Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia

BACKGROUND

Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization.

METHODS

We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint.

RESULTS

Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications).

CONCLUSIONS

Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.

Management of Elevated Blood Pressure in the Hospital-Rethinking Current Practice

This Clinical Insight proposes a new framework for managing asymptomatic blood pressure elevation in the hospital setting.

Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards

Introduction

Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards.

Methods

A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS).

Results

At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge.

Discussion

Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.

Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade

BACKGROUND

Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years.

METHODS

Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another.

RESULTS

Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82).

CONCLUSIONS

Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.

Management of Inpatient Elevated Blood Pressures : A Systematic Review of Clinical Practice Guidelines

BACKGROUND

Management of elevated blood pressure (BP) during hospitalization varies widely, with many hospitalized adults experiencing BPs higher than those recommended for the outpatient setting.

PURPOSE

To systematically identify guidelines on elevated BP management in the hospital.

DATA SOURCES

MEDLINE, Guidelines International Network, and specialty society websites from 1 January 2010 to 29 January 2024.

STUDY SELECTION

Clinical practice guidelines pertaining to BP management for the adult and older adult populations in ambulatory, emergency department, and inpatient settings.

DATA EXTRACTION

Two authors independently screened articles, assessed quality, and extracted data. Disagreements were resolved via consensus. Recommendations on treatment targets, preferred antihypertensive classes, and follow-up were collected for ambulatory and inpatient settings.

DATA SYNTHESIS

Fourteen clinical practice guidelines met inclusion criteria (11 were assessed as high-quality per the AGREE II [Appraisal of Guidelines for Research & Evaluation II] instrument), 11 provided broad BP management recommendations, and 1 each was specific to the emergency department setting, older adults, and hypertensive crises. No guidelines provided goals for inpatient BP or recommendations for managing asymptomatic moderately elevated BP in the hospital. Six guidelines defined hypertensive urgency as BP above 180/120 mm Hg, with hypertensive emergencies requiring the addition of target organ damage. Hypertensive emergency recommendations consistently included use of intravenous antihypertensives in intensive care settings. Recommendations for managing hypertensive urgencies were inconsistent, from expert consensus, and focused on the emergency department. Outpatient treatment with oral medications and follow-up in days to weeks were most often advised. In contrast, outpatient BP goals were clearly defined, varying between 130/80 and 140/90 mm Hg.

LIMITATION

Exclusion of non-English-language guidelines and guidelines specific to subpopulations.

CONCLUSION

Despite general consensus on outpatient BP management, guidance on inpatient management of elevated BP without symptoms is lacking, which may contribute to variable practice patterns.

PRIMARY FUNDING SOURCE

National Institute on Aging. (PROSPERO: CRD42023449250).

Systolic blood pressure levels and mortality in Australian medical inpatients

The epidemiology of elevations in blood pressure is incompletely characterized, particularly in Australia. Given the lack of evidence regarding the frequency and the optimal management of in-hospital hypertension, the authors performed a multicenter retrospective cohort study of consecutive medical admissions in South Australia over a 2-year period to investigate systolic blood pressure levels and their association with in-hospital mortality. Among 16 896 inpatients, 76% had at least one systolic blood pressure reading of ≥140 mmHg and 11.7% of ≥180 mmHg during hospitalization. A statistically significant negative relationship was observed between having at least one reading ≥140 mmHg and a likelihood of in-hospital mortality (odds ratio 0.41, 95% CI: 0.35 to 0.49, P < .001). Our results suggest that elevations in systolic blood pressure are common in Australian medical inpatients. However, the inverse association observed between systolic blood pressure values ≥140 mmHg and in-hospital mortality warrants further research to determine the clinical significance and optimal management of blood pressure elevations in this group.

Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults

Importance

Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists.

Objective

To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions.

Design, Setting, and Participants

This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization.

Interventions

Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission.

Main Outcome and Measures

The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment.

Results

Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history.

Conclusions and Relevance

The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.

Antihypertensive treatment changes and related clinical outcomes in older hospitalized patients

BACKGROUND

Hypertension management in older patients represents a challenge, particularly when hospitalized.

OBJECTIVE

The objective of this study is to investigate the determinants and related outcomes of antihypertensive drug prescription in a cohort of older hospitalized patients.

METHODS

A total of 5671 patients from REPOSI (a prospective multicentre observational register of older Italian in-patients from internal medicine or geriatric wards) were considered; 4377 (77.2%) were hypertensive. Minimum treatment (MT) for hypertension was defined according to the 2018 ESC guidelines [an angiotensin-converting-enzyme-inhibitor (ACE-I) or an angiotensin-receptor-blocker (ARB) with a calcium-channel-blocker (CCB) and/or a thiazide diuretic; if >80 years old, an ACE-I or ARB or CCB or thiazide diuretic]. Determinants of MT discontinuation at discharge were assessed. Study outcomes were any cause rehospitalization/all cause death, all-cause death, cardiovascular (CV) hospitalization/death, CV death, non-CV death, evaluated according to the presence of MT at discharge.

