Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure

Somnath Bose; Danielle Groat; Joanna L Stollings; Patrick Barney; Victor D Dinglas; Valerie M Goodspeed; Harris Carmichael; Mustafa Mir-Kasimov; James C Jackson; Dale M Needham; Samuel M Brown; Carla M Sevin; APICS-01 Study Team

doi:10.1016/j.aucc.2024.02.001

Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure

Aust Crit Care. 2024 Apr 29:S1036-7314(24)00030-4. doi: 10.1016/j.aucc.2024.02.001. Online ahead of print.

Authors

Collaborators

APICS-01 Study Team:
Julia Crane¹¹, Benjamin Hoenig¹¹, Maria Karamourtopoulos¹¹, Julia Larson¹¹, Andre De Souza Licht¹¹, Isabel Londoño¹¹, Andrew Toksoz-Exley¹¹, Alison Turnbull¹², Narjes Akhlaghi¹², Swetha Aloori¹², Elise Caraker¹², Sai Phani Sree Cherukuri¹², Naga Preethi Kadiri¹², Mounica Koneru¹², Pooja Kota¹², Mounika Lakhmalla¹², Emma Maelian Lee¹², Mazin Ali Mahmoud¹², Albahi Malik¹², Roozbeh Nikooie¹², Darin Roberts¹², Sriharsha Singu¹², Sarah Beesley¹³, Ramona O Hopkins¹³, Brent Armbruster¹³, Valerie Aston¹³, Katie Brown¹³, Austin Daw¹³, Melissa Fergus¹³, Ellie Hirshberg¹³, Naresh Kumar¹³, Rilee Smith¹³, Craig High¹⁴, Emily Beck¹⁴, Rebecca Abel¹⁵, Margaret Hays¹⁵, Susan Mogan¹⁵, Megan Roth¹⁵

Affiliations

¹ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA. Electronic address: sbose2@bidmc.harvard.edu.
² Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA.
³ Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.
⁴ Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
⁵ Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁶ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
⁷ Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA.
⁸ Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA; Section of Pulmonary and Critical Care Medicine, George E Wahlen VA Medical Center, Salt Lake City, UT, USA.
⁹ Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
¹⁰ Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA.
¹¹ Beth Israel Deaconess Medical Center, USA.
¹² Johns Hopkins University, USA.
¹³ Intermountain Medical Center, USA.
¹⁴ Salt Lake City Veterans Administration, USA.
¹⁵ Vanderbilt University Medical Center, USA.

PMID: 38688808
DOI: 10.1016/j.aucc.2024.02.001

Abstract

Background: Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue.

Research question: The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge.

Study design and methods: Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis.

Results: Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32).

Conclusion: At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation.

Keywords: Acute respiratory failure; Discharge planning; Health services research; Long-term outcomes; Medication management; Medication reconciliation; Post–intensive care syndrome.