case management for several geriatric patients, and reports many medication reconciliation problems after hospital discharge
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17. Cheung NW, Wong VW, McLean M. The hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) study. Diabetes Care. 2006;29:765-770.
18. The NICE-Sugar Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.
19. Agency for Healthcare Research and Quality. Adverse events after hospital discharge. http://psnet.ahrq.gov/primer.aspx?primerID=11. Accessed August 21, 2014.
20. Helling DK, Johnson SG. Defining and advancing ambulatory care pharmacy practice: it is time to lengthen our stride. Am J Health Syst Pharm. 2014;71:1348-1356.