RESULTS

Hypertensive patients were older than normotensives, with a more impaired functional status, higher burden of comorbidity and polypharmacy. A total of 2233 patients were on MT at admission, 1766 were on MT at discharge. Discontinuation of MT was associated with the presence of comorbidities (lower odds for diabetes, higher odds for chronic kidney disease and dementia). An adjusted multivariable logistic regression analysis showed that MT for hypertension at discharge was associated with lower risk of all-cause death, all-cause death/hospitalization, CV death, CV death/hospitalization and non-CV death.

CONCLUSIONS

Guidelines-suggested MT for hypertension at discharge is associated with a lower risk of adverse clinical outcomes. Nevertheless, changes in antihypertensive treatment still occur in a significant proportion of older hospitalized patients.

Treatment of Hypertension Among Non-Cardiac Hospitalized Patients

PURPOSE OF REVIEW

This review provides a contemporary perspective and approach for the treatment of hypertension (HTN) among patients hospitalized for non-cardiac reasons.

RECENT FINDINGS

Elevated blood pressure (BP) is a common dilemma encountered by physicians, but guidelines are lacking to assist providers in managing hospitalized patients with elevated BP. Inpatient HTN is common, and management remains challenging given the paucity of data and misperceptions among training and practicing physicians. The outcomes associated with intensifying BP treatment during hospitalization can be harmful, with little to no long-term benefits. Data also suggests that medication intensification at discharge is not associated with improved outpatient BP control. Routine inpatient HTN control in the absence of end-organ damage has not shown to be helpful and may have deleterious effects. Since routine use of intravenous antihypertensives in hospitalized non-cardiac patients has been shown to prolong inpatient stay without benefits, their routine use should be avoided for inpatient HTN control. Future large-scale trials measuring clinical outcomes during prolonged follow-up may help to identify specific circumstances where inpatient HTN control may be beneficial.

Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System

IMPORTANCE

Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization.

OBJECTIVE

To investigate outcomes associated with intensification of outpatient diabetes medications at discharge.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021.

EXPOSURE

Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge.

RESULTS

The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled.

CONCLUSIONS AND RELEVANCE

In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.

Pro Re Nata Antihypertensive Medications and Adverse Outcomes in Hospitalized Patients: A Propensity-Matched Cohort Study

[Figure: see text].

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

IMPORTANCE

Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied.

OBJECTIVES

To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching.

EXPOSURES

Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.

MAIN OUTCOMES AND MEASURES

The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.

RESULTS

Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year.

CONCLUSIONS AND RELEVANCE

In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.

Performance of an automated blood pressure measurement device in a stroke rehabilitation unit

CONTEXT

Valid blood pressure (BP) measurements are needed in post-stroke rehabilitation hospital units for the management of hypertension. Automated devices could be used to improve on usual care BP measurement. However, more information is needed about the performance of these devices in such a context.

METHODS

This prospective nonrandomized study was performed in stroke patients with hypertension hospitalized in a stroke rehabilitation unit. Two in-hospital BP assessment strategies were compared: usual care BP and in-hospital automated office BP (AOBP) standardized measurements. In-office AOBP and ambulatory BP monitoring (ABPM) were also performed on these patients. The main outcome was SBP. Study follow-up was until discharge, up to a maximum of 4 weeks.

RESULTS

Sixty-two patients with stroke hospitalized in a rehabilitation unit were included. Usual care BP was 130 ± 12/79 ± 9 mmHg and differed from an in-hospital AOBP of 117 ± 14/75 ± 12 mmHg (P < 0.001/P < 0.001). In-hospital and in-office AOBP measurements did not differ. Twenty percent of patients reached SBP therapeutic goals according to in-hospital AOBP but not according to usual care BP measurements.

CONCLUSION

This study shows that in a post-stroke rehabilitation unit, standardized in-hospital AOBP estimates are on average much lower than the usual care BP correlates and similar to the in-office AOBP estimates. In-hospital AOBP devices in a stroke rehabilitation unit could add important information for the management of hypertension.

Medication Use Quality and Safety in Older Adults: 2019 Update

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes

OBJECTIVES

Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing.

DESIGN

National, retrospective cohort study.

SETTING AND PARTICIPANTS

Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg.

MEASURES

Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing.

RESULTS

Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood.

CONCLUSIONS AND IMPLICATIONS

Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

Importance

Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.

Objective

To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.

Design, Setting, and Participants

This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.

Main Outcomes and Measures

Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.

Results

Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.

Conclusions and Relevance

In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

IMPORTANCE

Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.

OBJECTIVE

To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.

EXPOSURES

Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.

MAIN OUTCOMES AND MEASURES

The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.

RESULTS

The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).

CONCLUSIONS AND RELEVANCE

Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use

BACKGROUND

Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance.

OBJECTIVES

The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use.

RESEARCH DESIGN

Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications.

RESULTS

The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care.

CONCLUSION

Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.