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Burry LD, Bell CM, Hill A, Pinto R, Scales DC, Bronskill SE, Williamson D, Rose L, Fu L, Fowler R, Martin CM, Dolovich L, Wunsch H. New and Persistent Sedative Prescriptions Among Older Adults Following a Critical Illness: A Population-Based Cohort Study. Chest 2023; 163:1425-1436. [PMID: 36610663 DOI: 10.1016/j.chest.2022.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization. RESEARCH QUESTION For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt? STUDY DESIGN AND METHODS This population-based cohort study included ICU survivors aged ≥ 66 years who had not filled sedative prescriptions within ≤ 6 months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within ≤ 7 days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6 months) were examined with a multivariable proportional hazards model. RESULTS A total of 250,428 patients were included (mean age, 76 years; 61% male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2% [95% CI, 1-3] to 44% [95% CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95% CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95% CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95% CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95% CI, 1.53-1.66), and ICU length of stay ≥ 7 days (aOR, 1.50; 95% CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95% CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95% CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95% CI, 0.80-0.93). INTERPRETATION One in 15 sedative-naive, older adult ICU survivors filled a new sedative within ≤ 7 days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Sinai Health System, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
| | - Chaim M Bell
- Department of Medicine, Sinai Health System, Toronto, ON, Canada; Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Susan E Bronskill
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health. University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada; Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada; Research Center, CIUSSS du Nord-de-l'Île-de-Montréal, QC, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England
| | | | - Robert Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Toronto, ON, Canada; Lawson Health Research Institute, London, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
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Halavonich L, Robert S, McGraw D, Weeda E, Mullinax K, Bass B. Management of delirium at an academic medical center: Plans for antipsychotic prescribing upon discharge. Ment Health Clin 2020; 10:25-29. [PMID: 31942275 PMCID: PMC6956973 DOI: 10.9740/mhc.2020.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Delirium is an acute, fluctuating change in mental status, often associated with behavioral manifestations such as agitation. Literature suggests that many patients who continue on antipsychotics for extended management of delirium are not provided instructions for discontinuation. However, there is a positive correlation between consult services and instructions for discontinuation. The objective of this study was to determine the frequency at which patients with delirium were prescribed an antipsychotic at hospital discharge and to characterize discharge antipsychotic prescribing for psychiatric consult and nonconsult cohorts. Methods This study was a retrospective chart review of adult patients with an International Classification of Diseases 10th revision code of delirium who received at least 1 dose of antipsychotic during their admission. Inclusion criteria were all patients aged 18 years or older with a diagnosis of or relating to delirium who were administered antipsychotics during their admission. Results A total of 152 patients were included, of which 43 received a psychiatric consult. Antipsychotics were prescribed at discharge for management of delirium for 52 (34.2%) of 152 total patients. More patients in the psychiatric consult cohort were discharged with an antipsychotic as compared to those in the nonconsult cohort (53.3% vs 26.6%, P = .02). Discussion Compared to previous studies, patients in this retrospective review were more likely to be discharged on an antipsychotic that was initiated during admission for management of delirium. Findings from this study also align with prior research demonstrating a positive association between antipsychotic discharge instructions and specialty consult recommendations.
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