Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population

<div><p>Background</p><p>Therapeutic interchange of a same class medication for an outpatient medication is a widespread practice during hospitalization in response to limited hospital formularies. However, therapeutic interchange may increase risk of medication errors. The objective was to characterize the prevalence and safety of therapeutic interchange.</p><p>Methods and findings</p><p>Secondary analysis of a transitions of care study. We included patients over age 64 admitted to a tertiary care hospital between 2009–2010 with heart failure, pneumonia, or acute coronary syndrome who were taking a medication in any of six commonly-interchanged classes on admission: proton pump inhibitors (PPIs), histamine H₂-receptor antagonists (H2 blockers), hydroxymethylglutaryl CoA reductase inhibitors (statins), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and inhaled corticosteroids (ICS). There was limited electronic medication reconciliation support available. Main measures were presence and accuracy of therapeutic interchange during hospitalization, and rate of medication reconciliation errors on discharge. We examined charts of 303 patients taking 555 medications at time of admission in the six medication classes of interest. A total of 244 (44.0%) of medications were therapeutically interchanged to an approved formulary drug at admission, affecting 64% of the study patients. Among the therapeutically interchanged drugs, we identified 78 (32.0%) suspected medication conversion errors. The discharge medication reconciliation error rate was 11.5% among the 244 therapeutically interchanged medications, compared with 4.2% among the 311 unchanged medications (relative risk [RR] 2.75, 95% confidence interval [CI] 1.45–5.19).</p><p>Conclusions</p><p>Therapeutic interchange was prevalent among hospitalized patients in this study and elevates the risk for potential medication errors during and after hospitalization. Improved electronic systems for managing therapeutic interchange and medication reconciliation may be valuable.</p></div

Flow diagram of study participants.

<p>Flow diagram of study participants.</p

Medications of interest characterized by drug class, formulary status and therapeutic interchange.

<p>Medications of interest characterized by drug class, formulary status and therapeutic interchange.</p

Characteristics of patients in each cohort^a.

<p>Characteristics of patients in each cohort<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0186075#t002fn001" target="_blank">^a</a>.</p

Suspected medication reconciliation errors at discharge, characterized by type.

<p>Suspected medication reconciliation errors at discharge, characterized by type.</p

Predictors for patients understanding reason for hospitalization

<div><p>Objective</p><p>To examine predictors for understanding reason for hospitalization.</p><p>Methods</p><p>This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home.</p><p>Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview. Predictors assessed were the following: jargon on discharge instructions, type of medical team, whether outpatient provider knew if the patient was admitted, and whether the patient reported more than one day notice before discharge.</p><p>Results</p><p>Among 377 patients, 59.8% of patients completely understood their diagnosis. Bivariate analyses demonstrated that outpatient provider being aware of admission and having more than a day notice prior to discharge were not associated with patient understanding diagnosis. Presence of jargon was not associated with increased likelihood of understanding in a multivariable analysis. Patients on housestaff and cardiology teams were more likely to understand diagnosis compared to non-teaching teams (OR 2.45, 95% CI 1.30–4.61, p<0.01 and OR 3.83, 95% CI 1.92–7.63, p<0.01, respectively).</p><p>Conclusions</p><p>Non-teaching team patients were less likely to understand their diagnosis. Further investigation of how provider-patient interaction differs among teams may aid in development of tools to improve hospital to community transitions.</p></div

Association of jargon and medical team with completely understanding diagnosis (n = 336).

<p>Association of jargon and medical team with completely understanding diagnosis (n = 336).</p

Baseline characteristics of the study cohort (n = 374).

<p>Baseline characteristics of the study cohort (n = 374).</p